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The role of anticoagulation in venous shunts

Learn about the vital role of anticoagulants in venous shunts with details on heparin, LMWH, warfarin, aspirin, and other medications. Understand the monitoring techniques, dosages, side effects, and associated risk factors.

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The role of anticoagulation in venous shunts

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  1. The role of anticoagulation in venous shunts - a brief overview

  2. The use of heparin • Activates antithrombin III • Typical regime – loading dose of 75-100 units/kg followed by 28units/kg/hr < 1yr, 20 units/kg/hr >1 yr and 18 unit/kg/hr in older children • Monitoring using APTT (other methods are heparin concentration, anti Factor Xa levels, ACT levels)

  3. LMWH • Longer t ½ • Administered sub-cutaneously • Lower side effects – thrombocytopenia and osteoporosis • Enoxaparin 1.5mg/kg 12h (<2mo) and 1mg/kg 12h (> 2mo) • Reviparin 150units/kg 12h (< 2 mo) and 100 units/kg 12h (> 2 mo)

  4. Warfarin etc • Inhibits Vit K dependent clotting factors • Oral loading dose 0.2mg/kg then adjusted using INR • Various ranges • 2-3 for prophylaxis against TE • 2.5-3.5 for valves • 3-4.5 for recurrent TE at lower range • 1.4-1.9 not tested in kids

  5. Aspirin • Decreases Platelet aggregation Aspirin+cyclo-oxygenase = TXA2 • Effect lasts for 7-10 days • 3-5mg/kg/day

  6. Dipyridamole • Inhibits phospho-diesterase cAMP • 2-5mg/kg/day • Adjunct therapy in patients with mechanical valves

  7. Pentoxiphylline • Enhances RBC flexibility, blood viscosity, platelet aggregation, TNFα • 20mg/kg/day • Used in • PVD with marginal improvement in PBF • Kawasaki

  8. Glenn and Fontan • Use of prosthetic material • Presence of fenestration and R-L shunting • Incidence of TE events 5-33% (retrospective, TTE) • One partially prospective study showed TEE to be superior to TTE and showed an incidence of thrombus formation in 33% of patients.

  9. Coagulopathies in Fontan • Liver derangements • Protein C, antithrombin III, Protein S, Plasminogen, Factors II, VII, IX, X, XIII • Factor VIII, plasmin-antiplasmin complex, activated partial thromboplastin time, thrombin- antithrombin III complex, D-dimer, Gamma GT, SGOT/PT

  10. Risk factors for development of thrombus • Low post op saturations • Large fenestration • Discordant sized bilateral SVC • Atrial dysrhythmia

  11. Various strategies No aspirin or warfarin Lifelong Warfarin Lifelong aspirin Warfarin for 3mo, 6 mo, 1 yr followed by aspirin 3-6 mo aspirin

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