ICU and Inpatient Clinical Pathway
for Children with Post-Cath Pulse Loss

1 hour
post cath
PT/PTT and creatinine obtained at catheter insertion in all infants < 1 year
Decreased Pulse
  1. Rule out ischemic limb.
  2. Initiate Lovenox per CHOP CPG guidelines
    OR at the discretion of MD, may start Heparin per CHOP Guidelines.
  3. Order ultrasound of femoral artery.
  4. Notify cath team (Contact Information)
*For patients ≥ 1 year, obtain an ultrasound of the femoral artery and notify the provider.
Abnormal Ultrasound
Normal Ultrasound
Continue Lovenox
Start discharge teaching & planning
Exam Normalized: Discontinue Lovenox.
Continue routine care, no specialized
follow-up.
Exam Still abnormal: Continue Lovenox for 24 hours and reassess.
  1. At 24 hrs if clinically improved, d/c Lovenox discharge to home, no specialized follow-up.
  2. If exam abnormal, repeat u/s- if abnormal, follow pathway; if normal, MD decision.
24 hours
Clinical
improvement
No Clinical
Improvement

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
Abnormal: Non-occlusive
Thrombus
Occlusive
Thrombus
Continue Lovenox and discuss with consulting services.
Repeat Ultrasound
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 follow-up with outpatient
MD decision point:
  1. Lovenox pathway OR
  2. Discuss need for rtPA with cath lab and thrombosis teams. Review rtPA protocol.
MD decision point:
  1. Lovenox pathway OR
  2. Discuss need for rtPA with cath lab and thrombosis teams. Review rtPA protocol.
2 week ultrasound
(or sooner if clinically indicated) and anti-Xa level if applicable
6 week ultrasound
(or sooner if clinically indicated) and anti-Xa level if applicable
12 weeks ultrasound
Stop Lovenox therapy
Patient < 1 month?
Yes
No
Supplement plasminogen with 10 cc/kg fresh frozen plasma

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
Continue tPA until pulse is normal OR max 72 hours
Stop tPA/uFH Initiate Lovenox pathway
Posted: November 2010
Revised: April 2020
Authors: J. Chang, CRNP; T. Demkin, NP; A. Glatz, MD; L. Raffini, MD; J. Rome, MD; R. Keashen, NP; W. Petrosa, NP