A 4-Year-Old Girl in Significant Distress

Alba Morales Pozzo, MD


March 05, 2019

The presence of CVC is the single most important risk factor for DVT in children, with at least 85% of cases related to CVC use.[4,5]

CVC-related thrombosis as a complication of diabetic ketoacidosis in young children has been described in the literature. In 2003, Gutierrez and colleagues[6] published a retrospective case-matched control series in the setting of a pediatric intensive care unit of two university-affiliated hospitals. He described eight pediatric patients with diabetic ketoacidosis who had femoral CVCs placed from 1998 to 2001 and age-matched control patients with femoral venous catheters and circulatory shock. CVC-related DVT was defined as persistent ipsilateral leg swelling after removal of a femoral CVC. Control patients who had other risk factors for DVT were excluded. Four of 8 patients with diabetic ketoacidosis developed CVC-related DVT compared with none of the 16 control patients. All four patients with DVT and diabetic ketoacidosis were younger than 3 years. DVT cases were confirmed by Doppler ultrasound in 3 out of 4 patients. This study suggested that young children with diabetic ketoacidosis have an increased incidence of DVT associated with the placement of CVCs.

In 2004, Worly and colleagues[7] described a retrospective cohort study of 113 patients with diabetic ketoacidosis in the pediatric intensive care unit. Six (5.3%) required femoral CVC for initial management; 50% of these patients developed ipsilateral DVT within 48 hours of CVC placement. All three patients required long-term therapy with low-molecular-weight heparin for persistent leg swelling. The patients with diabetic ketoacidosis who developed DVT after CVC use were younger (median age, 10.5 months) than patients with diabetic ketoacidosis and CVC use who did not develop DVT. The authors concluded that femoral CVCs should be avoided in patients with diabetic ketoacidosis or removed as soon as possible and that DVT prophylaxis should be considered if a CVC is needed for management.

Potential mechanisms that could explain this increased risk for CVC-related thrombosis in pediatric patients with diabetic ketoacidosis include the following:

  • Increased platelet aggregability during hyperglycemia[8]

  • Erythrocyte wall rigidity increase in the hyperglycemic and acidic bloodstream, increasing viscous resistance and causing poor blood flow[9,10]

  • Dehydration during diabetic ketoacidosis that could increase venous stasis (part of Virchow's triad of pathogenesis of thrombosis)

  • Small caliber of the vessels in toddlers because the median age of the children who developed CVC-related DVTs in the published cases was only 18 months

A high index of suspicion for DVT in critically ill children is important, as unrecognized DVT can give rise to pulmonary embolism, can become a nidus for infection, and can lead to stasis dermatitis and ulceration. Clinical signs of DVT can be difficult to assess because critically ill children are often edematous and overloaded with fluid.


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