1 hour post
cath
PT/PTT and creatinine obtained at catheter insertion in all infants < 1 year
Decreased Pulse
*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.
- At 24 hrs if clinically improved, d/c Lovenox discharge to home, no specialized follow-up.
- If exam abnormal, repeat u/s- if abnormal, follow pathway; if normal, MD decision.
24 hours
Clinical
improvement
No Clinical
Improvement
Contraindication to rtPA?
- Major surgery within 7 days
- Active bleeding
- CNS ischemia/trauma/ hemorrhage within 30 days
- Fibrinogen <100, Plt count < 75,000
- 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
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
Contacts:
- Attending cardiac interventionalist
- Cath lab NP – Taylor Demkin
(during business hours)
- Thrombosis team NP – Rachel Keashen (during business hours)
- On-call cardiology fellow (x10154) for nights/weekend/holidays
Posted: November 2010
Revised: July 2011, February 2016, February 2018 (Reviewed), May 2018
Authors: J. Chang, CRNP; T. Demkin, NP; A. Glatz, MD; L. Raffini, MD; J. Rome, MD; R. Keashen, NP; W. Petrosa, NP