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  6. Anticoagulation and antiplatelet therapy in paediatric cardiac patients (1180)
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

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.