Heparin Drip Research Articles

Effect of pre-procedural interrupted apixaban on heparin anticoagulation during catheter ablation for atrial fibrillation: a prospective observational study.

Effective intraprocedural anticoagulation is considered essential to minimize the risk of thromboembolism in catheter ablation (CA) of atrial fibrillation (AF). The effect of interrupted apixaban on intraprocedural heparin dosing requirements and levels of achieved anticoagulation with heparin has not been well studied. The purpose of the present study was to compare heparin administration and activated clotted times (ACTs) for patients undergoing CA for AF treated with interrupted apixaban before the procedure with patients on uninterrupted warfarin. Consecutive patients undergoing CA for AF treated with interrupted apixaban or uninterrupted warfarin were prospectively enrolled. Heparin administration determined by a standard protocol and normalized to patient weight and procedure duration, as well as rapidity, and degree of anticoagulation with heparin (as measured by mean ACT, peak ACT, time to ACT ≥300 s, and time to ACT ≥350 s) were compared between the groups. Forty-eight patients were enrolled (25 apixaban and 23 warfarin). Heparin administered by bolus (51.3 ± 21.5 vs 27.8 ± 9.6 units/kg/h; p < 0.001) and mean heparin drip rate (25.3 ± 3.6 vs 20.7 ± 2.4 units/kg/h; p < 0.001) were significantly higher in the apixaban group compared to the warfarin group. Despite greater heparin administration, apixaban patients achieved a significantly lower mean ACT (332.3 ± 17.0 vs 384.5 ± 53.9; p < 0.001) and peak ACT (369.5 ± 22.6 vs 432.3 ± 75.8, p < 0.001) compared to the warfarin group. The time to ACT ≥350 s (66.7 ± 35.8 vs 26.9 ± 34.0; p < 0.001) was significantly longer for apixaban-treated patients. Outcome differences persisted after analysis using linear models and Cox proportional hazard regression with adjustment for propensity scores. A standard intraprocedural heparin protocol results in delayed and lower levels of anticoagulation as measured by the ACT for interrupted apixaban-treated patients in comparison to those on uninterrupted warfarin during CA of AF.

Total Pancreatectomy With Islet Cell Transplantation for the Treatment of Pancreatic Cancer.

Resection or removal of the pancreas causes loss of parenchyma, which can result in extreme disruption of glucose homeostasis and malabsorption of dietary nutrients. However, islet autotransplantation (IAT) may reduce or prevent the severity of pancreatogenic diabetes. This article explores total pancreatectomy with IAT within the context of pancreatic cancer treatment. At a Glance • The liver is the preferred site for implantation because of easy vascular access. • Following islet autotransplantation, the liver becomes an insulin-producing organ as the transplanted beta cells begin making insulin. • The most significant complication of implantation in the liver is portal vein occlusion because of thrombosis; consequently, a heparin drip is infused for the first seven days postoperatively to prevent portal vein thrombus formation.

Minor trauma causing stroke in a young athlete.

A 17-year-old Caucasian male presented with sudden dizziness, ataxia, vertigo, and clumsiness lasting for a couple of hours. He had a subtle trauma during a wrestling match 2 days prior to the presentation. A CT Angiogram (CTA) and MRI showed left vertebral artery dissection (VAD). The patient was treated with anticoagulation with heparin drip in the ICU. The patient was discharged home on the third day on Lovenox-warfarin bridging. This case underscores the importance of considering VAD as a differential diagnosis in patients with sports-related symptoms especially in activities entailing hyperextension or hyperrotation of neck. Due to a varied latent period, often minor underlying trauma, and subtle presentation, a low index of suspicion is warranted in timely diagnosis and treatment of VAD. Considering recent evidence in treatment modality, either antiplatelet therapy or anticoagulation may be used for treatment of VAD.

A Single Center Retrospective Analysis of Outcomes Following the Use of 4-Factor Prothrombin Complex Concentrate for Warfarin Reversal in Real-Life Settings

▪IntroductionReversal of vitamin K antagonists (VKA) is required in patients presenting with acute major bleeding or requiring urgent surgery. Recent clinical trials lead to FDA approval of a 4 Factor-PCC (4F-PCC, Kcentra) for urgent VKA reversal. The thromboembolic events (TEE) are most concerning side effects of PCC; these studies showed similar TEE as compared to plasma. However, clinical trials had many exclusion criteria that would not apply in real-life practice. Therefore, we performed a retrospective analysis of real-life patients undergoing urgent VKA reversal with 4F-PCC to evaluate TEE and all-cause mortality.MethodsA retrospective chart review was performed for patients who received 4F-PCC between April 2013 to July 2014 at 3 UT Southwestern hospitals to look for TEE and deaths. Patients were identified from pharmacy and transfusion services information systems. We recorded patients’ demographics, indications for VKA and PCC, and coagulation parameters before and after PCC administration. TEE was defined as any arterial or venous event detected by imaging, elevation in cardiac biomarkers, and clinical documentation.ResultsFifty-two patients (age 27-89, 32 males) received PCC for VKA reversal for acute major bleeding or prior to urgent surgical procedure. Thirty-four (65.4%) patients had acute bleeding and 18 (34.6%) patients required urgent surgery. The median length of hospital stay was 8.5 days. The median time from pre-PCC INR to PCC administration was 2 h and 48 min. The median PCC dose was 33 IU/kg. Median pre-PCC INR was 3.1 (range 1.5-14), post-PCC INR was 1.3 (range 0.9-1.9), and at 24 hours 24h-INR was 1.2 (range 0.9-3.5). Vitamin K was given to 46/52 patients (mean dose 6.5 mg; 30 IV, 9 oral and 3 subcutaneous).There were 2 TEE (3.8%). One occurred in a patient with antiphospholipid antibody syndrome who presented with gastro-intestinal bleed. Exploratory laparotomy on day 2 post-PCC revealed necrotic bowel. Repeat CT abdomen on day 3 showed a new occlusion of an accessory renal artery along with ischemic changes in the liver, spleen and colon. The patient was in septic shock and was made comfort measures; care was withdrawn 4 days post-PCC. This TEE was possibly related to PCC. The second patient had non-ischemic cardiomyopathy and mural thrombus and received 30.4 IU/kg of PCC for an INR of 1.5 prior to a heart transplant. She developed a lower extremity deep vein thrombosis 7 days post-PCC, while she was on heparin drip for intra-aortic balloon pump and thus was unrelated to PCC. Twelve patients died. Six died during the same hospitalization; 3 died within 3 days of PCC administration due to massive subdural hematomas, metastatic pancreatic cancer, and massive retroperitoneal hemorrhage complicated with septic shock and multi-organ failure. The remaining 3 died on post-PCC days 4, 5 and 48 due to septic shock resulting in multi-organ failure, hemorrhagic shock following cardiac surgery, and rejection of heart transplant, respectively. Six patients died following discharge; 4 in hospice care between 11 to 90 days post-PCC, 1 committed suicide at 9 days post-PCC, and 1 patient with multiple comorbidities died at home 3 months post-PCC.ConclusionThis is the first retrospective analysis studying TEE and all-cause mortality following 4F-PCC for warfarin reversal in the real world setting. Our data show that 4F-PCC is safe for warfarin reversal when appropriately administered. Risks and benefits of using 4F-PCC should be addressed, especially in patients with a hypercoagulable state. DisclosuresSarode:CSL Behring: Consultancy.

Abstract 19335: Not Your Typical Atrial Flutter

Case: Mr M. presented to the emergency room with two months of progressive shortness of breath and was found to be in atrial flutter with 2:1 conduction at a rate of 140 bpm. His medical history was significant for tobacco use, etoh abuse, and hypertension. Key objective findings included tachycardia, hypoxia an elevated JVP, bibasilar crackles, a summation gallop, and lower extremity edema. His work up included an echocardiogram that illustrated a globally depressed EF (15-20%) and a large “worm like” mass that was free floating and extended into the RV. Management: A heparin drip was already infusing as the initial plan included cardioversion. Since the patient remained hemodynamically stable and there was no evidence of concurrent deep vein thrombosis, a TEE was performed to fully evaluate the mass and to assess the intra-atrial septum for right to left shunting. The TEE with 3D renderings demonstrated a mobile 0.8 x 10 cm mass most consistent with a thrombus that intermittently prolapses through the tricuspid valve into the RV. CT surgery was consulted and discussed the options of thrombolysis vs surgical thrombectomy. Due to the size and apparent dense organization of the thrombus, surgical thrombectomy was performed. When the right atrium was opened after initiation of bypass, there was no visible clot. The main PA was explored and without evidence of the thrombus. As bypass flow decelerated, the clot proceeded into the RA from the IVC cannula. The attached picture illustrates the thrombus removed from the RA and associated echo images. Discussion: Right atrial or ventricular thrombi in transit in hypoxic patients create a challenging clinical dilemma, as distal embolization may be fatal. In this case we chose to surgically remove the thrombus instead of the more commonly employed thrombolytic therapy. The determining factors included clot organization, relative patient stability, and surgical candidacy.

Inpatient hemodialysis without anticoagulation in adults.

BackgroundAnticoagulation use during hemodialysis (HD) is standard practice but issues related to an increased risk of hemorrhage associated with inpatients make this a concern.MethodsAn anticoagulation-free protocol in which (i) the dialysis circuit is aggressively primed with normal saline (NS) in an attempt to flush it of all air, (ii) blood flow during the HD treatment is maximized to up to 400 mL/min, (iii) the dialysis circuit is flushed every 15 min with 100 mL of NS, and (iv) the use of bloodlines that lack a blood–air interface was developed and used for all adult inpatient HD treatments at Rush University Medical Center. The purpose of this study was to evaluate the rate of HD circuit clotting using this approach and to determine if factors such as access type, blood flow, arterial and venous bloodline pressures, the need for reversing the arterial and venous access lines for low blood flow or high venous or arterial bloodline pressures, or the amount of net ultrafiltration were associated with HD circuit clotting. Patients were excluded from analysis if they were on a heparin drip, clopidogrel, warfarin or direct thrombin inhibitors. We reviewed 400 HD treatments in 400 adult patients from 12/12 to 10/13.ResultsThe HD access in these patients consisted of catheters in 45%, native AV fistulas in 40% and grafts in 15% of the patients. The average blood flow in the treatments was 378 ± 46 mL/min. In 5% of the treatments, the arterial and venous bloodlines were reversed. Only 4 of the 400 (1%) of the treatments clotted the dialysis circuit. Factors associated with clotting were lower achieved blood flows (225 ± 50 mL/min versus 379 ± 44 mL/min), higher arterial bloodline pressures (−198 ± 24 mmHg versus −151 ± 45 mmHg) and reversal of arterial and venous access lines.ConclusionOur anticoagulation-free protocol allows inpatient HD to be performed in adults across all access types and with essentially no circuit clotting.

An Unusual Cause of Headache in Ulcerative Colitis

Introduction: A 21-year-old female with pan-colonic ulcerative colitis (UC) was admitted to our hospital with headache, abdominal pain, bloody diarrhea, and seizures. Two months prior to presentation, she was diagnosed with moderate UC and was initiated on oral and rectal mesalamine. On arrival to the ED, she had a seizure and was treated with anti-epileptics. Initial labs were notable for a WBC count of 24.3, platelets of 530, normal hemoglobin, sodium of 126, albumin of 2, and ESR/CRP of 40/15.5 respectively. A head CT showed left temporal hemorrhage with additional hemorrhage in the region of the sigmoid sinus. A subsequent MRI/MRV revealed thrombus in the left transverse sinus, sigmoid sinus, and jugular veins, as well as the cortical vein of Labbe. The patient was admitted to neurology and started on a heparin drip. The gastroenterology service was consulted for the bloody diarrhea. The patient was supposed to take oral mesalamine, but due to the pill burden, was non-compliant with therapy. A CT scan of abdomen/pelvis demonstrated pan-colitis with backwash terminal ileitis. C. diff and stool cultures were negative. The patient was restarted on oral and rectal mesalamine in addition to high-dose IV steroids. Her bloody diarrhea improved over a few days and she returned to regular, brown, formed bowel movements. The patient made a full neurologic recovery and was discharged on hospital day 9. Patients with IBD have been reported to have a 2- to 4-fold increase in lifetime risk of developing venous thrombosis (VTE). An estimated 1.3-6.4% of adults with IBD will develop cerebrovascular complications at some point in their lifetime. This increased risk can be attributed to factors such as inflammatory activity, hospitalization, medications (particularly steroids), and increased platelet number/activity. CVT almost invariably presents with headache as the major symptom, and approximately one-third of patients can experience generalized tonic-clonic seizures. IBD patients who develop CVT tend to be predominantly female, present at a younger age than the general population, and have active bowel disease at the time of presentation. CVT should be strongly considered in any IBD patient presenting with a new headache. MRI/MRA are the best imaging modalities for diagnosis and for follow-up. Prompt recognition and treatment is imperative in order to prevent mortality and neurologic sequelae. Thrombolytics and heparin are the treatments of choice in the acute period. Warfarin, low molecular weight heparin, and aspirin can be used for long-term prophylactic therapy.

Incidental Aortic Thrombus in a Patient With Crohn’s Disease

Introduction: Thromboembolism is a well-known complication of inflammatory bowel disease (IBD). Patients with IBD are at least 3 times more likely to experience thromboembolism than general population. They are most often venous in origin than arterial with deep venous thrombosis/pulmonary embolism being the most common. A total of 13 cases were reported in literature with aortic mural thrombus. We are presenting a case of Crohn’s disease with incidental aortic thrombus detected on imaging which was done to evaluate disease flare. Case Report: A 34-year-old female with Crohn’s disease for past 10 years came to our hospital with rectal bleeding and abdominal pain for past 1 week. She has been taking IBD medications intermittently when she has flares. Past medical history is significant for pulmonary embolism diagnosed 5 years ago. Vital signs were unremarkable except for mild tachycardia. Exam revealed diffuse mild tenderness in all quadrants with no guarding, rigidity or organomegaly. Rest of the exam was unremarkable including good distal extremity pulses. Lab tests were significant for mild leukocytosis and significant thrombocytosis with platelet count of 1.1 million/dL. CT scan of abdomen and pelvis showed acute exacerbation of Crohn’s disease and incidental detected infra renal aortic thrombus occupying 50% of the lumen. Heparin drip was initiated and patient was monitored in-house for few more days. Decision was made to manage medically as she did not have any vascular compromise and hence discharged on enoxaparin. Complete hypercoagulable work up was sent, which was negative. Patient had repeat imaging 4 weeks later which showed complete resolution of thrombus. Discussion: Several studies have confirmed the fact about IBD being an independent risk factor for thromboembolism. Probable pathogenetic mechanisms include increased pro inflammatory cytokines, circulating immune complexes, and decreased fibrinolysis all of which activate coagulation cascade. Most important risk factors in IBD patients are active disease, post-operative status, and steroid use. Inherited risk factors for thrombosis have same incidence in IBD patients compared to non IBD controls as shown in cohort studies. It is still remains unclear if there is a role for extensive hypercoagulable work up in these patients. Management of aortic thrombus remains controversial due to rarity of this complication. Medical management is preferable due to ease of administration with surgical intervention reserved for patients with end organ ischemia from thrombus embolization. We conclude that clinicians should be aware of this complication in IBD patients as it can cause fatal outcomes.

Evaluation of the activated clotting time and activated partial thromboplastin time for the monitoring of heparin in adult extracorporeal membrane oxygenation patients

Historically, the activated clotting time (ACT) has been the preferred monitoring test of the heparin effect in extracorporeal membrane oxygenation (ECMO) patients. However, few adult studies have evaluated its correlation to the heparin dose or other monitoring tests, such as the activated partial thromboplastin time (aPTT). This retrospective study sought to evaluate the correlation between the heparin dose and these monitoring tests. Patients administered a heparin drip during ECMO were included in this study. The primary endpoints were the correlation between heparin dose and ACT or aPTT and the relationship between paired ACT and aPTT samples. Forty-six patients met the criteria for study inclusion. A better correlation was observed for heparin dose and aPTT (Pearson product-moment correlation coefficient (r) = 0.43 - 0.54) versus ACT (r = 0.11 - 0.14). Among the paired sample data, ACT values did not differ significantly between Groups two (aPTT 60 - 75 seconds) and three (aPTT >75 seconds). The heparin dose correlated better with aPTT relative to ACT and, thus, may be considered a more effective tool for the dosing of heparin in adult ECMO patients. Paired ACT and aPTT sample data suggested a poor relationship between these two anticoagulant monitoring tests.

Abstract 59: Patients With Ischemic Stroke Have More Than Three-Fold Higher Rates of In-Hospital Mortality If Their Troponin is Elevated

INTRODUCTION Stroke and heart disease have similar risk factors. Some patients admitted with acute stroke have elevated serum troponin levels concerning for simultaneous myocardial infarction (MI). However, the relationship between troponin elevation and stroke outcomes has not been described. METHODS We identified patients with ischemic stroke treated at a stroke network referral hospital whose data were available in the prospectively-collected “Get With The Guidelines” registry. Additional clinical data were obtained from the hospital laboratory, pharmacy, and billing departments. Characteristics of patients with and without abnormal troponin levels were compared, and logistic regression was used to evaluate the association between troponin elevation and mortality after accounting for clinical factors with nominal statistical significance (p&lt;0.1 level) in the bivariate comparisons. RESULTS Of 1145 patients treated for ischemic stroke from 2008-2012, troponin was elevated in 199 patients (17.3%). Troponin-positive patients had more cardiovascular risk factors, cardiology consultations, and referral for coronary angiography and intervention (Table). Medical therapy was similar between groups, although patients with troponin elevation were more likely to be treated with intravenous heparin drip early during the hospitalization. Most notably, these individuals had markedly worse in-hospital mortality than those without troponin elevation (27% vs. 8%, p&lt;0.001). This relationship persisted after adjustment for 14 clinical characteristics (odds ratio 4.28 [2.40-7.63]). Conclusions: Patients with ischemic stroke and simultaneous troponin elevation have greater burdens of medical comorbidities, higher use of cardiology services, and more than three-fold higher in-hospital mortality than patients without troponin elevation. Further study of these patients is needed to identify potential etiologies behind this high mortality rate.

Cerebral Venous Thrombosis

A 42-year-old woman with a history of Crohn disease presented with left temporal headache for 1 week. On the day of presentation, she had transient word finding difficulty, lasting for 1 to 2 minutes and worsening headache. The patient reported starting prednisone 10 days earlier for a flare of Crohn's disease associated with dehydration. She had been using the Nuva ring (ethinyl estradiol vaginal ring) for birth control. Neurological examination was significant for moderate expressive aphasia. Emergent computed tomography (CT) head revealed a hyperdense focus with surrounding hypodensity in the left temporoparietal lobe. Subsequent MRI of the brain revealed a venous infarct in the anterior left temporal lobe with surrounding edema and areas of hemorrhagic transformation. Magnetic resonance venography (MRV) showed left transverse and sigmoid thrombosis. Hypercoagulable studies were sent including Protein C & S, factor V leiden, prothrombin G20210A gene mutation, lupus anticoagulant, anticardiolipin antibody, homocysteine, and antithrombin III. Systemic anticoagulation (unfractionated heparin drip) was started immediately. Prednisone was continued for Crohn disease. For the next 2 days, her aphasia improved. At the time of discharge, she was transitioned to warfarin with low molecular weight (LMW) heparin bridge. After 1 month, the aphasia and headache completely resolved. Hypercoagulable workup revealed that she was heterozygous for prothrombin G20210A gene mutation, whereas other laboratory tests were unremarkable. Repeat MRV at 3 months showed partial recanalization of the left transverse sinus. Cerebral venous and dural sinuses thrombosis (CVT) is an uncommon and frequently unrecognized, representing ≈0.5% to 1% of all strokes.1 CVT is potentially serious and life threatening. Symptoms in CVT are usually secondary to increased intracranial pressure or focal brain injury from venous infarction or hemorrhage. Headache is often localized and is the most frequent and usually the first symptom. Isolated headache without focal neurological findings or papilledema occurs in …

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Introduction: In today's world of competition, we are in constant race to achieve the most in the least amount of time. Energy drinks promises to keep us awake and running. However, are we risking more than just our sleep? Case Presentation: 48 y/o healthy male had taken about 5-6 energy drinks that day. He was working overtime in a furniture factory, when he suddenly collapsed. He was resuscitated first with an onsite AED and then by EMS for witnessed Ventricular fibrillation. After 10 minutes of resuscitation, his pulse was revived. When he arrived to the hospital, he was unresponsive and CT head was unremarkable. He was put on Hypothermia protocol within 3 hours of cardiac arrest. Heparin drip was started empirically for 48 hours since ischemic coronary artery disease is the most common cause of cardiac arrest. The EKG was normal without any signs of ischemia or QTc prolongation. Echocardiography was negative for congenital structural abnormalities, valvular abnormality or ventricular hypertrophy. Cardiac catheterization was normal. Toxicology screen including alcohol, cocaine, amphetamine, cannabis and opiate were negative. Cardiac Electrophysiological study did not show any evidence of abnormal electrical circuit. After 4-5 days, he showed progressive neurological improvement. He was discharged to rehabilitation with an AICD for secondary prevention of sudden cardiac death. Discussion: In the absence other common etiology, the ingestion of excessive energy drinks was thought to be responsible for the fatal ventricular arrhythmia in the patient. Caffeine toxicity has been known to be associated with coronary vasospasm and arrhythmia. Adults are recommended to limit their caffeine intake <500 mg/day and adolescents <100 mg/day. A usual 16-oz. can of energy drink contains about 160 mg of caffeine. (5-6 cans of energy drinks would amount to 800-960 mg of caffeine). Caffeine inhibits the adenosine receptor and acts as a phosphodiesterase inhibitor. Other ingredients like Guarana, taurine and glucuronolactone has similar stimulatory effects. However, exact mechanism is unknown. U.S. Food and Drug administration does not regulate energy drinks since they are considered dietary supplements. Moreover, the bottles and cans of energy drinks are not marked on the amount of caffeine content. Conclusion: There are number of similar incidences of fatal cardiac arrhythmia associated to energy drinks. These incidences deserve formal reporting, since it is a public hazard that put young people at risk of fatal arrhythmia. These drinks need to be closely monitored for the amount if toxic ingredients by the responsible bodies such as FDA. Also, larger studies that can establish the causality of energy drinks to fatal arrhythmia is needed.

A Rare Cause of Acute Abdomen

Introduction: Superior mesenteric venous thrombosis is a rare but important cause of mesenteric ischemia. Mesenteric ischemia, if untreated, can lead to bowel gangrene, septic shock, and death. 75% of patients with isolated mesenteric venous thrombosis have an inherited thrombotic disorder. Case presentation: A 62-year-old HIV-positive Caucasian male presented with a four-day history of sudden onset, severe abdominal pain. The patient also had decreased appetite and nausea. He was passing flatus. His last CD4 count was 612, a month ago. On abdominal examination, there was tenderness around the umbilicus. Abdominal and pelvic CAT scan with contrast showed superior mesenteric venous thrombosis with patent portal and splenic veins. Patient was made nil per oral and started on heparin drip. A complete hypercoagulability panel was sent. The patient was diagnosed with heterozygous mutation of MTHFR (Methyl-tetra-hydro-folate-reductase), heterozygous mutation of prothrombin gene, and hyper-homocysteinemia. The patient was started on warfarin to overlap with heparin for long-term anticoagulation. The patient recovered uneventfully, and was started on an oral diet and discharged home. Discussion: In patients presenting with superior mesenteric vein thrombosis hypercoagulability, work-up is necessary, as 75% of the patients have underlying coagulation defects. The patient needs to be on long-term anti-coagulation to prevent re-occurrence. Superior mesenteric vein thrombosis, although a rare but important cause of abdominal pain, should be considered in a patient presenting with acute abdomen. If diagnosed early, it can be treated successfully and prevent devastating consequences like bowel gangrene, perforation, and sepsis.

ST-segment elevation myocardial infarction after drowning

A 16-year-old boy with no significant past medical history was brought to the emergency department (ED) after drowning in Lake Michigan where he was reportedly submerged in water for 15 min before being pulled out. On arrival of the paramedics, he was unresponsive with an initial rhythm of pulseless electrical activity. He was intubated at the scene, and cardiopulmonary resuscitation was performed for 8 min with restoration of spontaneous circulation. In the ED, the patient’s electrocardiogram (EKG) revealed an acute infero-postero-lateral ST-segment elevation myocardial infarction (STEMI) (Fig. 1, panel a). He was started on heparin and eptifibatide (INTEGRILIN; Merck and Co., Whitehouse Station NJ) drip, and was transferred to the cardiac catheterization lab for percutaneous coronary angiogram. A repeat EKG performed immediately prior to the procedure revealed resolution of ST-segment elevation, and the procedure was therefore deferred and the patient was sent to the intensive care unit (ICU). Upon arrival in the ICU, the patient was unconscious, hypothermic (temperature 32.5 C), and hypotensive requiring vasopressors and inotropic support. Follow-up EKG 3 h later revealed deep Q waves in the inferior leads (Fig. 1, panel b). Laboratory investigations were significant for a troponin [50 ng/mL (N 0–0.08), creatinine phosphokinase (CPK) 4104 unit/L (N 32–294), creatinine kinase MB (CKMB) 297 ng/mL (N 0–5), a combined metabolic and respiratory acidosis with a pH 7.1, bicarbonate (HCO3) 16 mmol/L and partial pressure of carbon dioxide (pCO2) 53 mmHg, international normalized ratio (INR) 3.2 and partial thromboplastin time (PTT) [150 s. Chest X-ray study revealed bilateral patchy infiltrates consistent with pulmonary edema. Shortly, the patient developed epistaxis and hematemesis, so antiplatelet and anticoagulant medications were discontinued. The patient’s level of consciousness deteriorated to a Glasgow Coma Scale of 3/15 with absence of all brainstem reflexes in addition to a positive apnea test and electroencephalogram (EEG) conformed to the diagnosis of brain death. Drowning is a major cause of death worldwide among boys 5–14 years of age [1]. There is scant data in the literature describing the myocardial ischemic complications of drowning. In the prospective study by Checchia et al. [2], there was a trend towards a higher mortality in children with acute out-of-hospital cardiac arrest after submersion injury who had a higher troponin elevation, however, the results did not reach statistical significance. In a retrospective analysis of autopsy and laboratory findings in 197 submersion cases by Papadodima et al. [3], 23 cases died from complications of coronary artery disease. A possible mechanism by which drowning can lead to myocardial infarction includes hypoxia-either due to fluid aspiration or laryngospasmand subsequent coronary spasm. Sheikh et al. [4] demonstrated the occurrence of transient ST H. R. Omar (&) E. El-Khabiry Y. Ali Internal Medicine Department, Mercy Hospital and Medical Center, Chicago, IL 60616, USA e-mail: hesham_omar2003@yahoo.com

Successful Abdominal Organ Donation after Brain Death in a Patient with a Biventricular Assist Device: Extending Extended Criteria

Few studies address the potential for donation after brain death (DBD) in the limited population of patients with ongoing mechanical circulatory support (MCS). A case study was conducted reviewing available records of both donor and recipient, and available literature. The donor was a young female with an acute myocardial infarction precipitating emergent off-pump 2-vessel bypass graft complicated by profound cardiogenic shock refractory to inotropes and intra-aortic balloon pump. A heparin drip was started following percutaneous placement of a left ventricular-assist device (TandemHeart?) which improved her hemodynamics to stabilize for transfer. She ultimately required surgical placement of biventricular assist device (CentraMag?) to normalize hemodynamics. Two days post-operatively, she developed a cerebellar hemorrhage and was declared brain dead. Pre-donation blood chemistry showed adequate end-organ function. Both kidneys were placed locally. The liver was rejected for two regional status 1 patients and by all other local centers. We accepted the liver for a patient with polycystic liver disease with a MELD exception score of 20. The recipient is now 4 years post-transplant with excellent graft function. Extending donor criteria to include MCS patients can result in successful transplantation and should be considered in selected circumstances once satisfactory donor end-organ function is established.

Hydatid cyst of liver complicated with Budd-Chiari syndrome and portal vein thrombosis

Hydatid cyst of liver complicated with Budd-Chiari syndrome and portal vein thrombosis

Pericarditis Post Pacemaker Implantation Progressing To Cardiac Tamponade after Treatment of an Incidental Pulmonary Embolism

This report presents a case of cardiac tamponade that developed after a patient who presented with a pleuritic chest pain 2 weeks after pacemaker implantation. The patient developed cardiac tamponade after being treated with heparin drip for an incidental pulmonary embolism.

In Vitro Analysis of Cell Salvage Blood Collection With a Laparoscopic Suction Device

Study ObjectiveTo determine whether cell salvage blood collection with a laparoscopic suction device is inferior to use of a traditional Yankauer suction device. DesignProspective, in vitro study. SettingAcademic teaching hospital. InterventionsIndividual units of donated packed red blood cells were diluted with normal saline solution to a hematocrit level of 21%. The blood was divided into 2 equal parts and then suctioned with either a laparoscopic suction device or a Yankauer plastic suction catheter tip connected to double-lumen cell salvage tubing with a diluted heparin drip and a vacuum pressure of 100 mm Hg. Collected blood was processed with a cell salvage device. Red blood cell volume was calculated by multiplying the hematocrit level by the total volume of blood product at the time of testing. Mean hemolysis indexes were compared between the laparoscopic and Yankauer method of blood collection by use of a 2-sample t test. Assuming a clinically acceptable limit of loss to be 7%, percent loss in red blood cell volume was tested with a 95% one-sided confidence limit to assess noninferiority. Measurements and ResultsThe mean hemolysis index was 43.33 with laparoscopic suction method and 34.67 with the Yankauer suction method. The mean difference was 8.67 and was not considered significant (p = .074). The percent loss in red blood cell volume after collection and cell salvage processing was 33.2% with the laparoscopic suction method and 29.57% with the Yankauer method. The mean difference was 3.63% and was within the acceptable 7% loss limit for noninferiority (p = .0278). ConclusionsLaparoscopic blood collection is not inferior to the standard Yankauer method for cell salvage collection.

A young woman with systemic lupus erythematosus and extensive mesenteric vasculitis involving small and medium vessels

History of the present illness The patient had 2 recent hospital admissions. Two months prior to her current presentation, she presented to the emergency department with a tooth abscess for which she underwent incision and drainage, and received a 1-week course of penicillin. One week later, she was admitted with a fever of 40.8°C and was noted to have tooth decay on panoramic radiographs without evidence of an abscess. She was treated with intravenous vancomycin and piperacillin tazobactam for 48 hours and then switched to oral clindamycin. Because of her elevated international normalized ratio (INR), she was unable to undergo tooth extraction prior to discharge. Two weeks later, she was readmitted with 4 days of recurrent fevers, malaise, diffuse arthralgias, and increased dyspnea with minimal exertion. Previous lupus exacerbations were characterized by arthralgias, rash, and hemolytic anemia. On this admission, laboratory evaluation revealed leukocytosis, worsening anemia and thrombocytopenia, creatinine of 0.7 mg/dl, alkaline phosphatase of 127 units/liter (normal value 111), spot urine proteinto-creatinine ratio of 1.47 (prior 1.1), low C3 and C4, and an increase in her double-stranded DNA by enzyme immunoassay from 120 to 768 IU/ml (normal value 30). She was empirically treated with vancomycin and piperacillin tazobactam given her recent tooth infection. The elevated alkaline phosphatase level prompted an abdominal ultrasound that showed multiple small hypoechoic areas in the spleen. An extensive infectious evaluation, including blood cultures, fungal serologies, knee arthrocentesis, magnetic resonance imaging of the lumbar spine, transthoracic and transesophageal echocardiograms, and computed tomography of the chest, abdomen, and pelvis, was negative. Her viral serologies were also unremarkable, other than evidence of IgG seropositivity for cytomegalovirus (CMV) with a negative viral load, consistent with prior exposure. Despite broad-spectrum antibiotics, she remained febrile. Her baseline prednisone dose of 12.5 mg was increased to 60 mg daily for possible lupus flare, after which she defervesced within 48 hours. Her thrombocytopenia was thought to be secondary to SLE-related idiopathic thrombocytopenic purpura because it resolved with high-dose steroids and intravenous immunoglobulin. She was discharged home 11 days after admission. The patient remained afebrile for 1 week at home. During this period she developed new-onset progressive upper abdominal pain with meals lasting 20–30 minutes. She denied associated constitutional symptoms, diarrhea, hematochezia, or melena.

Does Recent DVT and/or Pulmonary Embolus Preclude Complex Extremity Flap Reconstruction?

Introduction: Over the prior 10 years of our reconstructive surgery practice, a high volume of extremity reconstructions requiring flap coverage have been performed. Our poly-trauma cases often present with multi-extremity injuries, have high amputation rates, and are accompanied by pelvic and/or long-bone fractures with extensive soft tissue wounds. These patients have high Injury Severity Scores (ISS) with many independent risk factors for developing deep vein thromboses (DVTs) and pulmonary emboli (PEs). This study will determine the incidence of DVT/PE in our traumatic extremity cases that underwent flap procedures and will review the outcomes and complications within this high-risk cohort of patients. METHODS: A retrospective review of flap procedures for extremity injuries from 2003-2011 was completed. For those patients requiring flap coverage with known DVT/PE, therapeutic anticoagulation or IVC filters were provided per accepted guidelines or standards of care. Outcomes evaluated in the DVT/PE cohort included flap success rates, with complications such as partial/total flap failure, donor and/or recipient site hematomas, seromas, or wound healing issues assessed. RESULTS: A total of 137 extremity flap procedures were performed (76 pedicle; 61 free flaps), with 22 patients (16.1%) having radiographic evidence of preoperative DVT/PE (11 pedicle and 11 free flap cases, respectively). Upper extremity cases had an even higher rate of confirmed preoperative DVT/PE (22.4% of all extremity cases and 68.2% of DVT/PE cases). The ISS averaged 23.8 for the DVT/PE cohort (range 19-39). Anticoagulation therapy consisted predominantly of weight-based therapeutic LMWH in 15 cases (68.2%), IVC filter in 5 patients (22.7%), and heparin drip in 2 patients (8.9%). The average duration of anticoagulation therapy was 16 days (range 4-50days) prior to flap transfer. The most common complications were partial flap necrosis (4.5%) and hematoma (4.5%). There were no total flap failures, infections, or adverse outcomes related to progression of an existing DVT or PE in this series. CONCLUSION: DVT/PE rate in our trauma patients was 16.1% for all cases requiring extremity flap coverage and 22.4% for those cases within the upper extremity flap cohort. Despite these preoperative thrombotic events and risks, flap transfers were performed with high success rates and relatively low complication rates. Pedicle and/or free flaps for extremity injuries can be considered safe to perform in carefully selected and treated patients with known preoperative DVT/PE.