Comparison between Edmonton antithrombotic guidelines and Stanford protocol for management of children with the Berlin Heart EXCOR pediatric VAD
| Medication . | Edmonton protocol . | Stanford protocol . | ||
|---|---|---|---|---|
| Initiation parameters . | Goal . | Initiation parameters . | Goal . | |
| Perioperative | ||||
| Antithrombin concentrate or plasma | Antithrombin activity < 70% | Antithrombin activity ≥ 70% | Antithrombin activity < 70% | Antithrombin activity ≥ 70% |
| Protamine | Completion of CPB | Complete heparin reversal (institution-dependent parameters) | Completion of CBP | Complete heparin reversal (institution-dependent parameters) |
| Postoperative | ||||
| UFH | 24 h postimplantation, platelets > 20 000/µL, normal TEG Platelet Mapping, TEG MAcKH > 46 mm, TEG RcKH < 10 | Anti-factor Xa 0.35-0.5 U/mL, TEG R 8.0-15.0 | 12-24 h postimplantation, platelets > 40 000/μL, no bleeding | Anti-factor Xa 0.35-0.5 U/mL |
| Antiplatelet | ||||
| Dipyridamole | 48 h postimplantation, platelets > 40 000/µL, TEG MAcKH > 56 mm, Platelet Mapping: net ADP G ≥ 4, AA inhibition < 70% | Platelet Mapping: net ADP G 4-8, AA inhibition > 70% | 8 d after implant, add after max dose of asa reached and no bleeding | Titrated to a weight-based dose of 15 mg/kg/d |
| Aspirin | 4 d postimplantation, TEG MAcKH > 72 mm, net ADP G > 2 | Platelet Mapping: net ADP G 4-8, AA inhibition > 70% | 3 d postimplantation, no bleeding | Titrated to a weight-based dose of 30 mg/kg/d (max dose 2000 mg/d) |
| Clopidogrel | No recommendation | 11 d postimplantation, after max dose of aspirin and dipyridamole reached and no bleeding | Titrated to weight-based dose of 0.2 mg/kg/d, max dose 1 mg/kg/d | |
| Long-term anticoagulant | ||||
| Enoxaparin | Age < 1 y, >48 h postimplantation, normal creatinine | Anti-factor Xa 0.6-1.0 U/mL | Age ≤ 2 y, or if unstable INR | Anti-factor Xa 0.6-1.0 U/mL |
| Warfarin | Age ≥ 1 y, full oral diet | INR 2.7-3.5 | Age > 2 y, full oral diet | INR 2.7-3.5 |
| Anti-inflammatory | ||||
| Prednisone | No recommendation | As needed for fibrinogen > 600 mg/dL or other signs of inflammation (fever, rise in CRP), no other signs of sepsis | Methylprednisolone should be initiated at a dose of 2 mg/kg/d IV (or PO equivalent) divided BID, discontinue when fibrinogen ≤ 400 mg/dL | |
| Medication . | Edmonton protocol . | Stanford protocol . | ||
|---|---|---|---|---|
| Initiation parameters . | Goal . | Initiation parameters . | Goal . | |
| Perioperative | ||||
| Antithrombin concentrate or plasma | Antithrombin activity < 70% | Antithrombin activity ≥ 70% | Antithrombin activity < 70% | Antithrombin activity ≥ 70% |
| Protamine | Completion of CPB | Complete heparin reversal (institution-dependent parameters) | Completion of CBP | Complete heparin reversal (institution-dependent parameters) |
| Postoperative | ||||
| UFH | 24 h postimplantation, platelets > 20 000/µL, normal TEG Platelet Mapping, TEG MAcKH > 46 mm, TEG RcKH < 10 | Anti-factor Xa 0.35-0.5 U/mL, TEG R 8.0-15.0 | 12-24 h postimplantation, platelets > 40 000/μL, no bleeding | Anti-factor Xa 0.35-0.5 U/mL |
| Antiplatelet | ||||
| Dipyridamole | 48 h postimplantation, platelets > 40 000/µL, TEG MAcKH > 56 mm, Platelet Mapping: net ADP G ≥ 4, AA inhibition < 70% | Platelet Mapping: net ADP G 4-8, AA inhibition > 70% | 8 d after implant, add after max dose of asa reached and no bleeding | Titrated to a weight-based dose of 15 mg/kg/d |
| Aspirin | 4 d postimplantation, TEG MAcKH > 72 mm, net ADP G > 2 | Platelet Mapping: net ADP G 4-8, AA inhibition > 70% | 3 d postimplantation, no bleeding | Titrated to a weight-based dose of 30 mg/kg/d (max dose 2000 mg/d) |
| Clopidogrel | No recommendation | 11 d postimplantation, after max dose of aspirin and dipyridamole reached and no bleeding | Titrated to weight-based dose of 0.2 mg/kg/d, max dose 1 mg/kg/d | |
| Long-term anticoagulant | ||||
| Enoxaparin | Age < 1 y, >48 h postimplantation, normal creatinine | Anti-factor Xa 0.6-1.0 U/mL | Age ≤ 2 y, or if unstable INR | Anti-factor Xa 0.6-1.0 U/mL |
| Warfarin | Age ≥ 1 y, full oral diet | INR 2.7-3.5 | Age > 2 y, full oral diet | INR 2.7-3.5 |
| Anti-inflammatory | ||||
| Prednisone | No recommendation | As needed for fibrinogen > 600 mg/dL or other signs of inflammation (fever, rise in CRP), no other signs of sepsis | Methylprednisolone should be initiated at a dose of 2 mg/kg/d IV (or PO equivalent) divided BID, discontinue when fibrinogen ≤ 400 mg/dL | |
Net ADP G = [(100 − %ADP inhibition) × GCKH]/100.
AA, arachidonic acid; ADP, adenosine diphosphate; asa, aspirin; BID, twice daily; CRP, C-reactive protein; IV, intravenous; MA, maximum amplitude; MAcK, maximum amplitude citrate kaolin; MAcKH, maximum amplitude citrate kaolin heparinase; max, maximum; PO, by mouth; RCK, reaction time citrate kaolin; RcKH, reaction time citrate kaolin heparinase; TEG, thomboelastogram.
Adapted from Steiner et al31 and Rosenthal et al32 with permission.