An algorithmic approach to the management of limb ischemia in infants and young children

BACKGROUND:: Vascular injuries in newborns are rare and most commonly occur in the process of obtaining vascular access for monitoring organ system functions or interventions in critical care. Care of vascular injuries in neonates poses several challenges, with the most significant arguably being the lack of clinical experience with such injuries. An algorithm for the management of arterial injuries in pediatric patients is investigated and reported. METHODS:: A retrospective chart analysis was performed on all patients consulted for the management of vascular injury by the plastic surgery service at Texas Children's Hospital between 1997 and 2005. The outcomes and procedures were reviewed. RESULTS:: Thirty vascular insults in 28 patients were evaluated and treated by the senior author (J.D.F.) using this protocol. Thirty-seven percent (11 of 30) were approached surgically, including two cases treated with thrombolysis alone. The remaining 63 percent (19 of 30) were managed with more conservative interventions, including anticoagulation and clinical optimization. When color Doppler imaging was used preoperatively to locate and describe the characteristics of vascular injuries, visualized lesions coincided with the surgical findings in 100 percent (11 of 11 cases). Twenty-three limbs (77 percent) were salvaged completely using this algorithm, one was initially salvaged but later developed limb-length discrepancy requiring amputation, and one experienced complete limb loss. The remaining patients (five of 30) died as a result of complications of their primary medical conditions before limb salvage could be assessed. CONCLUSION:: This evaluation demonstrates the efficacy of the proposed algorithm used to determine direction of care in the event of arterial injury in small children. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.