Post-Cath Pulse Loss Clinical Pathway — ICU and Inpatient

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

Goal and Metrics
Patient Education
Provider Resources
1 hour
post cath
PT/PTT and creatinine obtained at catheter insertion in all infants < 1 year
Decreased pulse
Assessment
and Definition
  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
For children ≥ 1 year, obtain an ultrasound of the femoral artery and notify the provider
Abnormal ultrasound
Normal ultrasound
Continue Lovenox
Start discharge teaching and 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)
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
No: rtPA Pathway
Infant < 1 month?
Yes
No
Supplement plasminogen with 10 mL/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: December 2022
Authors: J. Chang, CRNP; L. Raffini, MD; J. Rome, MD; R. Keashen, NP