Outcomes using a clinical practice pathway for the management of pulse loss following pediatric cardiac catheterization

Objective: Objectives To describe the results of a clinical practice pathway (CPP) for the management of postcatheterization pulse loss in a children's hospital. Background: Standardized approaches to the diagnosis and management of postcatheterization arterial thrombus are lacking. As a result, substantial practice variation exists. Methods: Data collected prospectively for quality improvement purposes were retrospectively reviewed. Results: Since initiation of the CPP, 93/1,672 (5.4%) catheterizations resulted in pulse loss at a median patient age and weight of 73 days (1 day-5.8 years) and 4.8 kg (2-14.1 kg). Arterial thrombus was documented by ultrasound (US) in 85. Of these, 66 resolved by 12 weeks of therapy, seven patients died, and four were lost to follow-up before completing treatment. Eight patients had persistent thrombus despite a full treatment course (89% success rate in those able to complete treatment). Of patients treated with unfractionated heparin as initial therapy, 46% (17/37) achieved a therapeutic partial thromboplastin time within 12 hr with 19% (67/343) of all levels therapeutic. As a result, the CPP was modified to use enoxaparin as first line agent, of which 57% (41/72) had a therapeutic anti-Xa level after the 2^nd dose and 88% by the 4^th dose. No bleeding complications were observed. A priori established process metrics were achieved. Conclusions: A CPP utilizing early initiation of anticoagulation and US to aid diagnosis of postcatheterization arterial thrombus and response to therapy is feasible and effective. In those able to complete up to 12 weeks of treatment, resolution occurs in nearly 90%.