Cardiology Nurse Practitioner Children's Mercy Hospital Kansas City Olathe, Kansas, United States
Abstract: Introduction/
Objective: Patients with congenital heart disease are at high risk for the development of central venous catheter related thromboembolism (CVC VTE), which are associated with higher morbidity and mortality. Best practice for CVC VTE prevention is not yet defined. An increasing rate of VTE within our Cardiac Intensive Care Unit (CICU) prompted a quality improvement initiative to decrease the CVC VTE rate utilizing low-dose anticoagulation and improved central line selection and usage.
Methods: Education was given to CICU providers regarding CVC VTE prevention through judicious line selection and early removal. Heparin or enoxaparin thromboprophylaxis was started in high-risk patients, identified using an evidence based scoring system, targeting first an anti-Xa level of 0.1-0.3units/mL and subsequently 0.3-0.5units/mL. Measures included the number of patients started on prophylaxis, CVC VTE rate, time from anticoagulant initiation to reaching targeted anti-Xa level, dose required, and types of lines used. The primary balancing measure was development of bleeding, which included bloody stools with cessation of feeds for >24 hours or any other bleeding event resulting in anticoagulation discontinuation.
Result: The incidence of CVC VTE in our CICU was 3.54 per 1000 patient days from 1/2018 to 10/2019. Education regarding VTE prophylaxis was initiated on 11/2019 and thromboprophylaxis with low-dose anticoagulation was initiated on 2/2020. Forty-six patients received thromboprophylaxis from 2/2020 through 11/2020. Of these patients, 10 (21%) developed a CVC VTE and required increased dosing to reach therapeutic anti-Xa level. The VTE rate was not significantly impacted, thus in 12/2020 the anti-Xa goal was increased to 0.3-0.5units/mL. Of the 77 patients on prophylactic anticoagulation from 12/2020 through 12/2021, 11 (14%) developed a CVC VTE with a decrease in overall VTE rate. CVC VTEs in the CICU were reduced to 0.802 per 1000 patient days with the higher anticoagulation goal. There were 5 bleeding events (11%) with anti-Xa goals of 0.1-0.3units/mL and 14 events (18%) with anti-Xa goals of 0.3-0.5units/mL. Bleeding events were primarily bloody stools. No events required surgical intervention.
Conclusion: Venous thromboembolisms pose a risk for patients with congenital heart disease. At our institution, we reduced unit-wide rates utilizing anticoagulation within low-therapeutic ranges, in a specific, high-risk population, with a slight increase in bleeding risk. This increase in risk of nonsurgical bleeding may be acceptable given the risk of CVC VTE related complications including infection, major thrombi in patients who may require future venous access, cerebrovascular incident, pulmonary embolism, and chylothorax. Further data analysis will be performed to determine best practices to safely decrease the incidence of CVC VTE in our institution.
