Intravenous Administration Of Heparin Research Articles

Cerebral thromboembolic complications during cerebral angiography and their risk factors in different subgroups: Analysis of 2,457 procedures.

Diagnostic cerebral digital subtraction angiography (DSA) is an invasive examination that involves catheterization of the major supra-aortic arterial trunks and evaluation of intracranial vessels for diagnostic purposes. Although considered the gold standard method for investigating cerebrovascular diseases, DSA carries measurable and potentially serious complication rates. This report describes the frequency of neurological and non-neurological complications of DSA performed in five hospitals in the state of São Paulo, Brazil, and analyzes them in different disease subgroups. It has a special focus on thromboembolic cerebral complications. We retrospectively reviewed clinical records of all adult patients who underwent DSAs between January 2019 and December 2022. Demographic variables, DSA reports, CT/MRI reports, and clinical follow-up notes were reviewed. Twenty-four patients experienced some type of complication among 2,457 diagnostic DSAs (0.97%). Thromboembolic complications were recorded in 9 patients (0.36%), and access site hematomas larger than 5cm were registered in six patients (0.24%). There was a statistical trend for thromboembolic complications in patients with cervical and/or intracranial atherosclerosis (p = 0.07), but age was not associated with them (p = 0.93). Patients who received heparin had lower rates of embolic complications than those who did not receive it, but there was no statistically significant difference (p = 0.17). Intravenous administration of heparin showed a trend toward significance with groin hematoma (p = 0.10). Diagnostic catheter DSAs have low complication rates.

Right ventricular failure due to acute pulmonary embolism associated with Graves’ disease: A case report

Background Graves' disease is a prevalent endocrine disorder characterized by diverse clinical manifestations affecting multiple organs, exhibiting varying degrees of severity. Cardiovascular system involvement is one of the most common manifestations, which include palpitation, tachycardia, cardiomyopathy, atrial fibrillation, pulmonary hypertension, or heart failure. Additionally, excessive thyroid hormone can lead to a hypercoagulable state, increasing the risk of venous thrombosis. However, thrombotic events, particularly deep vein thrombosis, cerebral venous thrombosis, or pulmonary embolism, are rare complications of Graves’ disease. Case presentation In this report, we present the case of a 53 years old woman who presented with progressively worsening dyspnea, orthopnea, paroxysmal nocturnal dyspnea, bilateral leg edema, and jaundice for 2 weeks. She had also reported a weight loss of 4 kilograms within 3 months. Upon admission to our hospital, she initially received a diagnosis of congestive heart failure with atrial fibrillation and thyrotoxicosis. Following diuretic therapy, the patient developed hypotension and severe hypoxemia. Subsequent investigation revealed acute right ventricular failure due to an acute sub-segmental pulmonary embolism, which was confirmed by computed tomography of the pulmonary artery. The patient's condition improved after resuscitation involving intravenous fluid administration to increase right ventricular preload, intravenous vasopressor infusion to elevate systemic blood pressure, management of severe thyrotoxicosis, and intravenous administration of heparin. Conclusion Graves’ disease, accompanied by hemodynamic disturbances due to acute right ventricular failure, necessitates admission to the intensive care unit for resuscitation and close monitoring. Although acute pulmonary embolism is an uncommon condition associated with Graves’ disease, it should be considered, particularly in patients who develop acute right ventricular failure.

The Impact of Heparin on Mortality Following Open Ruptured Abdominal Aortic Aneurysm Repair

Systemic administration of heparin is widely used in patients undergoing open elective abdominal aortic aneurysm (AAA) repair. However, no clear consensus exists in the use of intraoperative heparin during open ruptured AAA (rAAA) repair. In this study, we assessed the safety of intravenous heparin administration in patients undergoing open rAAA repair. A retrospective cohort study comparing patients who received and did not receive heparin during open rAAA repair in the Vascular Quality Initiative database between 2003 and 2020 was conducted. The primary outcomes were 30-day and 10-year mortality. The secondary outcomes included estimated blood loss, number of packed red blood cells transfused, early postoperative transfusions, and postsurgical complications. Propensity score matching was used to adjust for potentially confounding variables. The outcomes were compared between the 2 groups using relative risk for binary outcomes and paired t-test and the Wilcoxon rank-sum test for normally and non-normally distributed continuous variables, respectively. Survival was examined using Kaplan-Meier curves and compared using a Cox proportional hazards model. A total of 2,410 patients who underwent open rAAA repair between 2003 and 2020 were studied. Of the 2,410 patients, 1,853 patients received intraoperative heparin and 557 did not. Propensity score matching on 25 variables yielded 519 pairs for the heparin to no heparin comparison. Thirty-day mortality was lower in the heparin group (risk ratio: 0.74; 95% confidence interval [CI]: 0.66-0.84) and in-hospital was also lower in the heparin group (risk ratio: 0.68; 95% CI: 0.60-0.77). Furthermore, estimated blood loss was 910mL (95% CI: 230mL to 1,590mL) lower in the heparin group and the mean number of packed red blood cells transfused intraoperatively and postoperatively were 17 units lower in the heparin group (95% CI: 8-42). Ten-year survival was higher for patients who received heparin, and their rate of survival was approximately 40% higher than those who did not receive heparin (hazard ratio: 0.62; 95% CI, 0.53-0.72; P<0.0001). In patients who received systemic heparin administration at the time of open rAAA repair, there were significant short-term and long-term survival benefits within 30days and at 10years. Heparin administration may have afforded a mortality benefit or been a surrogate for healthier and less moribund patients at the time of the procedure.

Systemic Heparinization After Neuraxial Anesthesia in Vascular Surgery: A Retrospective Analysis

The American Society of Regional Anesthesia and Pain Medicine's guidelines recommend a 1-hour interval after neuraxial anesthesia (NA) before systemic heparinization to mitigate the risk of spinal hematoma (SH). The study authors aimed to characterize the time interval between NA and systemic heparinization in vascular surgery patients (primary outcome). The secondary outcomes included the historic incidence of SH, and risk estimation of the SH formation based on available data. Heparin dose, length of surgery, difficulty and/or the number of NA attempts, and patient demographics were recorded. A retrospective analysis between April 2012 and April 2022. A single (academic) center. Vascular surgery patients. Intravenous heparin administration. All (N=311) vascular patients were reviewed, of whom 127 (5 femoral-femoral bypass, 67 femoral-popliteal bypass, and 55 endovascular aneurysm repairs [EVAR]) received NA and were included in the final analysis. Patients receiving general anesthesia alone (N=184) were excluded. Neuraxial anesthesia included spinal (N=119), epidural (N=4), or combined spinal-epidural (N=4) blocks. The average time between NA and heparin administration was 42.8 ± 22.1 minutes, with 83.7% of patients receiving heparin within 1 hour of NA. The time between NA and heparin administration was 40.4 ± 22.3, 50.1 ± 23.4, and 31.3 ± 12.5 minutes for femoral-femoral bypass, femoral-popliteal bypass, and EVAR, respectively. Heparin was administered after 1 hour of NA in 20% of femoral-femoral bypass, 27% of femoral-popliteal bypass, and 3.9% of EVAR patients. No SHs were reported during the study period. The vast majority of vascular surgery patients at the authors' center received heparin within 1 hour of NA. Further studies are required to assess if their findings are consistent in other vascular surgery settings and/or centers.

Association of intravenous heparin administration with in-hospital clinical outcomes among hospitalized patients with acute heart failure

BackgroundsPatients with acute heart failure (AHF) possess a high risk for thromboembolism, and thromboembolism prophylaxis using heparin has been recommended by the guidelines. MethodsAmong 4056 patients enrolled in the KCHF Registry, the current study population consisted of 2525 patients after excluding patients with acute coronary syndrome and oral anticoagulants on admission and those with mechanical circulatory supports. There were 789 patients (31%) with heparin administration within 24 h after admission, and 1736 patients (69%) without. ResultsThe baseline characteristics included mean age: 78 ± 13 years, New York Heart Association class IV: 51%, ischemic etiology: 30%, atrial fibrillation: 31% and mean left ventricular ejection fraction: 45%. During median hospitalization length of 16 days, 161 patients had all-cause death, 34 patients developed ischemic stroke, and 48 patients developed major bleeding. Multivariable logistic regression analyses demonstrated that heparin administration compared with no heparin administration was not associated with a lower risk for all-cause death (OR: 1.39, 95%CI: 0.90–2.15; P = 0.14), nor for ischemic stroke (OR: 1.14, 95%CI: 0.53–2.43; P = 0.74), but was associated with a higher risk for major bleeding (OR: 2.88, 95%CI: 1.54–5.41; P < 0.001). ConclusionsIn patients with AHF, heparin administration within 24 h after admission was not associated with a lower risk of all-cause death and ischemic stroke, but was associated with a higher risk of major bleeding during hospitalization. Our study raises questions about the routine use of heparin for thromboembolism prophylaxis in hospitalized patients with AHF. Further studies are warranted to address the utility of anticoagulant therapy in these patients.

Real World studies on undesirable effects of some Anti-Thrombotic Drugs in a tertiary Hospital

Introduction: Antithrombotic drugs include antiplatelet, anticoagulant and fibrinolytics. Antithrombotic drugs either block the formation of new clots, or prevent the growth of existing clots or reduce risk of complications from blood clots. These drugs are used in various Cardio and neurological diseases ranging from Angina, stroke to as Dual Antiplatelet Therapy (DAT) in post implantation of permanent medical devices. Antithrombotic drugs have numerous side effects from gastritis, prolonged bleeding, hemorrhage, tachycardia, tinnitus based on the class of drugs.&#x0D; Study design and Objective: Though the undesirable effects of antithrombotic drugs are well established in controlled trails, there were rare studies in Real world population. Hence a prospective observational study was under taken to understand the undesirable effects in a Tertiary hospital in India and analyze the pattern based on age, gender, intended and indications of use and dosage regimen. The undesirable effects of Aspirin, Heparin and Clopidogrel were studied in 92 patients over a period of 6 months.&#x0D; Results and Discussion: In the current study there were 8 cases were heparin was indicated and 50% of the patients complained of haemorrhage / bleeding and in 2 cases there is heavy bleeding during cut wounds. All this cases were found in patients where Heparin is used in Cardiology and neurological diseases and old age group on different indications of use. In 60 patients who are on Aspirin therapy 43 patients are in cardiology and 17 in neurological treatment. Most of the indications are for CAD, Myocardial Infraction (MI) and Angina. Important undesirable effects noted in the present study include SOB-9 patients, Tachycardia- 5, Blood in stools-4 patients, Tinnitus -3 patients and Ulcers in 3 patients. Of the 92 cases, Clopidogrel was prescribed for different indications of use in 24 patients. Of them 19 patients are in cardiology and 5 patients are in neurology treatment. Most commonly patients were diagnosed with MI, unstable angina and CVA Ischemic stroke, with observed undesirable effects like prolonged bleeding, dyspepsia, headache, indigestion, heart burn and tachycardia. The study clearly shows that prolonged bleeding was observed in 40% of the patients on clopidogrel mainly in segment with higher doses and on co-medication&#x0D; Conclusion: The present study has shown similar undesirable effects evidenced in controlled clinical trials. However, the study indicates Intravenous administration of Heparin is advised than subcutaneous route and need for larger studies to substantiate the same. It is also recommended that patients on Aspirin should be recommended for low dose mainly in indications related to cardiovascular diseases than higher dosed. Most of the adverse effects are found in patients taking more than 75 mg and BID and TID. It could be related to dose induced effects and also the includes the age factor as most of them are geriatrics and not on anti-ulcer drugs. The study clearly shows that prolonged bleeding was observed in 40% of the patients on clopidogrel mainly in segment with higher doses and on co-medication. A case was reported on overdose of Clopidogrel which resulted in abnormalities in platelet aggregation that required emergency medical care.

Pharmacokinetic profiles of intravenous versus subcutaneous administration of low molecular weight heparin for thromboprophylaxis in critically ill patients: A randomized controlled trial.

Low molecular weight heparins (LMWH) are recommended for thromboprophylaxis in ICU patients but often fail to reach adequate peak anti-Xa activity. To compare the pharmacokinetic profiles of intravenous (IV) versus subcutaneous (SC) route of administration of LMWH. This was a prospective, monocentric, randomized trial. Patients were randomized to the IV route of administration with a 4-h infusion of nadroparin 3800 IU or to the SC route of administration. Randomization was stratified according to the need for vasopressor or not. Anti-Xa activity was measured at baseline, and at 1, 2, 4, 6, 8, 12 and 24 h after the administration was started. Sixty patients were included, of whom 30 were randomized to the IV group and 30 to the SC route. Pharmacokinetic profiles were significantly different. Mean peak anti-Xa activity was 0.38 IU/ml in the IV group vs 0.20 IU/ml in the SC group (p < 0.001). Trough values and AUC (0-24 h) were similar in both groups. Pharmacokinetic profiles were similar whether patients received vasopressors or not. The IV route of administration with a 4-h infusion lead to a significantly higher peak anti-Xa activity without affecting trough value or the AUC (0-24 h). Whether the IV administration of LMWH might improve the efficacy of thromboprophylaxis requires further research. ClinicalTrials.gov, NCT04982055, retrospectively registered 08 July 2021, https://clinicaltrials.gov/ct2/show/NCT04982055?cond=NCT04982055&draw=2&rank=1.

Subcutaneous Enoxaparin for Systemic Anticoagulation of COVID-19 Patients During Extracorporeal Life Support.

BackgroundExtracorporeal membrane oxygenation, with an inherent requirement for anticoagulation to avoid circuit thrombosis, is a key element in the treatment of respiratory failure associated with COVID-19. Anticoagulation remains challenging, the standard of care being intravenous continuous administration of unfractionated heparin. Yet regimens vary. Some intensive care units in our center have successfully used enoxaparin subcutaneously in recent years and throughout the pandemic.MethodsWe retrospectively analyzed adult COVID-19 patients with respiratory failure who had been systemically anticoagulated using either enoxaparin or unfractionated heparin. The choice of anticoagulant therapy was based on the standard of the intensive care unit. Defined thromboembolic and hemorrhagic events were analyzed as study endpoints.ResultsOf 98 patients, 62 had received enoxaparin and 36 unfractionated heparin. All hazard ratios for the thromboembolic (3.43; 95% CI: 1.08–10.87; p = 0.04), hemorrhagic (2.58; 95% CI: 1.03–6.48; p = 0.04), and composite (2.86; 95% CI: 1.41–5.92; p = 0.007) endpoints favored enoxaparin, whose efficient administration was verified by peak levels of anti-factor Xa (median: 0.45 IU ml−1; IQR: 0.38; 0.56). Activated partial thromboplastin time as well as thrombin time differed significantly (both p<0.001) between groups mirroring the effect of unfractionated heparin.ConclusionsThis study demonstrates the successful use of subcutaneous enoxaparin for systemic anticoagulation in patients with COVID-19 during extracorporeal membrane oxygenation. Our findings are to be confirmed by future prospective, randomized, controlled trials.

Delayed-Type Heparin Allergy: Intravenous Tolerance Despite Inflammatory Skin Reaction After Subcutaneous Injection

Heparin allergy most frequently manifests as delayed-type hypersensitivity (DTH) causing an itchy inflammatory skin reaction at the site of subcutaneous injection. An important differential diagnosis is circumscribed skin necrosis due to heparin-induced thrombocytopenia. An inflammatory skin reaction to subcutaneously injected heparin generally entails the quest for alternative anticoagulation; concerns may particularly arise in an emergency situation requiring intravenous heparin administration. All heparin DTH cases seen in our department over the last 17 years underwent standardized allergy diagnostics including challenge testing, that is, subcutaneous injection of fondaparinux and intravenous administration of unfractionated heparin (UFH). Of a total of 50 patients with confirmed heparin allergy, DTH was found in 48 (96.0%), and immediate-type, presumably IgE-mediated hypersensitivity was diagnosed in only 2 (4.0%). In the 48 DTH cases, intradermal testing revealed broad cross-reactivity between UFH and low-molecular-weight heparins (LMWH) including nadroparin, dalteparin, and enoxaparin. Cross-reactivity with (or concomitant sensitization to) fondaparinux was seen in only 3 (6.3%) cases. Intravenous administration of UFH was tolerated by all 45 patients challenged, despite DTH to UFH and LMWH as demonstrated by intradermal testing. If an inflammatory skin reaction at the site of subcutaneously injected heparin is observed or reported without any evidence of skin necrosis or thrombocytopenia, intravenous administration of UFH seems to be sufficiently safe and may be considered without allergy testing if urgently indicated in an emergency situation. Fondaparinux is the most suitable alternative for subcutaneous application.

Parenteral anticoagulants in the treatment of acute coronary syndrome: what modern clinical guidelines say

Parenteral administration of high (therapeutic) doses of anticoagulants is a mandatory component of the initial treatment of acute coronary syndrome (ACS) unless contraindicated. In ACS, intravenous administration of unfractionated heparin, the use of low molecular weight heparin enoxaparin, selective antagonist of activated X clotting factor fondaparinux sodium and direct thrombin antagonist bivalirudin are possible. The review presents current approaches to the choice of drugs and the specifics of parenteral anticoagulant use depending on ACS variant (with or without persistent ST-segment elevations on ECG), approaches to myocardial revascularization, previous use of oral anticoagulants, renal function, risk of major bleeding, presented in current versions of European Society of Cardiology and Russian Society of Cardiology guidelines, approved by the Russian Ministry of Health. It is shown that, according to the results of randomized controlled trials and expert opinion, for most ACS treatment scenarios (streptokinase thrombolytic therapy or no reperfusion therapy in ACS with persistent ST elevation on ECG, ACS without persistent ST elevation) the optimal approach is parenteral administration of sodium fondaparinux. Exceptions include primary percutaneous coronary intervention and very early invasive treatment of ACS without persistent ST-segment elevation, but initial treatment with sodium fondaparinux does not prevent these approaches. Additional advantages of sodium fondaparinux are the absence of the need to monitor the coagulation system, a fixed dose, as well as the possibility of use in patients with significant thrombocytopenia. If short-term use of parenteral anticoagulant is expected (in early invasive treatment of ACS), there are contraindications or limitations to the use of sodium fondaparinux and sodium enoxaparin, the means of choice for most cases is intravenous administration of unfractionated heparin.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Strategies for the prevention of maternal death from venous thromboembolism clinical recommendations based on current literature.

Venous thromboembolism (VTE) is one of the leading causes of direct maternal deaths. It has been estimated that approximately 50% of these deaths are potentially preventable. The UK Confidential Enquiries into Maternal Deaths and the National Partnership for Maternal Safety have proposed strategies for the prevention of maternal deaths from VTE based on current guideline recommendations. The main strategies include: - Early recognition and comprehensive assessment of risk factors for VTE at different times from the beginning of pregnancy until patient's discharge from hospital. - Appropriate risk stratification using standardized VTE risk assessment tools (e.g. the Royal College Scoring System). - Risk-based antenatal and postnatal heparin thromboprophylaxis adjusting the heparin dosage and the duration of prophylaxis to the individual patient's risk. - Adequate management of heparin prophylaxis before and after delivery. - Preference of universal rather than selective post-cesarean heparin thromboprophylaxis and application of perioperative mechanical prophylaxis. - Avoidance of gaps in the postpartum prescription of heparin. - Good communication and cooperation between primary and secondary care including community midwifery staff in the postpartum period. - Immediate intravenous administration of (unfractionated) heparin, if pulmonary embolism is suspected. - Critical analysis of all thromboembolic events, particularly in association with maternal death to learn from failures and to realize, if and where improvement is needed. Adequate pharmacological thromboprophylaxis has the potential to reduce the risk of VTE by 60-70% in pregnant women at increased risk.

Complete primary aortic ascending thrombosis resolution after dabigatran therapy.

A 36-year-old man visited hospital with chest pain and shortness of breath since a few days. There was no medical history. Due to troponin elevation 0.07 µg/L (normal <0.04 µg/L), a triple rule out computed tomography (CT) was performed and showed an extensive thrombosis starting from the aortic arch across to the brachiocephalic artery, measuring 25 × 35 mm, irregular, polylobular, in the ascending aortic lumen, 5 cm below the aortic arch, and bilateral pulmonary embolism (Panels A and B). No clue for dissection or other wall pathologies were found, normal size of the ascending aorta, no sign of intramural haematoma, no hypercoagulable disease in the medical history, or blood investigations. Aortic ascending thrombus in a non-aneurysmal aorta is an extremely rare event and has potentially very severe complications, with a life-threatening risk of myocardial infarction and cerebral embolization. After 2 weeks of intravenous heparin administration, the CT follow-up showed no change of the thrombus size and we decided to prescribe dabigatran 150 mg b.i.d. The patient felt very well and therefore he refused surgical resection, despite of heart team consensus. After 8 weeks, we find the thrombus getting smaller in the suprasternal echocardiographic view compared with the first imaging (Video still image E and see Supplementary material online, Video S1). After 3 months, there was a complete resolution in the suprasternal echocardiographic view (Video still image F and see Supplementary material online, Video S2). The use of dabigatran leads to complete resolution and prevented the recurrence of the disease during 2-year follow-up (Panels C and D).

Analysis of D-Dimer Level and Prothombin Time (PT) Activated Prothombin Thromboplastin (APTT) on Heparin Administration to COVID-19 Patients

Coronavirus Disease 2019 (COVID-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). Coronavirus is a dangerous pathogen that affects both humans and animals. Symptoms and indicators of COVID-19 infection include fever, cough, and shortness of breath, which are common in respiratory illnesses. COVID-19 has spread globally with high mortality and morbidity rates. Prothrombin Time (PT), Activated Prothrombin Thromboplastin (APTT), and D-Dimer parameters are blood tests to evaluate the coagulation status of COVID-19 patients, all these parameters increased in COVID-19 patients. This study aims at determininig the levels of D-Dimer, PT, and APTT in COVID-19 patients. Clinical and laboratory records were retrospectively reviewed from 100 cases of COVID-19 admitted to hospitals. This study used a a cross-sectional, descriptive, secondary data analysis design. The sample included patients from the Bhayangkara TK. I R.Said Sukanto Hospital between April-July 2021. The sample is a COVID-19 patient who was treated in the Intensive Care Unit (ICU), worsened, and given heparin. An independent variable is the administration of intravenous heparin at prophylactic doses. Dependent variables are D-Dimer, PT, and APTT values. The collected data is processed using Microsoft Office Excel and then being analyzed. D-Dimer, PT, and APTT levels in COVID-19 patients were initially high or increased after heparin administration decreased or became normal. In conclusion, there was a decrease in D-dimer levels, PT values, and APTT after administration of intravenous heparin at prophylactic doses.

Modern Appraisal of Patency and Complications in Cerebral Bypass Surgery: A Single Institution Experience.

Cerebral bypass is a valuable surgical technique in well-selected patient populations. Updated clinical guidelines and improved surgical techniques warrant a contemporary reevaluation of the complications and patency to inform clinical practice and enhance postoperative patient care. To assess the complication rates and postoperative graft patency for the 3 most common indications for bypass surgery: moyamoya disease, intracranial atherosclerosis, and intracranial aneurysms. Perioperative notes of 175 consecutive bypass patients at a single institution were retrospectively identified to evaluate the clinical course and complications of surgery. The rate of total postoperative complications between moyamoya disease (9 of 98, 9.2%), intracranial atherosclerotic disease (7 of 57, 12.3%), and intracranial aneurysm (4 of 20, 20%) was not statistically different (P = .33). Immediate postoperative bypass patency was significantly higher in moyamoya disease (90 of 96, 93.8%) and intracranial atherosclerotic disease (48 of 51, 94.1%) than in intracranial aneurysm (13 of 18, 72.2%; P = .02). Intravenous heparin administration during bypass suturing was negatively associated with immediate postoperative patency (87% heparin patency vs 99% no heparin patency; P = .02). Double-barrel bypass trended toward an increased risk of wound healing complications (2 of 13, 15.4%) compared with the single-barrel bypass technique (4 of 156, 2.6%; P = .07). Cerebral bypass surgery remains an excellent surgical treatment for moyamoya disease, intracranial atherosclerosis, and intracranial aneurysms. This study suggests bypass is safer in moyamoya disease and intracranial atherosclerosis. Additional studies to clarify the risk of single-barrel vs double-barrel bypass and intraoperative heparin-stratified complications may be beneficial.

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.

The Impact of Coagulopathy on Clinical Outcomes following Microsurgical Breast Reconstruction.

Autologous breast reconstruction has evolved considerably from pedicled muscle-based approaches to microsurgical perforator-based techniques. Patients with documented coagulopathy, however, remain a particularly challenging population. The authors present their experience in microsurgical breast reconstruction in patients with coagulopathy and discuss their treatment protocol. A prospectively maintained database was queried for patients with coagulopathy who underwent microsurgical breast reconstruction between 2016 and 2019. Information regarding patient demographics, type of coagulopathy, and anticoagulation regimen were retrieved, and clinical outcomes were investigated. Nineteen patients who underwent 34 microsurgical breast reconstructions with free abdominal flaps were included in the study. The most common coagulopathy was factor V Leiden [n = 7 (38.6 percent)]. Nine patients (47.4 percent) developed thrombotic complications (the majority occurring intraoperatively); notably, arterial and venous thrombosis in four (21.1 percent) and two patients (10.5 percent), respectively. Postoperative thrombotic complications included pulmonary embolism [n = 2 (10.5 percent)] and flap congestion secondary to venous thrombosis [two flaps (5.9 percent)]. Only one flap loss was observed secondary to delayed venous thrombosis on postoperative day 6 (2.9 percent). The anticoagulation regimen in the majority of patients consisted of intraoperative intravenous administration of heparin (2000 U [bolus]) followed by a 5-day heparin infusion at 500 U/hour [n = 10 (52.6 percent)]. The high rate of thrombotic complications in patients with coagulopathy who underwent microsurgical breast reconstruction is contrasted by a low flap loss rate. Although coagulopathy is a risk factor for thrombotic complications, successful microsurgical breast reconstruction is still possible in the majority of patients.

Current practice and effects of intravenous anticoagulant therapy in hospitalized acute heart failure patients with sinus rhythm

Although the risk of thromboembolism is increased in heart failure (HF) patients irrespective of atrial fibrillation (AF), especially during the acute decompensated phase, the effects of intravenous anticoagulants for these patients remain unclear. We sought to investigate the current practice and effects of intravenous anticoagulant therapy in acute HF (AHF) patients with sinus rhythm. We analyzed a nationwide prospective cohort from April 2012 to March 2016. We extracted 309,015 AHF adult patients. After application of the exclusion criteria, we divided the 92,573 study population into non-heparin [n = 70,621 (76.3%)] and heparin [n = 21,952 (23.7%)] groups according to the use of intravenous heparin for the first 2 consecutive days after admission. Multivariable logistic regression analyses demonstrated that heparin administration was not associated with in-hospital mortality (OR 0.97, 95% CI 0.91–1.03) and intracranial hemorrhage (OR 1.18, 95% CI 0.78–1.77), while heparin administration was significantly associated with increased incidence of ischemic stroke (OR 1.49, 95% CI 1.29–1.72) and venous thromboembolism (OR 1.62, 95% CI 1.14–2.30). In conclusion, intravenous heparin administration was not associated with favorable in-hospital outcomes in AHF patients with sinus rhythm. Routine additive use of intravenous heparin to initial treatment might not be recommended in AHF patients.

COMPARISON OF INTRAVENOUS VERSUS INTR-ARTERIAL HEPARIN FOR THE PREVENTION OF RADIAL ARTERY OCCLUSION DURING TRANSRADIAL CORONARY ARTERY CATHETHERIZATION

Objective: To determine the relative efficacy of intravenous heparin as compared to intra-arterial heparin used during transradial coronary angiography for the prevention of radial artery occlusion.&#x0D; Study Design: Comparative cross-sectional study.&#x0D; Place and Duration of Study: Study was conducted at the Department of Cardiology, AFIC/NIHD Rawalpindi, Pakistan, from Jul 2019 to Dec 2019.&#x0D; Methodology: A total number of 144 patients were considered for the study using the consecutive sampling technique who were undergoing diagnostic coronary angiography. Patients were divided into the intra-arterial group (n=72) who received 50 IU/kg of unfractionated heparin (maximal dose 5,000 U) intra-arterially, and an intravenous group (n=72) received the similar dose through intravenous route. All patients were administered 100 mcg of nitroglycerin to minimize radial artery spasm. Coronary Angiography was performedusing a 6F introducer sheath and diagnostic catheters. Early radial artery occlusion (RAO) at 24 hours after the procedure was detected by performing the plethysmographic (reverse Barbeau’s) and doppler USG evaluation. Chronic RAO was assessed 30 days after the procedure by performing the same tests. Data was collected through a predesigned proforma and analyzed using SPSS 23. A p-value of less than 0.05 was considered as significant.&#x0D; Results: Early RAO was found in 4 (5.6%) of the patients from the intra-arterial groupand 5 (6.9%) of the intravenous group. The difference was found to be statistically insignificant (p-value 0.731). Chronic RAO was observed in 3 (4.4%) of the intra-arterial group as compared to 4 (6%) of the intravenous group. This difference was also statistically insignificant (p-value 0.683) for chronic RAO.&#x0D; Conclusion: Intra-arterial and intravenous heparin administration providedsimilar efficacy to prevent RAO.

Timing of Heparin Administration Modulates Arterial Occlusive Thrombotic Response in Rats.

Background: The timing for initiation of effective antithrombotic therapy relative to the onset of arterial thrombosis may influence outcomes. This report investigates the hypothesis that early administration of heparin anticoagulation relative to the onset of thrombotic occlusion will effect a reduction in occlusion. Methods: A standard rat model of experimental thrombosis induction was used, injuring the carotid artery exposure with FeCl3-saturated filter paper, followed by flow monitoring for onset of occlusion and subsequent embolization events. Intravenous heparin administration (200 units/mL) was timed relative to the initiation of injury or onset of near occlusion, compared with controls (no heparin administration). Results: No occlusion was found for delivery of heparin 5 min prior to thrombus induction, whereas all vessels occluded without heparin. Unstable (embolic) thrombi were seen with heparin given at or shortly after initial occlusion. Only 9% (1/11) of the vessels had permanent occlusion when heparin was given at the time of thrombotic onset (p < 0.0001 vs. unheparinized), while 50% occluded when heparin was delayed by 5 min (p > 0.05). Conclusions: These findings provide evidence that antithrombotic therapy may need to be administered prior to the onset of anticipated loss of patency, with less effectiveness when given after occlusion has occurred.