Post-cath Pulse Loss Pathway
1 hour post
cath
PT/PTT and creatinine obtained at catheter insertion in all infants < 1 year
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Decreased Pulse
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  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 (contacts below)
*For patients ≥ 1 year, obtain an ultrasound of the femoral artery and notify the provider.
Abnormal Ultrasound
Normal Ultrasound
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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.
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  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
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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
Continue Lovenox and discuss with consulting services.
Repeat Ultrasound
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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.
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2 week ultrasound
(or sooner if clinically indicated) and anti-Xa level if applicable
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6 week ultrasound
(or sooner if clinically indicated) and anti-Xa level 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

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