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  6. Anticoagulation and antiplatelet therapy in paediatric cardiac patients (1180)
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Anticoagulation and antiplatelet therapy in paediatric cardiac patients (1180)

Objectives: To allow standardised anticoagulation practice in paediatric cardiac patients and provide guidance for staff administering or prescribing anticoagulation therapy. This guideline does not replace the clinical experience and judgement of the practitioners looking after the patient. When a tailored patient-specific approach to anticoagulation is required, the rationale and collegiate discussion must be clearly documented in the patient medical record.

Scope: This guideline applies to any cardiac patient being prescribed or administered anticoagulation therapy.

Audience: All healthcare professionals prescribing, supplying or administering anticoagulation therapy should be aware of this guideline.

Contents

  • Antithrombotic therapy for all patients except valves surgery
  • Antithrombotic therapy post-valves surgery
  • Anticoagulation after catheter procedures
  • Prophylactic IV Heparin use
  • Therapeutic IV Heparin use
  • Procedures on IV Heparin, LMWH or Warfarin on PICU and ward 1E
  • Reversal of IV Heparin
  • Aspirin guidance
  • Warfarin guidance
  • LMWH Enoxaparin guidance
  • Central Venous Liner-related venous thrombosis
  • Direct-acting Oral Anticoagulants (DOACs) use in postoperative period
  • Switching between different antithrombotic therapy modalities
  • Adolescent risk of venous thromboembolism management
  • Management of established antithrombotic therapy for patients with congenital heart disease requiring cardiac catheterisation, surgical or dental procedures

Resources

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Editorial Information

Last reviewed: 04/12/2024

Next review date: 28/02/2027

Author(s): A Buller, M Davidson, P Donnelly, M Ilina, E Liston, E Peng, F Pinto.

Approved By: Paediatric Cardiac Guideline Group

Document Id: 1180

Related resources

This guideline replaces the previous guidelines:

  • Anticoagulation Therapy for Post-op Cardiac Patients in PICU
  • Pre-operative management of anticoagulation therapy pathway for paediatric patients with congenital heart disease
References
  1. Monagle,P. et al. Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133, 887S-968S (2008)
  2. SPCS Cardiac Catheterisation Pathway
  3. Lok,J.M., Spevak,P.J. & Nichols,D.G. Critical Heart Disease in Infants and Children. Nichols,D.G. et al. (eds.) (Mosby Inc, Philadelphia,2010)
  4. Motz,R., Wessel,A., Ruschewski,W. & Bursch,J. Reduced frequency of occlusion of aorto-pulmonary shunts in infants receiving aspirin. Young. 9, 474-477 (1999).
  5. Tweddell,J.S. Aspirin: a treatment for the headache of shunt-dependent pulmonary blood flow and parallel circulation? Circulation 116, 236-237 (2007).
  6. Mullen,J.C., Lemermeyer,G. & Bentley,M.J. Modified Blalock-Taussig shunts: to heparinize or not to heparinize? J. Cardiol. 12, 645-647 (1996).
  7. Andrew,M. Anticoagulation and thrombolysis in children. Heart Inst. J. 19, 168-177 (1992).
  8. BNF for Children https://bnfc.nice.org.uk
  9. Schroeder A, Axelrol D, Silverman N et al. A continuous heparin infusion does not prevent catheter-related thrombosis in infants after cardiac surgery. Pediatric Crit Care Med 11,489-495 (2010).
  10. McCrindle BW1, Manlhiot C, Cochrane A, Roberts R, Hughes M, Szechtman B, Weintraub R, Andrew M, Monagle P; Fontan Anticoagulation Study Group. Factors associated with thrombotic complications after the Fontan procedure: a secondary analysis of a multicenter, randomized trial of primary thromboprophylaxis for 2 years after the Fontan procedure. J Am Coll Cardiol. 22 61, 346-53 (2013)
  11. Potter BJ1, Leong-Sit P, Fernandes SM, Feifer A, Mayer JE Jr, Triedman JK, Walsh EP, Landzberg MJ, Khairy P. Effect of aspirin and warfarin therapy on thromboembolic events in patients with univentricular hearts and Fontan palliation. Int J Cardiol. 168,3940-3 (2013)
  12. Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Muñoz DR, Rosenhek R, Sjögren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL; 2017 ESC/EACTS Guidelines for the management of valvular heart disease. ESC Scientific Document Group. Eur Heart J. 2017 Sep 21;38(36):2739-2791
  13. Paediatric Formulary https://app.clinibee.com/signin?returnUrl=%2F 
  14. McCrindle BW, Michelson AD, Van Bergen AH, et al. Thromboprophylaxis for Children Post-Fontan Procedure: Insights From the UNIVERSE Study [published correction appears in J Am Heart Assoc. 2021 Dec 21;10(24):e020766]. J Am Heart Assoc. 2021;10(22):e021765.
  15. GOS Guidelines for the management of anticoagulation and antiplatelet therapy in children 2012 and 2020
  16. Warfarin (starship.org.nz)
  17. BCH angicoagulation policy https://kids.bwc.nhs.uk/wp-content/uploads/2021/06/Anticoagulation-protocol-March-2020.pdf
  18. University Hospital Bristol Warfarin Management for Paediatric Cardiac patients https://uhbw.mystaffapp.org/diliboards/83/diliboard_contents/456/document_view.pdf
  19. Palaniswamy, C. & Selvaraj, D. R. (2011). Periprocedural Bridging Anticoagulation: Current Perspectives. American Journal of Therapeutics, 18 (4), e89-e94. doi: 10.1097/MJT.0b013e3181d41ed6.
  20. Keeling D, Baglin T, Tait C, et al. Guidelines on oral anticoagulation with warfarin - fourth edition. Br J Haematol. 2011;154(3):311-324
  21. Chalmers E. Anti-Thrombotic Protocol, RHC v.5 2021
  22. Baglin TP, Keeling DM, Watson HG; British Committee for Standards in Haematology. Guidelines on oral anticoagulation (warfarin): third edition--2005 update. Br J Haematol. 2006;132(3):277-285.
  23. Palaniswamy, Chandrasekar MD*; Selvaraj, Dhana R MD. Periprocedural Bridging Anticoagulation: Current Perspectives. American Journal of Therapeutics 18(4):p e89-e94, July 2011.
  24. Douketis, J. D. (2011). Perioperative management of patients who are receiving warfarin therapy: an evidence-based and practical approach. Blood, The Journal of the American Society of Hematology, 117(19), 5044-5049.
  25. Hirsh, J., Guyatt, G., Albers, G. W., Harrington, R., & Schünemann, H. J. (2008). Executive summary: American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 133(6), 71S-109S.
  26. Antithrombotic therapy in paediatric cardiology patients. Clinical guidance. Evelina Children’s Hospital, Guy’s and St Thomas NHS Foundation Trust, 31st January 2024
Evidence method

These guidelines have been written in consultation with the medical literature using the current gold standard for anticoagulation practice which reviews the best levels of evidence available. There are few randomised controlled trials (RCT) available in this area and the majority of evidence is level 3. The guidelines incorporate extensive consultation with intensive care, cardiology, cardiac surgery, haematology and pharmacy taking into consideration local practice, as well as current practice guidelines from other paediatric cardiac surgical centres. 

These guidelines will be reviewed with reference to clinical governance including review of clinical incidents and audit and will be reviewed every 3 years, or sooner if indicated.