Heparin Administration Research Articles

Antibody Response to the Coronavirus Disease 2019 Ad26.COV2.S Vaccine Among Maintenance Dialysis Patients

Antibody Response to the Coronavirus Disease 2019 Ad26.COV2.S Vaccine Among Maintenance Dialysis Patients

Heparin, Enoxaparin, and Mechanical Prophylaxis Utilization Evaluation in DVT Prophylaxis in a Major Teaching Hospital in West of Iran

Background: Considering the high prevalence and risk of Deep Vein Thrombosis (DVT) and pulmonary thromboembolism (PTE) in hospitalized patients and the existence of different prophylaxis methods in these patients, the necessity of evaluating the rational administration of heparin or enoxaparin and mechanical prophylaxis is one of the important priorities. The present study aimed to evaluate the consistency of the Heparin/Enoxaparin administration in comparison to guidelines in patients admitted to Imam Reza Hospital. Methods: In this prospective study drug use evaluation (DUE), 300 hospitalized patients receiving venous thrombosis prophylaxis were enrolled, of which 150 patients were selected from surgical wards and 150 patients from internal wards. The demographic and clinical data of patients were collected using clinical records of them. We used the checklists based on the Geneva System for patients admitted to internal wards and the Caprini Questionnaire for patients in surgical wards to evaluate whether patients had received heparin/enoxaparin prophylaxis and mechanical DVT prevention according to guidelines. Results: In the surgical ward, prophylactic treatment for venous thrombosis was administered in 85 (56.6%) patients admitted to surgical wards in accordance with the clinical guideline and in the internal ward, in 42 (28%) patients, with a significant difference between two sections (P: 0.0001). Mechanical prophylaxis, including compressive socks, was performed in 99 (66%) patients in the surgical ward and in the internal ward only in 56 (37.4%) patients, according to the guideline. Drug prophylaxis was administered in surgical wards in 116 (77.3%) patients and in internal wards, in 79 (52.6%) patients according to the guideline. Conclusion: Intravenous thrombosis prophylaxis, according to the guidelines, is more common in patients admitted to surgical wards than in internal wards. But in both sectors, statistics are far from international standards.

Effect of Therapeutically Related Drugs on Coagulation-Anticoagulation Balance in Acute Promyelocytic Leukemia.

Acute promyelocytic leukemia (APL) usually presents with a series of coagulation-anticoagulation disturbance. Early administration of All-trans retinoic acid (ATRA) can reduce the risk of bleeding, but the potential for thrombosis needs to be addressed in some cases. The role of arsenic agent in correcting coagulation disorder remains to be studied, but oral arsenic agent shows potential advantages in coagulation recovery compared with intravenous agent, and chemotherapy can aggravate the progress of coagulation disease. In addition to early application of ATRA, avoiding invasive procedures and transfusion support can reduce the risk of bleeding. Whether the administration of heparin, thrombomodulin, recombinant factor VIIa or antifibrinolytics reduces the risk of bleeding and thrombosis associated with APL remains to be further explored, and their routine use outside of clinical trials is not recommended. This article reviews the effects of related drugs on coagulation-anticoagulation balance in APL patients.

Early prophylactic anticoagulation with heparin alleviates mortality in critically ill patients with sepsis: a retrospective analysis from the MIMIC-IV database.

BackgroundMinimal data exist on anticoagulation use and timing and the dose of heparin in patients with sepsis, and whether heparin use improves sepsis survival remains largely unclear. This study was performed to assess whether heparin administration would provide a survival advantage in critically ill patients with sepsis.MethodsA retrospective cohort study of patients with sepsis in the Medical Information Mart for Intensive Care (MIMIC)-IV database was conducted. Cox proportional hazards model and propensity score matching (PSM) were used to evaluate the outcomes of prophylactic anticoagulation with heparin administered by subcutaneous injection within 48 h of intensive care unit (ICU) admission. The primary outcome was in-hospital mortality. Secondary outcomes included 60-day mortality, length of ICU stay, length of hospital stay and incidence of acute kidney injury (AKI) on day 7. E-Value analysis were used for unmeasured confounding.ResultsA total of 6646 adult septic patients were included and divided into an early prophylactic heparin group (n = 3211) and a nonheparin group (n = 3435). In-hospital mortality in the heparin therapy group was significantly lower than that in the nonheparin group (prematched 14.7 vs 20.0%, hazard ratio (HR) 0.77, 95% confidence interval (CI) [0.68–0.87], p < 0.001, and postmatched 14.9 vs 18.3%, HR 0.78, 95% CI [0.68–0.89], p < 0.001). Secondary endpoints, including 60-day mortality and length of ICU stay, differed between the heparin and nonheparin groups (p < 0.01). Early prophylactic heparin administration was associated with in-hospital mortality among septic patients in different adjusted covariates (HR 0.71–0.78, p < 0.001), and only administration of five doses of heparin was associated with decreased in-hospital mortality after PSM (HR 0.70, 95% CI 0.56–0.87, p < 0.001). Subgroup analysis showed that heparin use was significantly associated with reduced in-hospital mortality in patients with sepsis-induced coagulopathy, septic shock, sequential organ failure assessment score ≥ 10, AKI, mechanical ventilation, gram-positive bacterial infection and gram-negative bacterial infection, with HRs of 0.74, 0.70, 0.58, 0.74, 0.73, 0.64 and 0.72, respectively (p <0.001). E-Value analysis suggested robustness to unmeasured confounding.ConclusionsThis study found an association between early administration prophylactic heparin provided to patients with sepsis and reduced risk-adjusted mortality. A prospective randomized-controlled study should be designed to further assess the relevant findings.

Improvement in Care and Maintenance of Port-A-Cath Following the Introduction of Care" Bundle.

Port-a-cath is a type of indwelling central venous catheter used to manage pediatric patients who require long-term intravenous therapy. The objective of this study was to improve the care and maintenance of port-a-cath among the nursing staff by introducing a care bundle. Pretraining and posttraining designs using PDSA (Plan, Do, Study, Act.) model were followed. We observed two sets of 30 procedures for accessing of port-a-cath by the nursing staff. Following the initial 30 observations of port-a-cath handling, a "care bundle" was designed as per the set standards of the maintenance of port-a-cath. It involved education and training and live audio-visual sessions. Two months after the initiation of the care bundle, the second set of 30 procedures was observed. Following the introduction of the care bundle, the observed efficacy on obtaining verbal consent improved to 100% from 83%, arrangement of drugs and instruments before insertion to 100% from 90%, not touching the needle while inserting from 60%, administration of adequate amount saline flush from 83.3% (25/30), heparin administration from 71.1%, and looking out for signs of extravasation to 100% from 80%. Two nursing staff involvement improved from 23% to 63%. A 100% efficacy in the management of nonbleeding back scenarios was observed. The cross-checking of drug expiry improved from an initial 26.6% to 89.3%. The port-a-cath infections have significantly come down (3 vs. 0) (P < 0.05). Implementation of a "care bundle" has significantly improved the quality of handling of port-a-cath and reduction in infections.

Thromboinflammation in Sepsis and Heparin: A Review of Literature and Pathophysiology.

Thromboinflammation is the pathophysiologic mechanism in which coagulation and inflammation interact and complement each other. It is observed in a number of degenerative diseases, one of them being sepsis. Quiescent endothelial cells exert antithrombotic and anti-inflammatory actions that are reduced during sepsis. The concomitant effect of the subsequent dysregulation of coagulation and complement actuation is platelet activation and aggregation, and leukocyte recruitment, with detrimental effects on the vascular endothelium. Tissue factor and α-thrombin are major sentinels in the pathogenesis of this process. This literature review aimed to cover the basic principles of the mechanisms implicated in thromboinflammation occurring during sepsis and also investigates the role of heparin as a possible therapeutic agent, since it exhibits both anticoagulant and anti-inflammatory functions. PubMed, SCOPUS and ScienceDirect databases were used for search of literature from inception to April 2022. To be included in our review, studies had to refer to the pathophysiologic mechanisms leading to coincident coagulation and inflammation, or to the administration of heparin either for treatment or prophylaxis, both in the context of sepsis. A total of 276 articles were drawn from the initial literature search. 124 were duplicated and out of the remaining 152 articles, 29 met our inclusion criteria and were reviewed. Clinical trials among sepsis patients have indicated that the thromboinflammatory process is more complex than believed, as adverse bleeding events continue to occur despite the use of anticoagulants with different pharmacodynamics. However, heparin has a pleiotropic effect that might provide protection against sepsis and related complications and merits further research.

Heparin and SARS-CoV-2: Multiple Pathophysiological Links.

Low molecular weight heparin, enoxaparin, has been one of most used drugs to fight the SARS-CoV-2 pandemic. Pharmacological properties of heparin recognize its specific ability, as with other oligosaccharides and glycosaminoglycan, to bind several types of viruses during their pass through the extracellular matrix of the respiratory tract, as well as its anticoagulant activity to prevent venous thromboembolism. Antithrombotic actions of enoxaparin have been testified both for inpatients with COVID-19 in regular ward and for inpatients in Intensive Care Units (ICUs). Prophylactic doses seem to be able to prevent venous thromboembolism (VTE) in inpatients in the regular ward, while intermediate or therapeutic doses have been frequently adopted for inpatients with COVID-19 in ICU. On the other hand, although we reported several useful actions of heparin for inpatients with COVID-19, an increased rate of bleeding has been recorded, and it may be related to several conditions such as underlying diseases with increased risks of bleeding, increased doses or prolonged administration of heparin, personal trend to bleed, and so on.

Effect of Anticoagulants on the Survival Rate in Critically Ill COVID-19 Patients

Background: The World Health Organization (WHO) declared Coronavirus disease 2019 (COVID-19), as a pandemic in January 2020. The morbidity and mortality associated with the disease are enormous COVID-19, with a multi-systemic pathology, exhibits thrombosis as a common manifestation. Disseminated intravascular coagulation (DIC) and thrombotic lesions have been reported in &gt;70% and &gt;30% of patients, respectively, who have died due to the COVID-19 and therefore, heparin is included in the treatment of moderate to severe cases. This retrospective study was undertaken to check the effectiveness of prophylactic therapy with heparin at reducing mortality in critically ill COVID-19 patients.&#x0D; Methodology: The study included retrospective data from case records of 169 critically ill COVID-19 patients with or without comorbidities and an anticoagulant regimen. The data were thoroughly studied for demographic profile, comorbidities, type and dosage of anticoagulants, length of intensive care unit stay, and mortality rates.&#x0D; Results: The male to female ratio of the study subjects was 125/44 (76%/24%). Patients with comorbidities were critically ill as compared to those with none (140/29), and diabetes mellitus was the most common comorbidity, found in 99 patients. Mortality rate was significantly higher in patients who had not received any anticoagulant (p = 0.015) and in patients who had received unfractionated heparin (p =0.036) as compared to those who received low molecular weight heparin (LMWH).&#x0D; Conclusion: The prophylactic administration of heparin improves the survival rate of the critically ill covid 19 patients is more when compared with the patients who do not receive heparin. LMWH is very effective in reducing thrombotic complications and mortality in critically ill COVID-19 patients.

Heparin-Induced Thrombocytopenia under Mechanical Circulatory Support by Large Impella for Acute Cardiogenic Shock.

Despite the critical feature of heparin-induced thrombocytopenia (HIT) for patients on mechanical circulatory support, reports on its incidence and outcome are still scarce. Thus, we report on clinical features of HIT in patients under Impella 5.0 or 5.5 (Abiomed Inc., Danvers, MA, USA) (Impella 5+) support for acute cardiogenic shock (CS) by focusing on observed thrombotic events. Between November 2018 and December 2020, a total of 56 consecutive patients were enrolled in a single-center retrospective study. A total of 21 patients (37.5%) were tested for HIT, and 6 (10.7%) proved positive for HIT at 10.5 ± 2.89 days after the first heparin administration during current admission. Interestingly, thrombocyte counts dropped under Impella support in all groups (all cases, no HIT test, and HIT negative group: p < 0.001, HIT-positive group: p = 0.001). All HIT-positive patients were switched from heparin to argatroban. HIT-associated thrombotic events were observed in two cases resulting in Impella dysfunction due to pump thrombosis (n = 1) and left ventricular (LV) thrombus formation (n = 1). Under large Impella support, the prevalence of HIT was relatively high. Further, thrombocytopenia does not deliver a high specificity in the setting of Impella 5+ support. Considering HIT manifestation, a routine HIT test may be considered to avoid critical thrombotic adverse events.

Antemortem Heparin in Organ Donation After Circulatory Death Determination: A Systematic Review of the Literature.

Donation after circulatory death determination frequently involves antemortem heparin administration to mitigate peri-arrest microvascular thrombosis. We systematically reviewed the literature to: (1) describe heparin administration practices and (2) explore the effects on transplant outcomes. We searched MEDLINE and EMBASE for studies reporting donation after circulatory death determination heparin practices including use, dosage, and timing (objective 1). To explore associations between antemortem heparin and transplant outcomes (objective 2), we (1) summarized within-study comparisons and (2) used meta-regression analyses to examine associations between proportions of donors that received heparin and transplant outcomes. We assessed risk of bias using the Newcastle Ottawa Scale and applied the GRADE methodology to determine certainty in the evidence. For objective 1, among 55 eligible studies, 48 reported heparin administration to at least some donors (range: 15.8%-100%) at variable doses (up to 1000 units/kg) and times relative to withdrawal of life-sustaining therapy. For objective 2, 7 studies that directly compared liver transplants with and without antemortem heparin reported lower rates of primary nonfunction, hepatic artery thrombosis, graft failure at 5 y, or recipient mortality (low certainty of evidence). In contrast, meta-regression analysis of 32 liver transplant studies detected no associations between the proportion of donors that received heparin and rates of early allograft dysfunction, primary nonfunction, hepatic artery thrombosis, biliary ischemia, graft failure, retransplantation, or patient survival (very low certainty of evidence). In conclusion, antemortem heparin practices vary substantially with an uncertain effect on transplant outcomes. Given the controversies surrounding antemortem heparin, clinical trials may be warranted.

Comments on "Regulations and Procurement Surgery in DCD Liver Transplantation: Expert Consensus Guidance From the International Liver Transplantation Society".

To the Editor: We read with great interest the article by Hessheimer et al titled “Regulations and Procurement Surgery in DCD Liver Transplantation: Expert Consensus Guidance From the International Liver Transplantation Society.”1 The authors summarize relevant literature and provide guidelines for donation after circulatory death (DCD) liver transplant procurement on behalf of the International Liver Transplantation Society (ILTS). Our research group recently emphasized the variations in DCD organ procurement policies in the United States with a national organ procurement organization (OPO) survey.2 We discovered tremendous disparities across regions that frequently diverged from American Society for Transplant Surgeons (ASTS) recommendations for DCD procurement and the latest consensus in the literature. It is paramount to optimize graft utilization and outcomes to meet the high demand for transplantable organs and growing waitlist. We commend the authors for their important contributions. We highlight the role of asystolic wait time in DCD liver procurement that was not addressed in the work and provide observations on DCD liver transplant (LT) and machine perfusion (MP) from the United States. Our OPO survey underscored the variations in the mandatory asystolic observation period. Despite current ASTS recommendation of a 2-min waiting time, there is little standardization across institutions that vary between 2 and 5 min. Similarly, other publications have demonstrated the lack of standardization in the declaration of circulatory death.3 Additional guidance by the ILTS on these topics would optimize DCD liver procurement process to further reduce warm ischemic times and ultimately improve patient outcomes. Currently, 11 high-volume transplant centers perform nearly half (46.3%) of all DCD LT in the United States.4 However, recent changes to the allocation policies will result in wider sharing of DCD organs and increase distribution to lower volume centers. This will undoubtedly place greater emphasis on procedures to maintain outcomes, such as broader use of hypothermic machine perfusion and normothermic machine perfusion in LT. Machine perfusion with LT has shown promising results in the United States. One investigation discovered no difference in patient survival in ex vivo MP despite substantially longer CIT.5 MP has the potential to significantly improve DCD liver procurement and reduce discard rates. In 2019 alone, 1945 potential DCD livers were not transplanted including 306 grafts, which were discarded after recovery. The trend of increasing DCD LT in the United States has been accompanied with 30% discard rate compared with 7.1% for DBD LT.5 Furthermore, one center reported that only 47.9% of DCD liver offers resulted in a successful procurement, compared with 92.3% for DBD.6 Nasralla et al demonstrated 50% reduction in graft injury, discard, and postreperfusion injury rates in an normothermic machine perfusion clinical trial.7 A publication by the Groningen group on dual hypothermic oxygenated MP highlighted lower rates of nonanastomotic biliary strictures, postreperfusion syndrome, and early graft dysfunction compared with static cold storage in DCD LT.8 MP could remarkably impact the American LT waitlist by increasing potential DCD livers that are transplanted. We congratulate Hessheimer et al on their valuable contributions. We are pleased to see the growing support for procurement procedures such as withdrawal of life support treatment in the operating room and premortem heparin administration. Despite strong surgeon preference for both of these, our survey revealed that 26 OPO did not have specific regulations on the location of withdrawal of life support treatment and 3 OPO prohibited heparin use.2,3 We hope that the ILTS recommendations lead to updates in DCD procurement protocol and regulations to comply with the latest evidence in the literature. We hope to see more analyses of liver perfusion solutions and the various additives. We anticipate similar best practice guidance by the ASTS for normothermic and hypothermic regional perfusion in liver transplantation in the near future. Reduction in variable DCD liver recovery will be tremendously impactful in increasing the utilization of DCD livers and reducing graft discard rates.

C47. Heparin Induced Thrombocytopenia (HIT) Associated with Multiple Deep Vein Thrombosis (DVT) and Intracardiac Thrombus Who Underwent Vena Cava Filter Prior to Surgical Thrombus Evacuation : a Case Report

Abstract Background Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction that increases patient’s risk of developing venous or arterial thromboembolism, which maybe life-threatening. The frequency varies from 0.5% to 5%, depending on population studies. This condition will worsen especially in patients with deep vein thrombosis. Case A 52 years old woman was reported swelling and decreased saturation of the lower extremities, with a history of Heparin therapy for 5 days before being referred to Haji Adam Malik Hospital Medan. Platelet count on admission day was 225.000/µl but dropped into 64.000/µl in the 7th post heparin treatment day. Doppler examination showed multiple thrombosis in deep femoral vein and and sign of stenosis peripheral artery. Echocardiography showed intracardiac thrombus without sign of acute pulmonary embolism. Two days after discontinuation of heparin, the platelet still tend to be low but in the next days, its count increases to within normal range. Due to the high risk of embolism, it was decided to place a vena cava filter prior to surgery for thrombus evacuation. Discussion This case demonstrates several interesting aspects of HIT, including thrombotic complication, limitation tools to support diagnosis of HIT, how to prepare this patient into surgical management, and the last is placing a IVCF prior to surgical thrombus evacuation and thrombectomy to reduce the risk of thromboemboli before surgical treatment. This is the first time procedure in Medan for placing a vena cava filter in a DVT patients who have contraindication to heparin administration.

C47. Heparin Induced Thrombocytopenia (HIT) Associated with Multiple Deep Vein Thrombosis (DVT) and Intracardiac Thrombus Who Underwent Vena Cava Filter Prior to Surgical Thrombus Evacuation : a Case Report

Abstract Background Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction that increases patient’s risk of developing venous or arterial thromboembolism, which maybe life-threatening. The frequency varies from 0.5% to 5%, depending on population studies. This condition will worsen especially in patients with deep vein thrombosis. Case A 52 years old woman was reported swelling and decreased saturation of the lower extremities, with a history of Heparin therapy for 5 days before being referred to Haji Adam Malik Hospital Medan. Platelet count on admission day was 225.000/µl but dropped into 64.000/µl in the 7th post heparin treatment day. Doppler examination showed multiple thrombosis in deep femoral vein and and sign of stenosis peripheral artery. Echocardiography showed intracardiac thrombus without sign of acute pulmonary embolism. Two days after discontinuation of heparin, the platelet still tend to be low but in the next days, its count increases to within normal range. Due to the high risk of embolism, it was decided to place a vena cava filter prior to surgery for thrombus evacuation. Discussion This case demonstrates several interesting aspects of HIT, including thrombotic complication, limitation tools to support diagnosis of HIT, how to prepare this patient into surgical management, and the last is placing a IVCF prior to surgical thrombus evacuation and thrombectomy to reduce the risk of thromboemboli before surgical treatment. This is the first time procedure in Medan for placing a vena cava filter in a DVT patients who have contraindication to heparin administration.

Effect of Systemic Intraoperative Heparin Use on Upper Extremity Arteriovenous Fistula Patency in End-Stage Renal Disease Patients.

The formation of the arteriovenous fistula is an important method of vascular access for patients with end-stage renal disease (ESRD). This allows renal filtration resulting in improved life quality and expectancy for ESRD patients. The biggest drawback to arteriovenous fistula formation is thrombosis, which can occur at an early or delayed stage. One suggested method of reducing postoperative arteriovenous fistula thrombosis rates is the administration of intraoperative systemic heparin. Heparin use in this context is debated, and there is currently no consensus on its use. There are a number of small randomised control studies trialling use of heparin but no large systematic trials. In this report, we collate existing evidence in the form of a review article and attempt to extrapolate a consensus of the evidence.

Results of early administration of low molecular weight heparin for prevention of venous thromboembolism after removal of brain tumors

Introduction. Patients with brain tumors are at increased risk for the development of venous thromboembolism (VTE). The most effective prevention method today is a combination of mechanical compression of the lower extremities and the introduction of low molecular weight heparin (LMWH). In 2018, an algorithm for the prevention of VTE was introduced in our clinic, which implies the early (in the first 48 h after surgery) administration of LMWH.The study objective is to assess the effect of early LMWH administration on the incidence of intracranial hemorrhage (ICH) after removal of brain tumors.Materials and methods. From January 2014 to December 2019, 3266 patients underwent removal of brain tumors. The group 1 included 2057 patients who were treated in the period before the introduction of the VTE prevention algorithm (2014– 2017), the group 2 included 1209 patients who were treated using this algorithm (2018–2019). In each of the groups, the frequency and timing of ICH were assessed. The severity of complications was assessed according to the F.A.L. Ibanez classification. The data were compared between groups 1 and 2, as well as between patients who received LMWH at the time of ICH and those who did not receive.Results. Patients of the group 1 were prescribed LMWH in 14.3 % of cases, on average on the 4th day after surgery. In this group, 26 (1.26 %) patients developed ICH. Patients of the group 2 were prescribed LMWH in 89 % of cases, on average on the 2nd day. In this group, 15 (1.24 %) patients developed ICH. Severe complications were in 6 (85.7 %) of 7 patients who received LMWH at the time of ICH, and in 25 (73.5 %) of 34 patients who did not receive LMWH (p = 0.66).Conclusion. The widespread use of LMWH for the prevention of VTE during the first 48 h after removal of brain tumors did not lead to an increase in the frequency of ICH. At the same time, patients with ICH who developed during the use of LMWH often had a more severe clinical course.

Nursing Skill and Responsibility in Administration of Low Molecular Weight Heparin by Prefilled Syringe

Abstract: Low-molecular-weight heparins (LMWHs) have proven to be effective in the prevention and treatment of thrombotic disorders, as well as substitute for unfractionated heparin (UFH). LMWHs are a diverse collection of medicines with different biochemical and pharmacological characteristics, despite the fact that they all have antithrombotic actions. Medicine is administered into the subcutaneous tissues with these injections. Small amounts of injections are delivered by the subcutaneous approach, which involves inserting a small thin needle beneath the skin and slowly injecting the medicine. Low molecular weight heparins make up dalteparin and enoxaparin, two anticoagulants. The rights of medicine administration must be followed by nurses. For patients on LMWH medication, the most essential blood test is prothrombin time. Following administration, look for any signs of bleeding, such as occult blood in the stool, malena, bleeding gums, and skin discoloration/hematoma. The antidote for low molecular weight heparin is protamine sulphate. It is effective at counteracting the effects of LMWH. 100 units of LMWH are neutralised by 1 mg of protamine sulphate.If it's been more than 8 hours since you've given LMWH, provide 0.5 mg protamin per 100 units of LMWH.

Heparinized swine models for better surgical/endoscopic training.

IntroductionAnimal experiments with large living animals are essential for the development of medical devices and the training of surgical procedures. Swine are frequently used in animal experiments due to their similar size and anatomy compared to humans. However, it is well known that swine has less local bleeding than humans. The aim of the study was to verify whether animal models with appropriate local bleeding capability could be established.MethodsThe activated clotting time (ACT) was measured for eight swine (piglet, 35 kg) under general anesthesia. The flexible endoscope was advanced orally, and the gastric mucosa was intentionally traumatized to bleed by biopsy forceps, and the time until spontaneous hemostasis was obtained (mucosal bleeding time). Then, heparin (50 U/kg) was administered intravenously. After 10 min, the ACT was remeasured, and the gastric mucosa was again damaged to bleed by biopsy forceps. The mucosal bleeding time was remeasured. The above measurements were repeated until the ACT exceeded 200 s.ResultsThe median ACT values (seconds) were 83 (no heparin), 155 (50 U/kg heparin), and 204 (100 U/kg heparin), which were significantly increased. The median mucosal bleeding times (seconds) were 152 (no heparin), 283 (50 U/kg), and 423 (100 U/kg), which were significantly extended.ConclusionA bleeding animal model for surgical and endoscopic training was successfully established by bolus heparin administration.

Long-term trends in treatment and outcomes of patients with diabetes and acute coronary syndromes: insights from the nationwide AMIS plus registry

Abstract Background Although impressive advances in the treatment of patients with acute coronary syndromes (ACS) have been achieved over the last decades, morbidity and mortality of patients with diabetes and ACS remain substantial. This study aimed at investigating long-term trends in treatment and outcomes of patients with diabetes and ACS, using data from a large, prospective, nation-wide database. Methods Patients with ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation myocardial infarction (NSTEMI) enrolled in the prospective AMIS Plus registry between 01/2003 and 12/2018 and available data on diabetes diagnosis were included in the analysis. Major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal myocardial infarction, and cerebrovascular events were assessed for each 3-year period. Results Out of 49'413 ACS patients, 10'200 (20.6%) had diabetes (29.4% women). In diabetic patients, the percentage of women decreased from 32.3% in 2002–2004 to 25.9% in 2017–2019 (p&amp;lt;0.001). Diabetic patients were older (p&amp;lt;0.001), more frequently women (p&amp;lt;0.001), and had a higher body mass index (p&amp;lt;0.001). They less often underwent percutaneous coronary intervention (p&amp;lt;0.001) and were more frequently treated by coronary artery bypass grafting (p&amp;lt;0.001). Over the 18-year period, the percentage of diabetic patients undergoing PCI or CABG increased (p&amp;lt;0.001). While treatment with glycoprotein IIb/IIIa inhibitors, low-molecular weight heparin, and beta blockers decreased over time, administration of aspirin, P2Y12 inhibitors, lipid-lowering drugs, and unfractionated heparin increased. Rates of MACE were 9.5% and 5.2% in diabetic and non-diabetic patients (p&amp;lt;0.001). Rates of mortality (7.7% versus 4.1%, p&amp;lt;0.001), recurrent myocardial infarction (1.5% versus 0.9%, p&amp;lt;0.001), and cerebrovascular events (1.2% versus 0.6%, p&amp;lt;0.001) were higher in diabetic as compared with non-diabetic patients, with highest rates of MACE, mortality, and myocardial infarction observed in diabetic women. Rates of MACE decreased from 11.8% in 2002–2004 to 7.5% in 2017–2019 in diabetic patients (p for trend &amp;lt;0.001). While rates of mortality (9.4% to 5.9%, p for trend =0.001) and rates of recurrent myocardial infarction (3.4% to 0.9%, p for trend &amp;lt;0.001) decreased over time, rates of cerebrovascular events remained stable (p for trend =0.34). Trends were the same in diabetic women and men. Conclusions Rates of MACE significantly decreased over the 18-year period in both diabetic women and men, with highest rates observed in diabetic women. Despite the observed improvements, rates of MACE remained 50% higher in diabetic as compared with non-diabetic patients. These findings emphasize that advanced strategies particularly targeting the vulnerable high-risk diabetic patient population are warranted to further improve quality of care in ACS. Funding Acknowledgement Type of funding sources: None.

Thromboprophylaxis in hospitalized COVID-19 patients: the efficacy and safety of the approved hospital protocol.

Introduction: Prothrombotic coagulopathy in COVID-19 has led to a strong recommendation for thromboprophylaxis in all hospitalized patients, although there are large differences in the dosage regimens among hospitals and their outcomes remain uncertain. Objectives: We aimed to determine the incidence of thrombotic events and bleeding in patients with COVID-19 using the approved local thromboprophylaxis protocol. Patients and methods: We adapted a self-developed pharmacological thromboprophylaxis protocol based on clinical and laboratory risk assessment of thrombosis in 350 consecutive patients (median age, 67 years) with confirmed COVID-19, treated in designated wards at a single center in Kraków, Poland from October 10, 2020, to April 30, 2021. We recorded in-hospital venous and arterial thromboembolic events, major or clinically relevant bleeding, and deaths along with other complications related to heparin administration. Results: Thromboprophylaxis with low-molecular-weight heparin was administered in 99.7% of patients, 57 (16%) were treated in the intensive care unit. As many as 92% of patients followed the protocol for more than 85% of hospitalization time. Thromboembolic events occurred in 16 patients (4.4%): venous thromboembolism (n = 4; 1.1%), ischemic stroke (n = 4; 1.1%), and myocardial infarction (n = 8; 2.2%). Hemorrhagic complications were observed in 31 patients (9%), including fatal bleeds (n = 3; 0.9%). The overall mortality was 13.4%. The prophylactic, intermediate, and therapeutic anticoagulation preventive strategies with heparin were not related to any of the outcomes. Conclusions: The thromboprophylaxis protocol approved in our institution was associated with a relatively low risk of thromboembolism and bleeding, which provides additional evidence supporting the adoption of institutional strategies to improve outcomes in hospitalized patients with COVID-19.

Morphological Assessment Of Wounds Healing In The Region Of Anal Canal In Rats On The Background Of Medicamental Hypocoagulation

Purpose of the study: to conduct a morphological study of experimental material to assess the features of wound healing in the anal sphincter area when using the domestic drug “Heprocel” as a hemostatic agent. Material and methods. The study was carried out in the Department of experimental surgery and the department of pathological anatomy of the Republican Specialized Scientific and Practical Medical Center for Surgery named after Academician V. Vakhidov. The state of experimental models of wounds with the application of a hemostatic agent in the form of a gel was studied. The experiments were carried out on 72 white male rats weighing 210-250 g. Two series of 36 animals each were produced. All animals were divided into groups: norm - experiment in the absence of drug hypocoagulation; control - an experiment with intravenous heparin to achieve drug hypocoagulation; experience - an experiment with intravenous administration of heparin to achieve drug hypocoagulation using an application on a model of a skin wound and a dissected anal sphincter of the hemostatic agent "Heprocel". Results. Morphological differences in the process of wound healing were most pronounced after 3 days of the study. In the control group of animals with hemostasis using an electrocoagulator, necrotic and exudative processes of inflammation in the stratified squamous epithelium and mucous membrane of the glands in the anal region were evident. In the experimental group, on the 3-5th day of the experiment, the proliferative process of inflammation predominated morphologically. A special feature is that the hemostatic gel is absorbed into the wound, forming a thin uniform layer. On the 10th day of the experiment, the above difference became more obvious. In the control group, chaotic squamous epithelial cells and fibroblasts were formed. The fibrin-necrotic layer is preserved. Focal infiltration of macrophages-lymphocytes was observed. In the experimental group, the intestinal layers began to change. In the area of the surgical incision, the hemostatic layer is preserved; in this area, the growth of thin fibrous connective tissue is observed. Differentiation and transformation of cells led to the regeneration of the epithelial layer and parakeratosis of the flat cell. Signs of complete remodeling were evident over a long period of time, such as 14 days. Conclusion. The use of a hemostatic agent in the form of a gel provides not only an increase in the processes of local hemostasis, but a decrease in the activity of inflammatory reactions and infection, as well as the risk of developing post-traumatic cicatricial deformity of the anus.