Management of urgent high-risk cardiopulmonary bypass in patients with heparin-induced thrombocytopenia type II and coexisting disorders of renal function: Use of heparin and epoprostenol combined with on-line monitoring of platelet function

Abstract

HEPARIN-INDUCED THROMBOCYTOPENIA TYPE II (HIT II) is an immunologic life-threatening condition that causes stroke, myocardial or mesenteric infarction, or thromboembolism in the lungs or extremities. 1 Shorten GD Comunale ME Heparin-induced thrombocytopenia. J Cardiothorac Vasc Anesth. 1996; 10: 521-530 Abstract Full Text PDF PubMed Scopus (36) Google Scholar , 2 Slaughter TF Greenberg CS Heparin-associated thrombocytopenia and thrombosis: Implications for perioperative management. Anesthesiology. 1997; 87: 667-675 Crossref PubMed Scopus (46) Google Scholar , 3 Bauer TL Arepaly G Konkele BA Prevalence of heparin-associated antibodies without thrombosis in patients undergoing cardiopulmonary bypass surgery. Circulation. 1997; 95: 1242-1246 Crossref PubMed Scopus (284) Google Scholar It is prudent that heparin not be administered in any form whenever possible. This recommendation poses a problem in patients being prepared for cardiopulmonary bypass (CPB). Suitable alternatives for heparin-free anticoagulation include defibrinogenation (ancrod); the synthetic heparinoid, orgaran; or the antithrombin, hirudin. 4 Koster A Kuppe H Hetzer R et al. Emergent cardiopulmonary bypass in five patients with heparin-induced thrombocytopenia type II employing recombinant hirudin. Anesthesiology. 1998; 89: 777-780 Crossref PubMed Scopus (68) Google Scholar , 5 Koster A Kuppe H Mertzlufft F Cardiopulmonary bypass with recombinant hirudin in patients with heparin-induced thrombocytopenia type II: A synopsis of 19 cases. Br J Anaesth. 1999; 82: A116 Google Scholar Recombinant hirudin (r-hirudin) has gained a pivotal role because of relevant advantages 4 Koster A Kuppe H Hetzer R et al. Emergent cardiopulmonary bypass in five patients with heparin-induced thrombocytopenia type II employing recombinant hirudin. Anesthesiology. 1998; 89: 777-780 Crossref PubMed Scopus (68) Google Scholar , 5 Koster A Kuppe H Mertzlufft F Cardiopulmonary bypass with recombinant hirudin in patients with heparin-induced thrombocytopenia type II: A synopsis of 19 cases. Br J Anaesth. 1999; 82: A116 Google Scholar , 6 Greinacher A Völpel H Janssens U et al. Recombinant hirudin (lepirudin) provides safe and effective anticoagulation in patients with heparin-induced thrombocytopenia: A prospective study. Circulation. 1999; 99: 73-80 Crossref PubMed Scopus (505) Google Scholar (eg, rapid onset, short half-life, and availability of reliable on-line monitoring). If, however, urgent CPB is required in patients with coexisting renal impairment, r-hirudin (as well as the other options) may involve considerable disadvantages, 4 Koster A Kuppe H Hetzer R et al. Emergent cardiopulmonary bypass in five patients with heparin-induced thrombocytopenia type II employing recombinant hirudin. Anesthesiology. 1998; 89: 777-780 Crossref PubMed Scopus (68) Google Scholar , 5 Koster A Kuppe H Mertzlufft F Cardiopulmonary bypass with recombinant hirudin in patients with heparin-induced thrombocytopenia type II: A synopsis of 19 cases. Br J Anaesth. 1999; 82: A116 Google Scholar which include the lack of an antidote 4 Koster A Kuppe H Hetzer R et al. Emergent cardiopulmonary bypass in five patients with heparin-induced thrombocytopenia type II employing recombinant hirudin. Anesthesiology. 1998; 89: 777-780 Crossref PubMed Scopus (68) Google Scholar , 6 Greinacher A Völpel H Janssens U et al. Recombinant hirudin (lepirudin) provides safe and effective anticoagulation in patients with heparin-induced thrombocytopenia: A prospective study. Circulation. 1999; 99: 73-80 Crossref PubMed Scopus (505) Google Scholar and a prolonged pharmacologic effect resulting from sustained renal elimination. 5 Koster A Kuppe H Mertzlufft F Cardiopulmonary bypass with recombinant hirudin in patients with heparin-induced thrombocytopenia type II: A synopsis of 19 cases. Br J Anaesth. 1999; 82: A116 Google Scholar