Femoral Artery Loss
1 hour post
cath
PT/PTT and creatinine obtained at catheter insertion in all infants
< 1 year
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Loss of Pulse
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  1. Rule out ischemic limb.
  2. Initiate Lovenox per CHOP CPG guidelines
    at 1 hour post LOP OR at the discretion of MD, may start Heparin per CHOP Guidelines.
  3. Order ultrasound of femoral artery.
Abnormal Ultrasound
Normal Ultrasound
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Continue Lovenox
Start discharge teaching & planning
Exam Normalized: Discontinue Lovenox.
Discharge.
Exam Still abnormal: Continue Lovenox for 24 hours and reassess.
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  1. At 24 hrs if clinically improved, d/c Lovenox discharge to home, no specialized f/u.
  2. If exam abnormal, repeat u/s- if abnormal, follow pathway; if normal, MD decision.
24 hours
Clinical
improvement
No Clinical
Improvement
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Contraindication to rtPa?

  1. Major surgery within 7 days
  2. Active bleeding
  3. CNS ischemia/trauma/ hemorrhage within 30 days
  4. Fibrinogen <100, Plt count < 75,000
  5. Uncontrolled hypertension

OBTAIN HEAD ULTRASOUND IN ALL INFANTS <1 MONTH

Yes
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Abnormal: Non-occlusive
Thrombus
Occlusive
Thrombus
Obtain surgical consult Continue Lovenox
Repeat Ultrasound
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Outpatient
Lovenox Pathway
  • Admission for Lovenox teaching and initiation, discharge planning
  • Obtain anti-Xa per protocol @ 2nd dose (therapeutic Anti XA 0.5-1.0)
  • Cath team to f/u with outpatient
MD decision point:
  1. outpt Lovenox pathway OR
  2. rtPa and start Heparin (as per tPA protocol)
MD decision point:
  1. outpt Lovenox pathway OR
  2. rtPa and start Heparin (as per tPA protocol)
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2 week clinic visit; ultrasond and anti-Xa level if applicable
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6 week clinic visit; ultrasound and anti XA if applicable
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12 weeks ultrasound
Stop Lovenox therapy
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Patient < 1 month ?
Yes
No
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Supplement plasminogen with 10 cc/kg fresh frozen plasma
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Start tPA: 0.1 mg/kg/hr;
Start uFH at 50% therapeutic dose, or 15 U/kg/hr if therapeutic range unknown

MONITORING

  • Q 1 hr neurovascular check
  • PT, PTT, CBC, FBN, D-dimer prior to starting and every 6-8 hours
  • Avoid IM injections, rectal temps, arterial sticks, NG tube insertion, intubation, urinary catheterization
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Continue tPA until pulse is normal OR max 72 hours
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Stop tPA/uFH Initiate Lovenox pathway

Posted : Nov. 2010
Updated :July 2011
Authors : Julie Chang, CRNP; Andrew Glatz, MD; Leslie Raffini, MD; Jonathan Rome, MD