Use Of Intravenous Heparin Research Articles

Abstract 454: Use of Intravenous Heparin For Patients With Acute Ischemic Stroke Due to Subocclusive Intracranial Thrombus

Background Sub‐occlusive thrombus in an intracranial artery is a rare cause of acute ischemic stroke, and there is limited data regards to its acute management. Historically, those patients had been treated with heparin drip and then transitioned to oral anticoagulation. We aim to analyze the effect of intravenous heparin in patients with acute ischemic stroke due to sub‐occlusive intracranial thrombus. Method We retrospectively reviewed patients with a diagnosis of acute ischemic stroke from 2019‐2023. We selected patients who met the inclusion criteria: 1) diagnosis of sub‐occlusive thrombus by neuroradiologist using Computed Tomography angiography (CTA), 2) acute treatment with heparin drip. We identified 18 patients with the diagnosis of sub‐occlusive thrombus. Good outcome at 90 days was defined as modified Rankin Score of ≤2, resolution of sub‐occlusive thrombus was evaluated with CTA at 6 months. Results Out of the 18 patients, 50% were females. The mean age was 62.7 years. The median duration of the heparin drip was 42.5 hours. The median NIHSS score on admission was 6. Of the 14 patients with a 90‐day mRS, 7 (50%) had a good outcome (mRS ≤2). In our study, 4 patients (22.2%) had recurrent ischemic stroke, one patient had a systemic hemorrhage, and two patients had an intracranial hemorrhage 10 days after the initial hospitalization. Thirteen patients (72.2%) were transitioned to apixaban, two patients (11.1%) to warfarin, one patient to rivaroxaban. Two were not able to transition secondary to mortality. Upon follow‐up, 39% (n=7) had resolution of thrombus on repeat imaging, 11 (61%) did not undergo repeat imaging. Conclusion The use of heparin drip in acute ischemic strokes associated with intracranial sub‐occlusive thrombus could be an effective and safe treatment. However, in our study, it was not a predictor of good outcome at 90 days. Further studies with bigger samples are needed to evaluate the effectiveness of intravenous heparin in those patients.

Peripheral arterial embolization and limb ischemia complicating septic internal jugular vein thrombosis: a case report of Lemierre’s syndrome

Purpose: Septic thrombophlebitis of the internal jugular vein is a life-threatening complication of venous thrombosis. While heparin is frequently added to antimicrobial therapy, its usefulness in patients with Lemierre’s syndrome is controversial. In this case report, we demonstrate that delayed use of intravenous heparin may be associated with septic embolization of peripheral arteries. Limb ischemia has rarely been reported in patients with Lemierre’s syndrome.
 Case presentation: Lemierre’s syndrome is a complex and unusual clinical entity, characterized by septic thrombophlebitis of the internal jugular vein and accompanied by sepsis. We present an unusual case of a young female with Lemierre’s syndrome who developed peripheral arterial embolization and Streptococcus pyogenes sepsis, complicating septic internal jugular vein thrombosis. The patient was initially treated with antibiotics without therapeutic heparin. The patient developed digital gangrene in all four extremities, septic meningitis, and a severe fungal infection; she died 6 weeks after admission secondary to multisystem organ failure. We discuss the importance of rapid diagnosis of disease extent in directing heparin treatment in patients with Lemierre’s syndrome.
 Conclusion: It may be advisable to treat Lemierre’s syndrome with anticoagulation in the acute setting.

Cost Reduction with Enoxaparin Vs. Heparin for Prophylactic and Therapeutic Use: A Retrospective Analysis in a Community Hospital Setting

BackgroundMost hospitals still use Unfractionated Heparin as the primary agent for Venous Thromboembolism (VTE) prophylaxis and therapy in the inpatient setting due to ease of use and insignificant cost. However, the incidence of Heparin-Induced Thrombocytopenia (HIT) has led to questions about other options for prophylaxis and therapeutic use in the hospital, with more recent data showing that Enoxaparin is safer in terms of incidence of HIT. This study examines the cost-effectiveness of Enoxaparin compared to Heparin for prophylactic and therapeutic usage in a community hospital.MethodsWe conducted a retrospective chart review of patients that had HIT panels ordered at the Inspira Health Network, Vineland campus (an approximately 262 bed community hospital located in southern New Jersey that services a population of approximately 61,050) from the period of April 1, 2015 through December 31, 2016. The starting date represents the time from which Enoxaparin became the primary alternative anticoagulant available at this hospital. Records of the total usage and cost of Heparin and Enoxaparin for the specified time period were collected from the hospital pharmacy database for evaluation, as were records of Heparin-Induced Thrombocytopenia (HIT) panels. The information was analyzed to establish whether or not a significant proportion of HIT panels was ordered for patients on Heparin versus Enoxaparin. Annual cost-savings for the hospital were extrapolated by using the comparative incidences of HIT panels and associated costs, including increased inpatient length of stay, hematology consultation, use of an alternative anticoagulant, and complications of Heparin-Induced Thrombocytopenia and Thrombosis (HITT). These variables were multiplied by the incidence rate for each specified drug and usage in order to determine the daily cost for each drug.ResultsThe overall use of Enoxaparin did not result in a significant decrease in the ordering of HIT panels in the hospital, with a relative rate ratio of 0.948 (95% Confidence Interval: 0.336, 2.21). However, when the data was stratified to reflect prophylactic and therapeutic usages of Enoxaparin and Heparin, there was a marked difference in the use of therapeutic Intravenous (IV) Heparin as opposed to therapeutic Enoxaparin. The rate ratio of HIT panel ordering when using therapeutic Enoxaparin instead of IV Heparin was 0.118 (0.006, 0.625). These numbers were used to extrapolate the total daily cost of Enoxaparin and IV Heparin; therapeutic Enoxaparin cost $30.62, while IV Heparin cost $161.94. IV Heparin use was associated with a higher incidence rate of HIT panel orders, and subsequently a higher daily cost due to the likelihood of increased length of stay, use of alternative anticoagulation, request for expert consultation, and complication of HITT.ConclusionEnoxaparin is associated with a significant cost-saving when used for therapy for patients with venous thromboembolism, when compared to IV Heparin. DisclosuresNo relevant conflicts of interest to declare.

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.

Acute limb ischemia in patients with COVID-19 pneumonia

ObjectiveThe aim of our study was to determine the incidence, characteristics, and clinical outcomes of patients with the novel coronavirus (COVID-19) infection who had presented with and been treated for acute limb ischemia (ALI) during the 2020 coronavirus pandemic. MethodsWe performed a single-center, observational cohort study. The data from all patients who had tested positive for COVID-19 and had presented with ALI requiring urgent operative treatment were collected in a prospectively maintained database. For the present series, successful revascularization of the treated arterial segment was defined as the absence of early (<30 days) re-occlusion or major amputation or death within 24 hours. The primary outcomes were successful revascularization, early (≤30 days) and late (≥30 days) survival, postoperative (≤30 days) complications, and limb salvage. ResultsWe evaluated the data from 20 patients with ALI who were positive for COVID-19. For the period from January to March, the incidence rate of patients presenting with ALI in 2020 was significantly greater than that for the same months in 2019 (23 of 141 [16.3%] vs 3 of 163 [1.8%]; P < .001)]. Of the 20 included patients, 18 were men (90%) and two were women (10%). Their mean age was 75 ± 9 years (range, 62-95 years). All 20 patients already had a diagnosis of COVID-19 pneumonia. Operative treatment was performed in 17 patients (85%). Revascularization was successful in 12 of the 17 (70.6%). Although successful revascularization was not significantly associated with the postoperative use of intravenous heparin (64.7% vs 83.3%; P = .622), no patient who had received intravenous heparin required reintervention. Of the 20 patients, eight (40%) had died in the hospital. The patients who had died were significantly older (81 ± 10 years vs 71 ± 5 years; P = .008). The use of continuous postoperative systemic heparin infusion was significantly associated with survival (0% vs 57.1%; P = .042). ConclusionsIn our preliminary experience, the incidence of ALI has significantly increased during the COVID-19 pandemic in the Italian Lombardy region. Successful revascularization was lower than expected, which we believed was due to a virus-related hypercoagulable state. The use of prolonged systemic heparin might improve surgical treatment efficacy, limb salvage, and overall survival.

Pharmacological Treatment of Pump-Related Thrombosis in Patients with Left Ventricular Assist Device (HearWare HVAD)

Left ventricular assist device (LVAD) is one of the stablished treatments for advanced heart failure. Pump thrombosis (PT) is a major complication, increasing morbidity and mortality in LVAD patients. PT management includes surgical and pharmacological measures but the optimal treatment is not well defined. For this purpose, we reviewed our experience. From June 2011 to July 2019, 85 patients were implanted with a third generation LVAD (HeartWare HVAD, Medtronic, Inc.). All patients were implanted as a Bridge to Transplantation (BTT). PT was considered using INTERMACS criteria. Pharmacological treatment was defined by the use of intravenous heparin alone or in association with systemic thrombolysis with tissue plasminogen activator, t-PA-Actiliyse or with left intraventricular thrombolysis with t-PA-Actilyse. Success of the treatment was defined as improvement on biological and/or LVAD parameters, no surgical pump exchange and survival at 30 days. Treatment complications were defined as ischemic or hemorrhagicstroke or fatal bleeding. There were 47 pump thrombosis in 15 patients (18.3%, 12 men) for a total event rate of 3.1 thrombosis/patient. The mean time for all thrombotic event was 100.2±134.23 months and mean time for the first thrombotic event for heparin alone, local fibrinolysis and systemic fibrinolysis was 85.7, 40.1 and 174.8 months respectively.Thirteen thrombotic events were treated with systemic heparin alone, 26 were treated with systemic thrombolysis and 8 were treated with left intraventricular thrombolysis. Pharmacological treatment was successful in 13 patients, two patients died (intraventricular thrombolysis): one from stroke hemorrhage and one from abdominal hemorrhage. 12 patients were successfully transplanted. One patient is still alive with the LVAD. The mean waiting time on the transplant list was 35.3±18.1 months after PT. The 30 days survival is not statistically significant between the different pharmacological treatments for pump thrombosis. LVAD thrombosis is a major complication after LVAD implantation. Pharmacological conservative treatment with heparin or fibrinolysis could be the first line treatment before considering pump exchange or urgent heart transplant.

Prediction of risk of major bleeding with using CRUSADE bleeding score in Acute coronary syndrome patients: A case series

Use of intravenous heparin in Acute coronary syndrome possess a major risk of bleeding to patients. However, the estimation of risk using bleeding scores in Indian settings is yet to be established. These case series assess the risk of major bleeding associated with the use of Antithrombotic agents in patients with acute coronary syndrome using CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) bleeding score. Relevant patient data was collected from hospital records and patients were followed up till discharge. All the four cases reported showed the risk of in-hospital bleeding with anti-thrombotic agents evident as two cases of hematuria, one case of gum bleeding and one case of hemorrhagic stools. All the patient presented with chest pain to the hospital; following a diagnosis of the acute coronary syndrome, they were prescribed with antiplatelets and anticoagulants. This accompanied a bleeding event which was categorized using CRUSADE bleeding risk score. In-hospital major bleeding imposes a burden on the patient's quality of life. Use of CRUSADE bleeding score helps to predict the severity of risk in a less expensive, non-invasive manner. Further, large scale studies will pave the way for using CRUSADE as an efficient bleeding predictor score.

Periprocedural Intravenous Heparin During Endovascular Treatment for Ischemic Stroke: Results From the MR CLEAN Registry.

Background and Purpose- Intravenous administration of heparin during endovascular treatment for ischemic stroke may improve outcomes. However, risks and benefits of this adjunctive therapy remain uncertain. We aimed to evaluate periprocedural intravenous heparin use in Dutch stroke intervention centers and to assess its efficacy and safety. Methods- Patients registered between March 2014 and June 2016 in the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke), including all patients treated with endovascular treatment in the Netherlands, were analyzed. The primary outcome was functional outcome (modified Rankin Scale) at 90 days. Secondary outcomes were successful recanalization (extended Thrombolysis in Cerebral Infarction ≥2B), symptomatic intracranial hemorrhage, and mortality at 90 days. We used multilevel regression analysis to evaluate the association of periprocedural intravenous heparin on outcomes, adjusted for center effects and prognostic factors. To account for possible unobserved confounding by indication, we analyzed the effect of center preference to administer intravenous heparin, defined as percentage of patients treated with intravenous heparin in a center, on functional outcome. Results- One thousand four hundred eighty-eight patients from 16 centers were analyzed, of whom 398 (27%) received intravenous heparin (median dose 5000 international units). There was substantial between-center variability in the proportion of patients treated with intravenous heparin (range, 0%-94%). There was no significant difference in functional outcome between patients treated with intravenous heparin and those without (adjusted common odds ratio, 1.17; 95% CI, 0.87-1.56), successful recanalization (adjusted odds ratio, 1.24; 95% CI, 0.89-1.71), symptomatic intracranial hemorrhage (adjusted odds ratio, 1.13; 95% CI, 0.65-1.99), or mortality (adjusted odds ratio, 0.95; 95% CI, 0.66-1.38). Analysis at center level showed that functional outcomes were better in centers with higher percentages of heparin administration (adjusted common odds ratio, 1.07 per 10% more heparin, 95% CI, 1.01-1.13). Conclusions- Substantial between-center variability exists in periprocedural intravenous heparin use during endovascular treatment, but the treatment is safe. Centers using heparin more often had better outcomes. A randomized trial is needed to further study these effects.

Role of Postoperative Anticoagulation in Predicting Digit Replantation and Revascularization Failure: A Propensity-matched Cohort Study.

The use of intravenous heparin after digit replantation or revascularization (DRR) varies greatly. The insufficient evidence presents a lack of clinical equipoise needed for a randomized trial; as such, a matched propensity score analysis was performed to evaluate the role of postoperative anticoagulation after DRR. The purpose of this study was to determine if the use of postoperative therapeutic anticoagulation reduced the risk of digit failure. A retrospective cohort of patients who underwent DRR from 2005 to 2016 was identified. A propensity score was calculated based on age, smoking, injury mechanism, procedure type, vein graft, and number of digits injured. Patients were matched 1:2 by propensity score to create 2 groups with similar risks of receiving anticoagulation postoperatively. Generalized estimating equation logistic model was used to determine differences in digit failure between groups. Digit replantation or revascularization was performed on 282 patients (92% male; median age, 43 years). Postoperative anticoagulation was administered in 69 (24%) patients, with continuous IV heparin in 34 patients and intravenous heparin with dextran in 35 patients. Digit failure occurred in 88 patients overall, representing 38% of patients receiving anticoagulation and 29% of those not. Major complications were higher among the anticoagulated patients (13% vs 3.3%). After propensity score matching, use of anticoagulation was not associated with digit failure (odds ratio, 0.79; 95% confidence interval, 0.47-1.32). Among DRR patients with similar predisposing characteristics for postoperative therapeutic heparin or dextran, the use of therapeutic anticoagulation does not have a protective effect against digit failure. Studies are needed to define the role of postoperative IV anticoagulation in DRR and to justify the risk of its administration.

Abstract WP318: Reduced Infarct Growth With IV Heparin in Acute Ischemic Stroke

Background: The role of IV heparin in acute ischemic stroke (AIS) is controversial. We investigated the effect of IV heparin on ischemic lesion growth. Methods: We analyzed data on 274 consecutive AIS patients with non-lacunar stroke prospectively enrolled in a study where diffusion/perfusion MRI (DWI-PWI) was completed &lt;12 hrs after last seen well and a follow-up MRI/CT completed after day 4. We excluded patients treated with tPA, and those with MTT-DWI mismatch &lt;20% of the DWI volume or absolute mismatch volume &lt;10 mL. Lesion growth was assessed by (a) Absolute Lesion Growth , i.e. final infarct volume - admission DWI lesion volume, and (b) Percentage mismatch lost (PML) , i.e. (final infarct volume - admission DWI volume)/(mismatch volume)x100%. Image analysis was blinded to clinical data. Univariable and multivariable analysis were performed to determine the effects of IV heparin on infarct growth. Results: N=113 met inclusion/exclusion criteria; 52 received IV heparin shortly after admission. Results of the univariable analysis are shown in Table 1. Heparin use was associated with smaller PML (p&lt;0.05); there was approximately 5-fold difference in PML between heparin users and non-users. Absolute lesion growth was significantly associated with admission glucose, blood pressure, NIHSS score, DWI volume and stroke etiological subtypes; and there was a trend for association with age and heparin use. Intravenous heparin use was an independent predictor of both PML and absolute lesion growth (Table 2), and was associated with better 3-month outcomes (modified Rankin scale score 0-2, 80% vs. 57%, p=0.04). Conclusion: These data suggest that IV heparin administration early after stroke may attenuate the progression of ischemic brain injury in non-thrombolyzed patients with significant ischemic penumbra.

Impact of Guidelines on Clinical Practice: Intravenous Heparin Use for Acute Ischemic Stroke.

Since its introduction, controversy has existed about the administration of intravenous heparin for the treatment of acute ischemic stroke. We studied trends in the intravenous heparin use during a 6-year time period and the potential influence of clinical guidelines in national language on intravenous heparin administration in Korea. On the basis of a prospective nationwide multicenter stroke registry, we collected data on patients with acute ischemic stroke who arrived within 7 days of symptom onset during the time period 2008 to 2013. We studied patient demographics, prestroke medical history, stroke characteristics, and stroke treatment. Data from a total of 23 425 patients from 12 university hospitals or regional stroke centers were analyzed. The administration of intravenous heparin steadily decreased throughout the study period: 9.7% in 2008, 10.9% in 2009, 9.4% in 2010, 6.0% in 2011, 4.7% in 2012, and 4.3% in 2013 (P for trend <0.001). The reduced intravenous heparin use was associated with moderate stroke severity, atrial fibrillation, and stroke of cardioembolic, other-, and undetermined etiology. In a multivariable logistic model, increase of 1 calendar year (odds ratio, 0.89; 95% confidence interval, 0.84-0.95; P<0.001) and release of clinical practice guidelines in Korean (odd ratio, 0.74; 95% confidence interval, 0.59-0.91; P<0.01) were independent factors associated with reduction in the frequency of intravenous heparin use. Use of intravenous heparin for acute ischemic stroke treatment has decreased in Korea, and this change may be attributable to the spread and successful implementation of regional clinical practice guidelines.

Abstract W P312: Secular Trends of Intravenous Heparin Use for Acute Ischemic Stroke in Korea: From 2008 To 2013

Background: Since the introduction of intravenous (IV) heparin for the treatment of acute ischemic stroke in 1941, its use has been an area of great controversy among neurologists. Current American Heart Association guideline does not recommend IV heparin for the treatment of acute ischemic stroke. We sought to obtain updated information regarding the practices of Korean neurologists with regard to acute heparin use. Methods: Based on a prospective multicenter stroke registry database (CRCS-5), we collected patients with acute ischemic stroke, arrived within 7 days of symptom onset, from 2008 to 2013. Patient’s demographics, medical history and stroke characteristics were compared between IV heparin user and non-user. Results: Total of 23,425 patients from 12 regional stroke centers or university hospitals across the nation was analyzed. The mean age was 67.8 years and 58.1% was male. Median initial NIHSS score was 4 (interquartile range, 2 - 9). Large artery atherosclerosis was the most common cause of acute ischemic stroke (37.1%), followed by cardioembolism (21.9%), and small-vessel occlusion (18.9%). During the study period, use of IV heparin decreased; 9.7% in 2008; 10.9% in 2009; 9.4% in 2010; 6.0% in 2011; 4.7% in 2012; 4.3% in 2013 (p for trend &lt; 0.001). The most prominent reduction was observed between 2010 and 2011, just after the first release of the Korean Stroke Guidelines in October, 2009. Cardioembolism (17.1%) and stroke of two or more causes (15.3%) were associated with IV heparin, and the decrease of IV heparin use in these stroke subtypes was a major contributor of the decrease in general. Age (age ≥ 75, 7.5%; age &lt;75, 6.6%; p = 0.014), initial stroke severity (NIHSS &lt; 5, 5.4%; NIHSS 5 - 24, 8.7%; NIHSS ≥ 25, 9.5%; p &lt; 0.001), and atrial fibrillation on electrocardiogram (atrial fibrillation, 19.9%; non-atrial fibrillation, 4.2%; p &lt; 0.001) were also associated with IV heparin. Conclusions: Use of IV heparin for patients with acute ischemic stroke is decreasing in Korea, and this change may be explained by the development and spread of the national stroke guidelines in the Korean language.

Risk factors for bleeding after endoscopic submucosal dissection of colorectal neoplasms

To investigate the risk factors for delayed bleeding following endoscopic submucosal dissection (ESD) treatment for colorectal neoplasms. We retrospectively reviewed the medical records of 317 consecutive patients with 325 lesions who underwent ESD for superficial colorectal neoplasms at our hospital from January 2009 to June 2013. Delayed post-ESD bleeding was defined as bleeding that resulted in overt hematochezia 6 h to 30 d after ESD and the observation of bleeding spots as confirmed by repeat colonoscopy or a required blood transfusion. We analyzed the relationship between risk factors for delayed bleeding following ESD and the following factors using univariate and multivariate analyses: age, gender, presence of comorbidities, use of antithrombotic drugs, use of intravenous heparin, resected specimen size, lesion size, lesion location, lesion morphology, lesion histology, the device used, procedure time, and the presence of significant bleeding during ESD. Delayed post-ESD bleeding was found in 14 lesions from 14 patients (4.3% of all specimens, 4.4% patients). Patients with episodes of delayed post-ESD bleeding had a mean hemoglobin decrease of 2.35 g/dL. All episodes were treated successfully using endoscopic hemostatic clips. Emergency surgery was not required in any of the cases. Blood transfusion was needed in 1 patient (0.3%). Univariate analysis revealed that lesions located in the cecum (P = 0.012) and the presence of significant bleeding during ESD (P = 0.024) were significantly associated with delayed post-ESD bleeding. The risk of delayed bleeding was higher for larger lesion sizes, but this trend was not statistically significant. Multivariate analysis revealed that lesions located in the cecum (OR = 7.26, 95%CI: 1.99-26.55, P = 0.003) and the presence of significant bleeding during ESD (OR = 16.41, 95%CI: 2.60-103.68, P = 0.003) were independent risk factors for delayed post-ESD bleeding. Location in the cecum and significant bleeding during ESD predispose patients to delayed post-procedural bleeding. Therefore, careful and additional management is recommended for these patients.

Incidence of heparin-induced thrombocytopenia type II and postoperative recovery of platelet count in liver graft recipients: a retrospective cohort analysis

BackgroundThrombocytopenia in patients with end-stage liver disease is a common disorder caused mainly by portal hypertension, low levels of thrombopoetin, and endotoxemia. The impact of immune-mediated heparin-induced thrombocytopenia type II (HIT type II) as a cause of thrombocytopenia after liver transplantation is not yet understood, with few literature citations reporting contradictory results. The aim of our study was to demonstrate the perioperative course of thrombocytopenia after liver transplantation and determine the occurrence of clinical HIT type II. MethodWe retrospectively evaluated the medical records of 205 consecutive adult patients who underwent full-size liver transplantation between January 2006 and December 2010 due to end-stage or malignant liver disease. Preoperative platelet count, postoperative course of platelets, and clinical signs of HIT type II were analyzed. ResultsA total of 155 (75.6%) of 205 patients had thrombocytopenia before transplantation, significantly influenced by Model of End-Stage Liver Disease score and liver cirrhosis. The platelet count exceeded 100,000/μL in most of the patients (n = 193) at a medium of 7 d. Regarding HIT II, there were four (1.95%) patients with a background of HIT type II. ConclusionsThe incidence of HIT in patients with end-stage hepatic failure is, with about 1.95%, rare. For further reduction of HIT type II, the use of intravenous heparin should be avoided and the prophylactic anticoagulation should be performed with low-molecular-weight heparin after normalization of platelet count.

Burning Bridges: Must Warfarin Be Stopped for Device Implantation?

Warfarin increases the risk for bleeding. Surgery is associated with bleeding. The intuitive inference that patients should discontinue chronic warfarin therapy before undergoing surgery, combined with concern about the ensuing thromboembolic risk, has led to the standard use of intravenous heparin or subcutaneous low-molecular-weight heparin as an anticoagulation “bridge” during warfarin …

A perioperative infusion of sodium bicarbonate does not improve renal function in cardiac surgery patients: a prospective observational cohort study

IntroductionCardiac-surgery-associated-acute-kidney-injury (CSA-AKI) is associated with increased morbidity and mortality. Recent data from patients undergoing on-pump coronary artery bypass grafting suggest that a perioperative infusion of sodium-bicarbonate may decrease the incidence of CSA-AKI. The present study aims to analyze the renoprotective effects of a 24h infusion of sodium-bicarbonate in a large, heterogeneous group of cardiac surgical patientsMethodsStarting in 4/2009, all patients undergoing cardiac surgery at our institution were enrolled in a prospective trial analyzing the relationship between preoperative cerebral oxygen saturation and postoperative organ dysfunction. We used this prospectively sampled data set to perform a cohort analysis of the renoprotective efficiency of a 24h continuous perioperative infusion of sodium-bicarbonate on the incidence of CSA-AKI that was routinely introduced in 7/2009. After exclusion of patients with endstage chronic kidney disease, off-pump procedures, and emergency cases, perioperative changes in renal function were assessed in 280 patients treated with a perioperative infusion of 4 mmol sodium-bicarbonate / kg body weight in comparison with a control cohort of 304 patients enrolled from April to June in this prospective cohort study.Postoperative changes in urine flow, plasma creatinine, estimated creatinine clearance, and the need for renal replacement therapy were determined according to AKI injury network criteria. Concomitantly, hemodynamics, treatments, complications, and clinical outcomes were recorded. Univariate statistical analyses were performed para- and nonparametrically, as appropriate.ResultsWith the exception of a lower prevalence of a history of myocardial infarction and a lower preoperative use of intravenous heparin in the bicarbonate-group, no significant between group differences in patient demographics, surgical risk, type, and duration of surgery were observed. Patients in the bicarbonate group had a lower mean arterial blood pressure after induction of anesthesia, needed more fluids, more vasopressors, and a longer treatment time in the high dependency unit. Despite a higher postoperative diuresis, no differences in the incidence of AKI grade 1 to 3 and the need for renal replacement were observed.ConclusionsRoutine perioperative administration of sodium bicarbonate failed to improve postoperative renal function in a large population of cardiac surgical patients.

Intravenous heparin use in digital replantation and revascularization: The Quebec provincial replantation program experience

No consensus exists among microsurgeons regarding the role of intravenous (IV) heparin in digital replantation/revascularization. The current experience of the Provincial Replantation Center in Quebec was reviewed over a 4-year period. An initial retrospective review of all revascularized or reimplanted digits at our Replantation Center from April 2004 to April 2006 was conducted. Then, data of all patients treated at our center from January 08 to September 08 were prospectively collected. The two cohorts were compared with regards to demographics, injury characteristics, postoperative thromboprophylaxis medication as well as complication and success rates. Proportions were compared using χ(2) tests/Fisher's exact tests. Multivariate analysis was conducted with logistic regression. 175 digits were treated from April 2004 to April 2006, including 104 revascularizations and 71 amputations. IV heparin was used in 35.1% of the cases and was associated with a 3.59-fold (95% CI, 1.55-8.31) increase risk of developing a complication compared with cases where heparin was not used (P = 0.001). In 2008, 106 digits were treated. IV heparin was used in 14.6% of the cases and was not significantly associated with a higher complication rate compared with cases where heparin was not used (P = 0.612). Both cohorts' success rates were very similar (P = 0.557). The number of complications decreased from the first period (20.5%) to the second one (12.8%). Routine use of IV heparin following digital replantation and revascularization is not warranted. Surgical technique and type of injury remains the most important predictors for success in these complex procedures.

Bleeding complications of unfractionated heparin

Introduction: Unfractionated heparin is an anticoagulant used in the treatment of myocardial infarction, pulmonary embolism and other thrombotic disorders. However, with anticoagulation comes the risk of bleeding and adverse events. These risks increase with supratherapeutic dosing.Areas covered: In this review, we discuss the reasons for supratherapeutic dosing, and the incidence of adverse events and clinical consequences of the same, with a focus on heparin use in acute coronary syndromes. We also provide some opportunities for safer use of intravenous heparin. At the end of this article, the reader should have a better understanding of the proper use of heparin as well as the magnitude of bleeding and a respect for its consequences.Expert opinion: Heparin is an indispensable anticoagulant used in a number of clinical scenarios. Careful attention must be paid to dosing in order to minimize the risk of bleeding and related adverse events including death. The use of weight-based nomograms is paramount. Devices to automate testing and titration are currently under development.

Risk of Hematoma Complications After Device Implant in the Clopidogrel Era

Device implant pocket hematoma is a recognized complication after permanent pacemaker (PM) and implantable cardioverter-defibrillator (ICD) implantation. Pocket hematoma is associated with local discomfort, an increased risk of infection, and may require surgical intervention or lead to lengthier hospital stays. The purpose of the study was to identify the clinical factors associated with hematoma formation after PM or ICD device implantation. The subjects of this prospective observational study were 935 consecutive patients at Beaumont Hospital who underwent implantation of a PM or an ICD. Clinical characteristics and anticoagulant/antiplatelet drug use were recorded. A pocket hematoma was documented in 89 of 935 patients. Significant predictors of device pocket hematoma included ongoing clopidogrel therapy (18.3% on therapy, 10.5% recently discontinued, and 7.9% off therapy; P<0.001) and use of intravenous heparin (22.0% on therapy versus 8.2%; P<0.0001). Patients in whom clopidogrel was discontinued >4 days before device implantation had no hematoma. Hematomas occur more frequently in patients receiving ICDs than those receiving PMs. Device pocket hematoma was associated with an increased median length of hospital stay (4 days [interquartile range, 1 to 9] days with versus 2 days [ interquartile range, 1 to 6] days without hematoma; P=0.004) and increased late complications or surgical intervention. The use of clopidogrel or intravenous heparin significantly increased the risk of hematoma at the time of PM or ICD implantation. By withholding clopidogrel before surgery, the excess risk of bleeding complications may be reduced.

Nurse-Driven Intravenous Heparin Protocol

Background Safe use of intravenous heparin is an important safety goal. Objective To improve the quality of intravenous heparin use. Methods A pre-post intervention design assessed the number of patients who reached a therapeutic activated partial thromboplastin time (aPTT), time to aPTT goal, and complications. Fifty traditional care patients were compared with 50 nurse-driven intravenous heparin protocol patients. The data were used to assess the effectiveness of a developed intervention package to improve the quality of intravenous heparin use. Results Sixteen percent of the preintervention group never reached the therapeutic goal compared with 8% in the postintervention group (P &amp;lt; .05). Mean time to achieve first therapeutic aPTT was 18.6 hours in the preintervention group compared with 15.2 hours in the postintervention group (P = .33). Neither group noted complications. Conclusions The multidisciplinary team approach produced improved patient care outcomes and important lessons for improving the quality of intravenous heparin use.