Instructions for use: Ikus - Berlin Heart

Anticoagulation therapy in young persons and adults
Changes:
• The chapter has been revised and supplemented.
9 Intensive care and post-operative care
9.1 Postoperative anticoagulation therapy
Start of therapy
No anticoagulants administered during first 24 hours postoperatively.
After approx. 24 hours, start i.v. administration of unfractionated heparin (UFH),
subject to platelet count (>80,000/µl) and the results of thrombelastography.
Oral anticoagulation
INR 3.0 - 3.5 Vitamin K antagonist, p.o.
INR 2.0 - 2.5 LMWH (e. g. enoxaparin) 1.0 mg/kg/ d - prophylactic doses
INR < 2.0 LMWH 1.0 mg/kg/ 2xd - therapeutic dose or UFH i. v.
9.2 Postoperative platelet aggregation inhibition therapy
Start of therapy
• not earlier than days 2-4 postoperatively
• if platelet count >100,000/µl
Monitoring frequency
• daily - until sufficient platelet inhibition is achieved
• weekly - until discharge
• monthly - after discharge
• after each dose adjustment
Platelet adhesion inhibition
2nd postoperative day - dipyridamol 150 mg/d to 1 g/d and ADP inhibition > 50%.
Platelet aggregation inhibition
4th postoperative day, drains removed and if activation by AA > 30% - start with ASA
50 mg/d and, if necessary, titration to 325 mg/d up to AA inhibition > 70% (AA =
arachidonic acid). If drains are still in on POD 7 and activation by AA > 30%: start
with ASA as described above.
In the event of aspirin resistance or thrombogenesis in the pumps, despite sufficient
anti-aggregation, clopidogrel 75 mg/d is sometimes administered
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