Management of neonatal arterial occlusion and thrombosis

Clear documentation in the baby’s notes of:

• Time
• Affected limb and location
• Colour
• Presence of pulses: poor/absent regional pulses
• Perfusion: capillary refill time (CRT)
• Any skin changes including blistering and necrosis
• Pain/irritability

Aims:

1. Halt thrombus propagation and improve tissue perfusion
2. Avoid reperfusion syndrome – further injury caused to the tissues in the affected area by reintroducing blood flow and resultant oxygenation causing increased production of free radical and reactive oxygen species.
3. Prevent life-threatening consequences of embolism

DOs

• Affected limb should be positioned in a semi-flexed position taking the strain off the joints. Do not elevate the limb.
• Maintain normothermia.
• Check the following blood tests:
  • FBC (Platelet count, haematocrit)
  • Coagulopathy screen (APTT, PT & fibrinogen)
  • Group & Save
  • Blood Gas.
• Assess fluid status of the baby. If signs of hypovolaemia then fluid resuscitate as appropriate.

DON’Ts

• Local massage of the affected area is no longer recommended.
• Apply topical glyceryl trinitrate (GTN) patches. This is NOT recommended and these should only be applied following discussion with specialist Plastic Surgery teams.

Review Patient in One Hour
If there is no improvement further investigations and referral is essential.

Urgent referral to Royal Hospital for Children, Glasgow. Call the ScotSTAR emergency line on 03333 990 240 and request a conference call with the following participants:

1. ScotSTAR Neonatal Consultant
2. RHC, Glasgow Receiving Neonatal Consultant.
3. RHC, Glasgow On-call Plastic Surgery Consultant.
4. RHC, Glasgow On-call Haematology Consultant.

1. Cranial Ultrasound
   • Assessment of Intraventricular haemorrhage.
   • Aiming to identify source of thrombus.

Further imaging: if not available locally will be performed at RHC, Glasgow

2. Ultrasound of affected limb with Doppler (if available)
   • To confirm location and size of thrombus.

3. Echo
   • Within 8 to 12 hours: aiming to identify source of thrombus.

The only medical management that should be initiated in the first 12 hours is unfractionated heparin. Decision to treat requires MDT discussions with the neonatal team, plastics team and haematology team.  Dosing and monitoring guidance available through the link below:

Anti-Thrombotic therapy, Haematology

Unfractionated heparin is the treatment of choice for initial anticoagulation. Going forward, there is an option to change to subcutaneous low molecular weight heparin.

There is a 12 hour window for assessment of the patient for consideration of thrombolysis and/or surgical intervention. This decision should be made with reference to the location of the insult and gestation of the infant and will involve input from neonatology, plastics and haematology.