1
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Gao P, Zhang Y, Jin Y, Zhang P, Wang W, Liu J. Development and Validation of a Nomogram for Predicting Heparin Resistance in Neonates and Young Infants Undergoing Cardiac Surgery: A Retrospective Study. Anesth Analg 2024; 138:1233-1241. [PMID: 37216291 PMCID: PMC11081478 DOI: 10.1213/ane.0000000000006507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Heparin resistance (HR) is a common finding in pediatric cardiac surgery and generally refers to decreased sensitivity to heparin. Antithrombin (AT) deficiency is considered the primary mechanism of HR; however, the etiology of HR may be multifactorial. Early identification of HR might help optimize heparin anticoagulation management. This study aimed to develop a predictive nomogram for HR in neonates and young infants undergoing cardiac surgery. METHODS From January 2020 to August 2022, a total of 296 pediatric patients 1 to 180 days of age were included in this retrospective study. The patients were randomly divided into development and validation cohorts in a 7:3 ratio. Univariable logistic regression and the Least Absolute Shrinkage and Selection Operator (LASSO) regularization were used for variable selection. A multivariable logistic regression was performed to identify predictors and establish a nomogram to predict HR risk. Discrimination, calibration, and clinical usefulness were assessed in the development and validation cohorts. RESULTS After the multistep variable selection, AT activity, platelet count, and fibrinogen were predictors for HR in neonates and young infants. The prediction model constructed using these 3 factors achieved an area under the receiver operating characteristic curve (ROC-AUC) of 0.874 and 0.873 in the development and validation cohorts. The Hosmer-Lemeshow test did not find evidence of a lack of fit ( P = .768). The calibration curve of the nomogram was close to the ideal diagonal line. Furthermore, the model performed well in neonate and infant subgroups. CONCLUSIONS A nomogram based on preoperative variables was developed to predict the HR risk in neonates and young infants undergoing cardiac surgery. This provides clinicians with a simple tool for the early prediction of HR, which may help optimize heparin anticoagulation strategies in this vulnerable patient population.
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Affiliation(s)
- Peng Gao
- From the Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Zhang
- Department of Laboratory Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Jin
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peiyao Zhang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenting Wang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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2
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Bader SO, Marinaro XF, Stone G, Lodaya K, Spears JB, Shander A. Antithrombin concentrates may benefit cardiopulmonary bypass patients with suspected heparin resistance: A retrospective analysis of real-world data. Heliyon 2023; 9:e19497. [PMID: 37809512 PMCID: PMC10558716 DOI: 10.1016/j.heliyon.2023.e19497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 10/10/2023] Open
Abstract
Background Heparin resistance is a common complication of surgical patients requiring anticoagulation, such as those undergoing cardiopulmonary bypass (CPB). Treatments to address heparin resistance include supplementation of antithrombin (AT) or fresh frozen plasma (FFP). This retrospective database analysis compared key outcomes in suspected heparin-resistant patients undergoing CPB treated with AT or FFP. Methods De-identified United States electronic health records (Cerner Health Facts®) were queried. International Classification of Diseases (ICD-9/10) codes were used to determine CPB procedures and FFP administration. AT administration was identified using medication data, while a combination of lab and medication data examining activated clotting times detected heparin resistance in FFP patients. Adult inpatients (≥18 years old) seen between 2001 and 2018 were included. Differences in mortality, intensive care unit (ICU) length of stay (LOS), and hospital-free days (using a 30-day post-discharge period) were assessed with univariate models as well as adjusted logistic regression models controlling for patient characteristics and Charlson Comorbidity Index (CCI) scores. Results Of the 502 patients identified, 247 received AT and 255 received FFP. The FFP cohort was associated with a higher CCI compared to the AT cohort (3.3 ± 2.4 vs. 2.3 ± 2.0, P < .001). The AT cohort was associated with a 71% (Odds Ratio [OR]: 0.29, 95% Confidence Interval [CI]: P = .003) and 66% (OR: 0.34, 95% CI: P = .01) reduction in mortality when compared to FFP using univariate and adjusted logistic regression models, respectively. Similarly, use of AT also showed a 22% shorter ICU LOS (P = .02) and 10% more hospital-free days in the 30 days following discharge (P = .004) according to the univariate models, though statistical significance was absent within adjusted models in both ICU LOS (P = .08) and hospital-free days (P = .53). Conclusions Compared to FFP, AT use suggests a reduction in the odds of mortality in suspected heparin-resistant patients undergoing CPB, though larger prospective studies are necessary to elucidate potential differences in hospital-free days or ICU LOS across treatment modalities.
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Affiliation(s)
- Stephen O. Bader
- Heritage Valley Health System-Beaver, Department of Anesthesiology, USA
| | | | - Glenda Stone
- Grifols Shared Services North America, Inc., USA
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3
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Khuong JN, Forsyth CJ, Manuel L, Kingsford-Smith K, Srivastava A, Bassin L. Paraprotein associated heparin resistance during cardiopulmonary bypass. Perfusion 2023; 38:1319-1321. [PMID: 35700111 DOI: 10.1177/02676591221109143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Heparin resistance during cardiopulmonary bypass poses a significant intraoperative dilemma. Antithrombin deficiency related heparin resistance is well described, but less common causes are still poorly understood and inadequately managed. CASE REPORT We present a case of heparin resistance during cardiopulmonary bypass in a gentleman with no previous haematological history or thrombotic risk factors. The patient required three times the regular dose of unfractionated heparin to achieve acceptable conditions to initiate and maintain bypass. The patient was found to have elevated serum immunoglobulin M (IgM) kappa paraprotein on post-operative investigation. DISCUSSION Paraproteins may exhibit non-specific binding to long polymeric chains of unfractionated heparin and inhibits the interaction between heparin and antithrombin. As a result, excessive doses of heparin are required to overcome this, which increases the risk of perioperative bleeding and other complications. CONCLUSION Elevated serum paraprotein levels should be recognised as a cause of heparin resistance during cardiopulmonary bypass.
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Affiliation(s)
- Jacqueline N Khuong
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Cecily J Forsyth
- Department of Medicine, Gosford Hospital, Gosford, NSW, Australia
| | - Lucy Manuel
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Kate Kingsford-Smith
- Perfusion and Autotransfusion Unit, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Arpit Srivastava
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Levi Bassin
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
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4
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Cartwright B, Mundell N. Anticoagulation for cardiopulmonary bypass: part one. BJA Educ 2023; 23:110-116. [PMID: 36844440 PMCID: PMC9947996 DOI: 10.1016/j.bjae.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 01/25/2023] Open
Affiliation(s)
- B. Cartwright
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- University of Sydney, Sydney, NSW, Australia
| | - N. Mundell
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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5
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Procaccini DE, Roem J, Ng DK, Rappold TE, Jung D, Gobburu JVS, Bembea MM. Evaluation of acquired antithrombin deficiency in paediatric patients supported on extracorporeal membrane oxygenation. Br J Clin Pharmacol 2023. [PMID: 36850024 DOI: 10.1111/bcp.15703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/10/2023] [Accepted: 02/12/2023] [Indexed: 03/01/2023] Open
Abstract
AIMS There remains a paucity of literature regarding best practice for antithrombin (AT) monitoring, dosing and dose-response in paediatric extracorporeal membrane oxygenation (ECMO) patients. METHODS We conducted a retrospective cohort study at a quaternary care paediatric intensive care unit in all patients <18 years of age supported on ECMO from 1 June 2011 to 30 April 2020. Adverse events and outcomes were characterized for all ECMO runs. AT activity and replacement were characterized and compared between two clinical protocols. AT activities measured post- vs. pre-AT replacement were compared in order to characterize a dose-response relationship. RESULTS The final cohort included 191 patients with 201 ECMO runs and 2028 AT activity measurements. The median AT activity was 65% (interquartile range [IQR], 51-82) and 879 (43.3%) measurements met the criteria of deficient. The overall median AT dose and increase in AT activity were 50.6 units/kg/dose (IQR, 39.5-67.2) and 23.5% (IQR, 9.8-36.0), respectively. In the protocol that restricted AT activity measurements to clinical scenarios concerning for heparin resistance, there was significantly higher dosing in conjunction with significantly fewer overall administrations. Approximately one third of AT activity remained deficient after repletion. There was no difference in mechanical complications, reasons for discontinuation of ECMO support, time on ECMO or survival between protocols. CONCLUSIONS There was a high prevalence of AT deficiency in paediatric ECMO patients. An AT replacement protocol based on evaluating heparin resistance is associated with fewer AT administrations, with similar circuit and patient outcomes. Further data are needed to identify optimal dosing strategies.
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Affiliation(s)
- David E Procaccini
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jennifer Roem
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Thomas E Rappold
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dawoon Jung
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Jogarao V S Gobburu
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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6
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Research progress of nephrotic syndrome accompanied by thromboembolism. Int Urol Nephrol 2023:10.1007/s11255-023-03474-8. [PMID: 36757656 DOI: 10.1007/s11255-023-03474-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 01/19/2023] [Indexed: 02/10/2023]
Abstract
Thromboembolism (TE) is a common and serious complication of nephrotic syndrome (NS). NS is associated with hypercoagulability, which may be induced by changes in coagulation, anticoagulant, and fibrinolytic factors. Moreover, accumulating evidence supports the hypothesis that the complex interactions between genetic and acquired risk factors in TE should be considered and that genetic susceptibility should not be ignored. Extracellular vesicles (EVs) also play unique roles. Further research on EVs may provide new insights into the discovery and treatment of TE associated with NS. The occurrence of NS accompanied by TE may be associated with various risk factors. Preventive anticoagulant therapy can not only reduce the risk of TE in patients but also aggravate the risk of bleeding. Heparin and vitamin K antagonists (VKAs), traditional anticoagulant drugs, have been extensively applied in the prevention and treatment of thromboembolic diseases, and emerging direct oral anticoagulants (DOACs) also provide an alternative choice. Owing to the particularity of NS, the safe application of DOACs still needs to be addressed. This review aimed to comprehensively describe the pathophysiology of TE in NS, as well as analyze the associated risk factors, the opportunity for preventive anticoagulation, and current anticoagulant information.
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7
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Rodgers GM, Mahajerin A. Antithrombin Therapy: Current State and Future Outlook. Clin Appl Thromb Hemost 2023; 29:10760296231205279. [PMID: 37822179 PMCID: PMC10571690 DOI: 10.1177/10760296231205279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 10/13/2023] Open
Abstract
Antithrombin (AT) is a natural anticoagulant pivotal in inactivating serine protease enzymes in the coagulation cascade, making it a potent inhibitor of blood clot formation. AT also possesses anti-inflammatory properties by influencing anticoagulation and directly interacting with endothelial cells. Hereditary AT deficiency is one of the most severe inherited thrombophilias, with up to 85% lifetime risk of venous thromboembolism. Acquired AT deficiency arises during heparin therapy or states of hypercoagulability like sepsis and premature infancy. Optimization of AT levels in individuals with AT deficiency is an important treatment consideration, particularly during high-risk situations such as surgery, trauma, pregnancy, and postpartum. Here, we integrate the existing evidence surrounding the approved uses of AT therapy, as well as potential additional patient populations where AT therapy has been considered by the medical community, including any available consensus statements and guidelines. We also describe current knowledge regarding cost-effectiveness of AT concentrate in different contexts. Future work should seek to identify specific patient populations for whom targeted AT therapy is likely to provide the strongest clinical benefit.
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Affiliation(s)
- George M. Rodgers
- Division of Hematology, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Arash Mahajerin
- Division of Hematology, Children's Hospital of Orange County, Orange, CA, USA
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8
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Chen Y, Phoon PHY, Hwang NC. Heparin Resistance During Cardiopulmonary Bypass in Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2022; 36:4150-4160. [PMID: 35927191 PMCID: PMC9225936 DOI: 10.1053/j.jvca.2022.06.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/09/2022] [Accepted: 06/17/2022] [Indexed: 12/15/2022]
Abstract
The use of heparin for anticoagulation has changed the face of cardiac surgery by allowing a bloodless and motionless surgical field throughout the introduction of cardiopulmonary bypass (CPB). However, heparin is a drug with complex pharmacologic properties that can cause significant interpatient differences in terms of responsiveness. Heparin resistance during CPB is a weighty issue due to the catastrophic consequences stemming from inadequate anticoagulation, and the treatment of it necessitates a rationalized stepwise approach due to the multifactorial contributions toward this entity. The widespread use of activated clotting time (ACT) as a measurement of anticoagulation during CPB is examined, as it may be a false indicator of heparin resistance. Heparin resistance also has been repeatedly reported in patients infected with COVID-19, which deserves further exploration in this pandemic era. This review aims to examine the variability in heparin potency, underlying mechanisms, and limitations of using ACT for monitoring, as well as provide a framework towards the current management of heparin resistance.
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Affiliation(s)
- Yufan Chen
- Department of Anaesthesiology, Singapore General Hospital, Singapore,Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore
| | - Priscilla Hui Yi Phoon
- Department of Anaesthesiology, Singapore General Hospital, Singapore,Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore.
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9
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Müther M, Schwindt W, Mesters RM, Minnerup J, Stracke P, Holling M, Wiendl H, Stummer W. Andexanet-Alfa-Associated Heparin Resistance in the Context of Hemorrhagic Stroke. Neurocrit Care 2022; 37:372-376. [PMID: 35931915 PMCID: PMC9519708 DOI: 10.1007/s12028-022-01573-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/08/2022] [Indexed: 11/28/2022]
Abstract
Background With a growing number of patients on new oral anticoagulants, interest in reversal agents is rising. Andexanet alfa is used for reversal of factor Xa inhibitors in intracranial hemorrhage. Methods We provide a brief review on andexanet-alfa-associated heparin resistance and discuss potentially critical situations from different clinical perspectives. Results Case reports point out that andexanet alfa can cause unresponsiveness to heparin, leading to catastrophic events. As a result, regulatory bodies have issued warning notices to avoid heparinization parallel to the use of andexanet alfa. Conclusions Although well known to hematologists, the phenomenon is underrecognized among stroke clinicians. However, patients with intracranial hemorrhage frequently undergo endovascular or surgical interventions that require periprocedural administration of heparin.
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Affiliation(s)
- Michael Müther
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Münster, Germany.
| | - Wolfram Schwindt
- Section of Interventional Neuroradiology, Department of Radiology, University Hospital Münster, Münster, Germany
| | - Rolf Michael Mesters
- Department of Medicine A-Hematology, Oncology, Hemostaseology, and Pneumology, University Hospital Münster, Münster, Germany
| | - Jens Minnerup
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Paul Stracke
- Section of Interventional Neuroradiology, Department of Radiology, University Hospital Münster, Münster, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Münster, Germany
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10
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Wahba A, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Puis L. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Eur J Cardiothorac Surg 2021; 57:210-251. [PMID: 31576396 DOI: 10.1093/ejcts/ezz267] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav's University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
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11
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Kumar G, Maskey A. Anticoagulation in ECMO patients: an overview. Indian J Thorac Cardiovasc Surg 2021; 37:241-247. [PMID: 33967447 DOI: 10.1007/s12055-021-01176-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 12/16/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a form of cardiorespiratory support, and is being increasingly used to support refractory heart and respiratory failure. It involves draining blood from the vascular system, which is then circulated outside the body by a mechanical pump and then later reinfused back into the circulation. The blood that is circulated outside the body comes in contact with a large surface area of non-endothelial biosurface. This exposure leads to a pro-thrombotic state, and hence anticoagulation is required. Unfractionated heparin is the most commonly used anticoagulation in most ECMO centers, but it does require close monitoring. Despite the advances made, hemostasis remains a challenge for physicians who manage patients on ECMO.
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Affiliation(s)
- Gaurav Kumar
- Department of Pulmonary Critical Care and Sleep Medicine, University of Kentucky, 740 S. Limestone, Second Floor, Wing C, Room 211, Lexington, KY 40536 USA
| | - Ashish Maskey
- Department of Pulmonary Critical Care and Sleep Medicine, Kentucky Clinic, University of Kentucky, 740 S. Limestone, 5th Floor L543, Lexington, KY 40536 USA
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12
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Comparison of Antithrombin III Products in Pediatric Patients Receiving Extracorporeal Membrane Oxygenation. ASAIO J 2021; 66:1042-1047. [PMID: 31977357 DOI: 10.1097/mat.0000000000001124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The study investigated the safety and efficacy of two antithrombin III (ATIII) products in pediatric patients receiving extracorporeal membrane oxygenation (ECMO) by performing a retrospective analysis of patients who received either recombinant ATIII (rATIII) or human-derived ATIII (hATIII). Twenty-two patients were included in the study from January 2014 to September 2015 and all received unfractionated heparin (UFH) as anticoagulation during ECMO. In total, 86 doses of ATIII were included in the analysis in which 37 doses (43%) were rATIII and 49 doses (57%) were hATIII. Unfractionated heparin rates were also evaluated for all cases (n = 86) at 24 hours post-ATIII supplementation. The UFH rate decreased after the administration of both types of ATIII. However, neither the reduction in UFH rate between the two ATIII products (p = 0.52) nor the UFH rates pre- and post-ATIII supplementation at 24 hours (p = 0.08) reached statistical significance. There was a significant difference in cost favoring the rATIII product (p < 0.0001). An ad-hoc estimation of waste associated with ATIII supplementation showed >$100,000 in financial loss of unused drug. Future studies are warranted to evaluate the efficacy of ATIII supplementation in pediatric ECMO.
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13
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Gazzaruso C, Paolozzi E, Valenti C, Brocchetta M, Naldani D, Grignani C, Salvucci F, Marino F, Coppola A, Gallotti P. Association between antithrombin and mortality in patients with COVID-19. A possible link with obesity. Nutr Metab Cardiovasc Dis 2020; 30:1914-1919. [PMID: 32907762 PMCID: PMC7386389 DOI: 10.1016/j.numecd.2020.07.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/18/2020] [Accepted: 07/24/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIMS Despite anticoagulation, usually with heparin, mortality for thromboembolic events in COVID-19 remains high. Clinical efficacy of heparin is due to its interaction with antithrombin (AT) that may be decreased in COVID-19. Therefore, we correlated AT levels with outcomes of COVID-19. METHODS AND RESULTS We recruited 49 consecutive patients hospitalized for COVID-19. AT levels were significantly lower in 16 non-survivors than in 33 survivors (72.2 ± 23.4 versus 94.6 ± 19.5%; p = 0.0010). A multivariate Cox regression analysis showed that low AT (levels below 80%) was a predictor of mortality (HR:3.97; 95%CI:1.38 to 11.43; p = 0.0103). BMI was the only variable that showed a significant difference between patients with low and those with normal AT levels (32.9 ± 7.9 versus 27.5 ± 5.9%; p = 0.0104). AT levels were significantly lower in obese patients than in subjects with normal weight or overweight (77.9 ± 26.9 versus 91.4 ± 26.9 versus 91.4 ± 17.1%; p = 0.025). An inverse correlation between AT levels and BMI was documented (r:-0.33; p = 0.0179). CONCLUSIONS Our data first suggest that AT is strongly associated with mortality in COVID-19. In addition, AT may be the link between obesity and a poorer prognosis in patients with COVID-19. Other studies should confirm whether AT may become a prognostic marker and a therapeutic target in COVID-19.
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Affiliation(s)
- Carmine Gazzaruso
- Emergency Unit and Endocrinology Unit, Istituto Clinico "Beato Matteo" (Hospital Group San Donato), Vigevano, Italy; Centre for Applied Clinical Research (Ce.R.C.A.), Istituto Clinico "Beato Matteo" (Hospital Group San Donato), Vigevano, Italy.
| | - Enrico Paolozzi
- Intensive Care Unit, Istituto Clinico "Beato Matteo" (Hospital Group San Donato), Vigevano, Italy
| | - Cinzia Valenti
- Cardiology Unit, Istituto Clinico "Beato Matteo" (Hospital Group San Donato), Vigevano, Italy
| | - Mauro Brocchetta
- Emergency Unit and Endocrinology Unit, Istituto Clinico "Beato Matteo" (Hospital Group San Donato), Vigevano, Italy
| | - Daniela Naldani
- Clinical Pathology, Istituto Clinico "Beato Matteo" (Hospital Group San Donato), Vigevano, Italy
| | - Claudio Grignani
- Internal Medicine Unit, Istituto Clinico "Beato Matteo" (Hospital Group San Donato), Vigevano, Italy
| | - Fabrizio Salvucci
- Cardiology Unit, Istituto Clinico "Beato Matteo" (Hospital Group San Donato), Vigevano, Italy
| | - Francesco Marino
- Intensive Care Unit, Istituto Clinico "Beato Matteo" (Hospital Group San Donato), Vigevano, Italy
| | - Adriana Coppola
- Centre for Applied Clinical Research (Ce.R.C.A.), Istituto Clinico "Beato Matteo" (Hospital Group San Donato), Vigevano, Italy
| | - Pietro Gallotti
- Internal Medicine Unit, Istituto Clinico "Beato Matteo" (Hospital Group San Donato), Vigevano, Italy
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15
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Gazzaruso C, Valenti C, Coppola A, Gallotti P. Impact of convalescent and nonimmune plasma on mortality of patients with COVID-19: a potential role for antithrombin. Clin Microbiol Infect 2020; 27:637-638. [PMID: 32919071 PMCID: PMC7480395 DOI: 10.1016/j.cmi.2020.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 08/24/2020] [Accepted: 09/01/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Carmine Gazzaruso
- Emergency Unit and Endocrinology Unit, Istituto Clinico 'Beato Matteo' (Hospital Group San Donato), Vigevano, Italy; Centre for Applied Clinical Research (Ce.R.C.A.), Istituto Clinico 'Beato Matteo' (Hospital Group San Donato), Vigevano, Italy.
| | - Cinzia Valenti
- Cardiology Unit, Istituto Clinico 'Beato Matteo' (Hospital Group San Donato), Vigevano, Italy
| | - Adriana Coppola
- Centre for Applied Clinical Research (Ce.R.C.A.), Istituto Clinico 'Beato Matteo' (Hospital Group San Donato), Vigevano, Italy
| | - Pietro Gallotti
- Internal Medicine Unit, Istituto Clinico 'Beato Matteo' (Hospital Group San Donato), Vigevano, Italy
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Nei SD, Pope HE. Part I: Anticoagulation for unique situations. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Piacente C, Martucci G, Miceli V, Pavone G, Papeo A, Occhipinti G, Panarello G, Lorusso R, Tanaka K, Arcadipane A. A narrative review of antithrombin use during veno-venous extracorporeal membrane oxygenation in adults: rationale, current use, effects on anticoagulation, and outcomes. Perfusion 2020; 35:452-464. [PMID: 32228213 DOI: 10.1177/0267659120913803] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND During extracorporeal membrane oxygenation, the large contact surface between the blood and the extracorporeal circuit causes a continuous activation of coagulation and inflammation. Unfractionated heparin, a glycosaminoglycan that must bind to antithrombin as a cofactor, is currently the standard anticoagulant adopted during extracorporeal membrane oxygenation. Antithrombin, beyond being a potent natural anticoagulant, acts in the cross-talk between coagulation and inflammatory system through anticoagulation and coagulation-independent effects. OBJECTIVES In this review, we describe, in the adult setting of veno-venous extracorporeal membrane oxygenation, the pathophysiological rationale for antithrombin use, the current practice of administration, and the effects of antithrombin on anticoagulation, bleeding, and outcomes. DATA SOURCES Studies on adults (18 years or older) on veno-venous extracorporeal membrane oxygenation published from 1995 to 2018 in order to evaluate the use of antithrombin. RESULTS In adults on veno-venous extracorporeal membrane oxygenation, antithrombin supplementation has a highly pathophysiological rationale since coagulation factor consumption, systemic inflammatory response syndrome, and endothelial activation are triggered by extracorporeal membrane oxygenation. Eleven articles are focused on the topic but among the authors there is no consensus on the threshold for supplementation (ranging from 70% to 80%) as well as on the dose (rarely standardized) and time of administration (bolus vs continuous infusion). Consistently, antithrombin is considered able to achieve better anticoagulation targets in or not in the presence of heparin resistance. The impact of antithrombin administration on bleeding still shows contrasting results. CONCLUSION Antithrombin use in veno-venous extracorporeal membrane oxygenation should be investigated on the threshold for supplementation, dose, and time of administration.
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Affiliation(s)
- Claudia Piacente
- Department of Anesthesia and Intensive Care, IRCCS-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (ISMETT), Palermo, Italy
| | - Gennaro Martucci
- Department of Anesthesia and Intensive Care, IRCCS-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (ISMETT), Palermo, Italy
- Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Vitale Miceli
- Research Department, IRCCS-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (ISMETT), Palermo, Italy
| | - Gaetano Pavone
- Department of Anesthesia and Intensive Care, IRCCS-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (ISMETT), Palermo, Italy
| | - Anna Papeo
- Department of Anesthesia and Intensive Care, IRCCS-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (ISMETT), Palermo, Italy
| | - Giovanna Occhipinti
- Department of Anesthesia and Intensive Care, IRCCS-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (ISMETT), Palermo, Italy
| | - Giovanna Panarello
- Department of Anesthesia and Intensive Care, IRCCS-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (ISMETT), Palermo, Italy
| | - Roberto Lorusso
- Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Maryland, Baltimore, Baltimore, MD, USA
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, IRCCS-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (ISMETT), Palermo, Italy
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Shirozu K, Karashima Y, Yamaura K. Effect of antithrombin in fresh frozen plasma on hemostasis after cardiopulmonary bypass surgery. Perfusion 2020; 36:395-400. [PMID: 32781884 DOI: 10.1177/0267659120948435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Supplementation of fresh frozen plasma immediately after cardiopulmonary bypass is an effective method to enhance clotting ability as coagulation factors are consumed in the extracorporeal circuit during cardiopulmonary bypass. On the other hand, the anticoagulation factors in fresh frozen plasma can also deter the clotting ability. This study investigated the effect of fresh frozen plasma administration on the comprehensive clotting ability following cardiopulmonary bypass. METHODS This prospective observational study included 22 patients scheduled for cardiac surgery. Clotting times and maximum clot firmness were evaluated using the types of rotational thromboelastometry, intrinsic rotational thromboelastometry, and heparinase thromboelastography preoperatively, immediately after cardiopulmonary bypass, and 1 hour after cardiopulmonary bypass. Activated clotting time, antithrombin activity, and heparin concentration were also measured at these time-points. RESULTS Antithrombin activity (62.9 ± 7.2% vs. 51.1 ± 7.4%, p < 0.0001) and activated clotting time (132.6 ± 9.6% vs. 120.0 ± 9.0%, p < 0.001) were significantly higher 1 hour after cardiopulmonary bypass compared to measurements taken immediately after cardiopulmonary bypass. Heparin concentration 1 hour after cardiopulmonary bypass was significantly decreased compared to that immediately after cardiopulmonary bypass. On the other hand, maximum clot firmness determined via intrinsic rotational thromboelastometry was significantly greater 1 hour after cardiopulmonary bypass (53.8 ± 4.8 mm) than that immediately after cardiopulmonary bypass (49.5 ± 4.8 mm). Clotting time determined via intrinsic rotational thromboelastometry and heparinase thromboelastography was also significantly shorter 1 hour after cardiopulmonary bypass than that immediately after cardiopulmonary bypass. CONCLUSION Fresh frozen plasma administration increased antithrombin activity and caused activated clotting time prolongation, but then increased clotting ability. Thus, testing by rotational thromboelastometry after cardiopulmonary bypass could be valuable in the detection of comprehensive clotting ability.
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Affiliation(s)
- Kazuhiro Shirozu
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Yuji Karashima
- Operating Rooms, Kyushu University Hospital, Fukuoka, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Aiello SR, Flores S, Coughlin M, Villarreal EG, Loomba RS. Antithrombin use during pediatric cardiac extracorporeal membrane oxygenation admission: insights from a national database. Perfusion 2020; 36:138-145. [PMID: 32650697 DOI: 10.1177/0267659120939758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The frequency of extracorporeal membrane oxygenation in pediatric patients continues to increase, especially in patients with complex congenital heart disease. Providing adequate anticoagulation is necessary for patients on extracorporeal membrane oxygenation and is achieved with adequate heparin administration. Antithrombin is administered to potentiate heparin's effects. However, the efficacy of antithrombin supplementation is unclear and a clear clinical benefit has not been established. We present a large retrospective study examining the effects of antithrombin on pediatric patients receiving extracorporeal membrane oxygenation. METHODS Data for this study were obtained from the Pediatric Health Information System and Pediatric Health Information System+ databases from 2004 to 2015. Pediatric patients receiving extracorporeal membrane oxygenation with a congenital heart disease diagnosis were included and divided into groups that did or did not utilize antithrombin. For all admissions, the following were captured: age of admission, gender, year of admission, length of stay, billed charges, inpatient mortality, the presence of specific congenital malformations of the heart, specific cardiac surgeries, and comorbidities. RESULTS A total of 9,193 admissions were included and 865 (9.4%) utilized antithrombin. Between groups, there were significantly different frequencies of co-morbidities, cardiac lesion types and antithrombin usage over the study period. There were significantly lower odds in the antithrombin group of venous thrombosis. Antithrombin was not significantly associated with hemorrhage; however, antithrombin was associated with increased inpatient mortality and a decrease in length of stay and billed charges. CONCLUSION Antithrombin administration is associated with increased mortality, a shorter length of stay, and decreased billing cost. Recently, antithrombin usage has been decreasing-potentially due to the reported lack of clinical benefit. Together, these results reinforce that antithrombin may not be indicated for all pediatric extracorporeal membrane oxygenation patients.
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Affiliation(s)
- Salvatore R Aiello
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School, Chicago, IL, USA
| | - Saul Flores
- Cardiac Intensive Care Unit, Section of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Megan Coughlin
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Enrique G Villarreal
- Cardiac Intensive Care Unit, Section of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School, Chicago, IL, USA
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Campbell CT, Diaz L, Kelly B. Description of Bivalirudin Use for Anticoagulation in Pediatric Patients on Mechanical Circulatory Support. Ann Pharmacother 2020; 55:59-64. [PMID: 32590908 DOI: 10.1177/1060028020937819] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Although heparin has previously been the anticoagulant of choice during mechanical circulatory support (MCS), there is a lack of consistency in dose-response in pediatric patients. Bivalirudin offers more consistent dose-response in adults; however, there are limited data for pediatrics use. OBJECTIVE The purpose was to characterize the usage, dosage, and safety profile of bivalirudin when used for pediatric MCS in a tertiary care pediatric hospital. METHODS A retrospective review of pediatric patients receiving bivalirudin for extracorporeal membrane oxygenation/ventricular assist device (ECMO/VAD) anticoagulation was conducted. The primary outcome was the average dose of bivalirudin. Additional outcomes included initial and maximum bivalirudin dose, time to first therapeutic activated partial thromboplastin time (aPTT), time within goal aPTT range, bleeding and clotting complications, and cost. Data were compared between ECMO and VAD patients. RESULTS Thirty-four patients were included. The median dose of bivalirudin was 0.37 mg/kg/h (interquartile range [IQR] = 0.21-0.56), with a maximum dose of 0.62 mg/kg/h (IQR = 0.33-0.91). VAD patients had a higher median and maximum dose as compared with ECMO patients. Patients achieved their therapeutic goal in a median of 6.1 hours and averaged 61.9% time within therapeutic aPTT. One patient had significant hemorrhage, whereas 3 patients had clotting requiring a circuit change. Bivalirudin acquisition cost was higher than heparin. CONCLUSION AND RELEVANCE Bivalirudin dosing in ECMO and VAD patients is consistent with dosing seen in previous reports but may be higher in VAD patients. Comparative studies between heparin and bivalirudin are necessary to compare cost-effective outcomes for pediatric patients.
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Affiliation(s)
- Christopher T Campbell
- University of Florida Health Shands Children's Hospital, Gainesville, FL, USA.,University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Lucas Diaz
- University of Florida Health Shands Children's Hospital, Gainesville, FL, USA
| | - Brian Kelly
- University of Florida Health Shands Children's Hospital, Gainesville, FL, USA
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Stammers AH, Francis SG, Miller R, Nostro A, Tesdahl EA, Mongero LB. Application of goal-directed therapy for the use of concentrated antithrombin for heparin resistance during cardiac surgery. Perfusion 2020; 36:171-182. [PMID: 32536326 DOI: 10.1177/0267659120926089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The maintenance of anticoagulation in adult patients undergoing cardiopulmonary bypass is dependent upon a number of factors, including heparin concentration and adequate antithrombin activity. Inadequate anticoagulation increases the risk of thrombosis and jeopardizes both vascular and extracorporeal circuit integrity. The purpose of this study was to evaluate a goal-directed approach for the use of antithrombin in patients who were resistant to heparin. Following institutional review board approval, data were obtained from quality improvement records. A goal-directed protocol for antithrombin was established based upon heparin dosing (400 IU kg-1 body weight) and achieving an activated clotting time of ⩾500 seconds prior to cardiopulmonary bypass. Two groups of patients were identified as those receiving antithrombin and those not receiving antithrombin. Outcome measures included activated clotting time values and transfusion rates. Consecutive patients (n = 140) were included in the study with 10 (7.1%) in the antithrombin group. The average antithrombin dose was 1,029.0 ± 164.5 IU and all patients had restoration to the activated clotting time levels. Patients in the antithrombin group were on preoperative heparin therapy (80.0% vs. 24.6%, p = 0.001). Prior to cardiopulmonary bypass the activated clotting time values were lower in the antithrombin group (417.7 ± 56.1 seconds vs. 581.1 ± 169.8 seconds, p = 0.003). Antithrombin patients had a lower heparin sensitivity index (0.55 ± 0.17 vs. 1.05 ± 0.44 seconds heparin-1 IU kg-1, p = 0.001), received more total heparin (961.3 ± 158.5 IU kg-1 vs. 677.5 ± 199.0 IU kg-1, p = 0.001), more cardiopulmonary bypass heparin (22,500 ± 10,300 IU vs. 12,100 ± 13,200 IU, p = 0.016), and more protamine (5.4 ± 1.2 vs. 4.1 ± 1.1 mg kg-1, p = 0.003). The intraoperative transfusion rate was higher in the antithrombin group (70.0% vs. 35.4%, p = 0.035), but no differences were seen postoperatively. Utilization of a goal-directed algorithm for the administration of antithrombin for the treatment of heparin resistance is effective in patients undergoing cardiac surgery.
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Affiliation(s)
| | | | | | - Anthony Nostro
- Department of Anesthesia, Pocono Medical Center, East Stroudsburg, PA, USA
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Mazzeffi M. Patient Blood Management in Adult Extracorporeal Membrane Oxygenation Patients. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00384-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Appignani M, Sciartilli A, Caputo M, Di Girolamo E. Successful treatment with rivaroxaban of an extended deep vein thrombosis complicated by pulmonary embolism in a patient with familial antithrombin III deficiency: a case report. Eur Heart J Case Rep 2020; 4:1-5. [PMID: 32128502 PMCID: PMC7047071 DOI: 10.1093/ehjcr/ytz235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/06/2019] [Accepted: 12/04/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Patients with low levels of antithrombin III (AT III) are at an increased risk of developing arteriovenous thromboembolic disease. CASE SUMMARY We report a case of a 28-year-old woman who presented with a 1-week history of spontaneous right calf pain and swelling. A heterozygous AT III deficiency, phenotypically expressed as deep vein thrombosis, was reported in the patient's mother and sister. Blood workup revealed residual AT III activity at 58% with normal protein C and protein S levels. Computed tomographic angiography (CTA) revealed subsegmental bilateral pulmonary embolism (PE) and deep vein thrombosis in the right leg extending into the inferior vena cava up to the confluence of the left renal vein. Placement of an inferior vena cava filter was not considered. Given the patient's haemodynamic stability, anticoagulant therapy with 15 mg of rivaroxaban twice a day was initiated instead. Echocardiography after 10 days of treatment revealed complete resolution of the thrombus located in the inferior vena cava, while CTA revealed complete resolution of the PE. DISCUSSION Patients with AT III deficiency are likely to be heparin-resistant and will require higher heparin doses or the administration of AT III replacement therapy for the treatment of thrombosis, both of which are associated with an increased risk for haemorrhagic complications. Direct factor Xa inhibition by rivaroxaban provided an alternative mechanism for anticoagulation, which was found to be particularly useful in this patient with familial AT III deficiency, deep vein thrombosis, and PE.
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Affiliation(s)
- Marianna Appignani
- Intensive Cardiac Care Unit, Heart Department, “SS. Annunziata” Hospital, Via Dei Vestini, 66100 Chieti, Italy
| | - Adolfo Sciartilli
- Intensive Cardiac Care Unit, Heart Department, “SS. Annunziata” Hospital, Via Dei Vestini, 66100 Chieti, Italy
| | - Marcello Caputo
- Intensive Cardiac Care Unit, Heart Department, “SS. Annunziata” Hospital, Via Dei Vestini, 66100 Chieti, Italy
| | - Enrico Di Girolamo
- Arrhythmology Unit, Heart Department, “SS. Annunziata” Hospital, Via Dei Vestini, 66100 Chieti, Italy
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Puis L, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Wahba A. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Interact Cardiovasc Thorac Surg 2020; 30:161-202. [PMID: 31576402 PMCID: PMC10634377 DOI: 10.1093/icvts/ivz251] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav s University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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Cardenas JC, Wang YW, Karri JV, Vincent S, Cap AP, Cotton BA, Wade CE. Supplementation with antithrombin III ex vivo optimizes enoxaparin responses in critically injured patients. Thromb Res 2020; 187:131-138. [PMID: 31986476 DOI: 10.1016/j.thromres.2020.01.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/17/2019] [Accepted: 01/13/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The high incidence of venous thromboembolism (VTE) following trauma persists in spite of aggressive thromboprophylaxis strategies. Approximately half of VTE patients do not achieve the recommended anti-FXa response to enoxaparin anticoagulation (0.1-0.4 IU/mL), however, research to explain or correct this phenomenon is lacking. We hypothesized that antithrombin III (AT) deficiency is associated with poor enoxaparin responsiveness in trauma patients that develop VTE which can be reversed through supplementation with AT. METHODS AND FINDINGS A retrospective cohort study was performed on plasma collected from trauma patients who did and did not develop pulmonary embolism (PE) as well as healthy volunteers. AT levels, thrombin generation, and anti-FXa levels were measured in the collected plasma at baseline and in response to supplementation with AT concentrate at 120-200% or plasma (30% volume). A total of 54 PE patients and 46 non-PE patients were enrolled in this study for analysis. Compared to healthy volunteers, trauma patients had lower levels of AT, elevated thrombin generation, and lower anti-FXa levels in response to enoxaparin. Moreover, thrombin generation was higher and responses to enoxaparin were lower in patients who developed PE compared to those who did not develop PE. We found that supplementation with AT, but not plasma, increased AT levels and improved enoxaparin-mediated inhibition of thrombin generation. CONCLUSIONS Supplementation with AT may provide a novel adjunct therapy to increase the effectiveness of enoxaparin thromboprophylaxis and reduce the incidence of VTE in the trauma population.
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Affiliation(s)
- Jessica C Cardenas
- The Center for Translational Injury Research, Department of Surgery, UTHealth McGovern Medical School, Houston, TX, United States of America; Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, United States of America.
| | - Yao-Wei Wang
- Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, United States of America
| | - Jay V Karri
- Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, United States of America
| | - Seenya Vincent
- Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, United States of America
| | - Andrew P Cap
- The Center for Translational Injury Research, Department of Surgery, UTHealth McGovern Medical School, Houston, TX, United States of America; U.S. Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX, United States of America
| | - Bryan A Cotton
- The Center for Translational Injury Research, Department of Surgery, UTHealth McGovern Medical School, Houston, TX, United States of America; Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, United States of America
| | - Charles E Wade
- The Center for Translational Injury Research, Department of Surgery, UTHealth McGovern Medical School, Houston, TX, United States of America; Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, United States of America
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Local and Recurrent Regional Metastases of Melanoma. CUTANEOUS MELANOMA 2020. [PMCID: PMC7123735 DOI: 10.1007/978-3-030-05070-2_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Up to 10% of patients with cutaneous melanoma will develop recurrent locoregional disease. While surgical resection remains the mainstay of treatment for isolated recurrences, locoregional melanoma can often present as bulky, unresectable disease and can pose a significant therapeutic challenge. This chapter focuses on the natural history of local and regionally recurrent metastases and the multiple treatment modalities which exist for advanced locoregional melanoma, including regional perfusion procedures such as hyperthermic isolated limb perfusion and isolated limb infusion, intralesional therapies, and neo-adjuvant systemic therapy strategies for borderline resectable regional disease. Hyperthermic limb perfusion (HILP) and isolated limb infusion (ILI) are generally well-tolerated and have shown overall response rates between 44% and 90%. Intralesional therapies also appear to be well-tolerated as adverse events are usually limited to the site of injection and minor transient flu-like symptoms. Systemic targeted therapies have shown to have response rates up to 85% when used as neoadjuvant therapy in patients with borderline resectable disease. While combination immunotherapy in the neoadjuvant setting has also shown promising results, this data has not yet matured.
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Sieg A, Pandya K, Winstead R, Evans R. Overview of Pharmacological Considerations in Extracorporeal Membrane Oxygenation. Crit Care Nurse 2019; 39:29-43. [PMID: 30936129 DOI: 10.4037/ccn2019236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Extracorporeal membrane oxygenation has become more widely used in recent years. Although this technology has proven to be lifesaving, it is not devoid of complications contributing to significant morbidity and mortality. Nurses who care for patients receiving extracorporeal membrane oxygenation should further their understanding of changes in medication profiles due to complex interactions with the extracorporeal membrane oxygenation circuitry. The aim of this comprehensive review is to give nurses a better understanding of analgesic, sedative, anti-infective, and anticoagulation medications that are frequently used to treat patients receiving extracorporeal membrane oxygenation.
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Affiliation(s)
- Adam Sieg
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support. .,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy. .,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia. .,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina.
| | - Komal Pandya
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support.,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy.,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia.,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina
| | - Ryan Winstead
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support.,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy.,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia.,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina
| | - Rickey Evans
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support.,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy.,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia.,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina
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Kunst G, Milojevic M, Boer C, De Somer FM, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Puis L, Wahba A, Alston P, Fitzgerald D, Nikolic A, Onorati F, Rasmussen BS, Svenmarker S. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Br J Anaesth 2019; 123:713-757. [DOI: 10.1016/j.bja.2019.09.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Şener YZ, Şener S. Factors Related With Outcomes in Patients With Intracardiac Thrombus. J Intensive Care Med 2019:885066619890268. [PMID: 31769333 DOI: 10.1177/0885066619890268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Yusuf Ziya Şener
- Cardiology Department, Hacettepe University Faculty of Medicine, Hacettepe University, Sohhıye, Ankara, Turkey
| | - Seher Şener
- Pediatrics Department, Gülhane Training and Research Hospital, Etlik, Ankara, Turkey
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Wells AV, Zarkhin E, Weiner MM, Katz D. Heparin Resistance due to an Acquired Antithrombin Deficiency in a Patient With Sickle Cell Disease During a Pregnancy Complicated by Bilateral Pulmonary Emboli: A Case Report. A A Pract 2019; 12:305-307. [PMID: 31048599 DOI: 10.1213/xaa.0000000000000917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a 31-year-old woman with sickle beta thalassemia zero who presented at 21 weeks gestational age with multiple bilateral pulmonary emboli and no hemodynamic instability. Acquired antithrombin deficiency was suspected due to a refractory response to therapeutic anticoagulation with enoxaparin, unfractionated heparin, and fondaparinux, and a reduced antithrombin antigen level. At 26 4/7 weeks, she developed signs concerning for increased pulmonary clot burden. To avoid the use of alternative anticoagulants that may cross the placenta and impact the fetus, a planned cesarean delivery was performed without complication at 27 weeks gestation. Both mother and child experienced successful long-term outcomes.
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Affiliation(s)
- Ashley V Wells
- From the Department of Anesthesiology, Perioperative & Pain Medicine
| | - Eli Zarkhin
- From the Department of Anesthesiology, Perioperative & Pain Medicine
| | - Menachem M Weiner
- Division of Cardiothoracic Anesthesia, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Daniel Katz
- From the Department of Anesthesiology, Perioperative & Pain Medicine
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31
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Eche IM, Elsamadisi P, Wex N, Wyers MC, Brat GA, Cunningham K, Bauer KA. Intraoperative Unfractionated Heparin Unresponsiveness during Endovascular Repair of a Ruptured Abdominal Aortic Aneurysm following Administration of Andexanet Alfa for the Reversal of Rivaroxaban. Pharmacotherapy 2019; 39:861-865. [DOI: 10.1002/phar.2306] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Ifeoma Mary Eche
- Department of Pharmacy Beth Israel Deaconess Medical Center Boston Massachusetts
| | - Pansy Elsamadisi
- Department of Pharmacy Beth Israel Deaconess Medical Center Boston Massachusetts
| | - Nicole Wex
- Department of Pharmacy Beth Israel Deaconess Medical Center Boston Massachusetts
| | - Mark C. Wyers
- Division of Vascular and Endovascular Surgery Beth Israel Deaconess Medical Center Boston Massachusetts
| | - Gabriel A. Brat
- Division of Acute Care Surgery Beth Israel Deaconess Medical Center Boston Massachusetts
| | - Katherine Cunningham
- Department of Pharmacy Beth Israel Deaconess Medical Center Boston Massachusetts
| | - Kenneth A. Bauer
- Division of Hemostasis and Thrombosis, Department of Hematology Beth Israel Deaconess Medical Center Boston Massachusetts
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Minami K, Kumagai K, Sugai Y, Nakamura K, Naito S, Oshima S. Efficacy of Oral Factor Xa Inhibitor for Venous Thromboembolism in a Patient with Antithrombin Deficiency. Intern Med 2018. [PMID: 29526957 PMCID: PMC6096030 DOI: 10.2169/internalmedicine.0483-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
A 19-year-old man was referred due to sudden onset of right foot pain and chest discomfort. Contrast-enhanced computed tomography revealed massive thrombi in the right pulmonary artery and femoral vein. The patient's father had experienced multiple recurrences of venous thromboembolism (VTE) and was diagnosed with inherited antithrombin deficiency by a genetic examination. The patient was administered the oral factor Xa inhibitor rivaroxaban (30 mg). After seven days, the thrombus disappeared. Rivaroxaban (15 mg) was continued for 6 months with no recurrence, indicating the efficacy of this factor Xa inhibitor for the treatment and prevention of VTE in patients with antithrombin deficiency.
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Affiliation(s)
- Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Japan
| | - Koji Kumagai
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Japan
| | - Yoshinao Sugai
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Japan
| | - Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Japan
| | - Shigeru Oshima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Japan
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Kawatsu S, Sasaki K, Sakatsume K, Takahara S, Hosoyama K, Masaki N, Suzuki Y, Hayatsu Y, Yoshioka I, Sakuma K, Adachi O, Akiyama M, Kumagai K, Motoyoshi N, Kawamoto S, Saiki Y. Predictors of Heparin Resistance Before Cardiovascular Operations in Adults. Ann Thorac Surg 2018; 105:1316-1321. [DOI: 10.1016/j.athoracsur.2018.01.068] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 01/02/2018] [Accepted: 01/22/2018] [Indexed: 10/17/2022]
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Zhang L, Zhang H, Zhang J, Tian H, Liang J, Liu Z. Rivaroxaban for the treatment of venous thromboembolism in patients with nephrotic syndrome and low AT-III: A pilot study. Exp Ther Med 2017; 15:739-744. [PMID: 29399079 PMCID: PMC5772665 DOI: 10.3892/etm.2017.5471] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/22/2017] [Indexed: 12/11/2022] Open
Abstract
The anticoagulation effect of heparin requires adequate serum antithrombin (AT)-III levels. Rivaroxaban, however, exhibits its anticoagulation effects independent of AT-III. The aim of the present study was to evaluate the efficacy and safety of rivaroxaban as a treatment for venous thromboembolism in patients with AT-III deficiency due to nephrotic syndrome. Patients with nephrotic syndrome and low serum concentration and functional activity of AT-III and venous thromboembolism were randomly assigned to the rivaroxaban group (n=8) and low weight molecular heparin group (n=8). The patients were treated for 4 weeks and evaluated at weeks 2 and 4. The primary endpoint was thrombus dissolution or a >90% decrease in thrombus volume in 4 weeks. Secondary endpoints included an increase in the volume of the pre-existing thrombosis and safety assessments. In each of the two groups, 7/8 patients achieved a primary endpoint. At week 2, 5 patients in the rivaroxaban group and 4 in the low weight molecular heparin group had achieved the primary endpoint. Notably, at week 2 the patients whose AT-III levels and functional activity remained low in the low weight molecular heparin group did not achieve the primary endpoint. The adverse effects were similar in both groups, with no severe hemorrhage observed. In conclusion, the results of this pilot study demonstrate that rivaroxaban may be an effective, safe, single-agent approach for treating vein thromboembolism in patients with nephrotic syndrome and low AT-III levels. The potential benefits of rivaroxaban over low weight molecular heparin treatment require further investigation with a larger sample size in order to validate the findings of the present study.
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Affiliation(s)
- Lihua Zhang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Haitao Zhang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Jiong Zhang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Hong Tian
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Ju Liang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210016, P.R. China
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Yamaguchi J, Hara N, Yamaguchi T, Nagata Y, Nozato T, Miyamoto T. Successful treatment of a massive pulmonary embolism using rivaroxaban in a patient with antithrombin III deficiency. J Cardiol Cases 2017; 16:144-147. [PMID: 30279820 PMCID: PMC6149282 DOI: 10.1016/j.jccase.2017.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 06/06/2017] [Accepted: 06/26/2017] [Indexed: 10/19/2022] Open
Abstract
We report a case of acute massive pulmonary embolism in a patient with antithrombin III deficiency. The patient was treated with rivaroxaban. The patient responded well to the therapy, and contrast-enhanced computed tomography showed nearly complete disappearance of the pulmonary embolism. Patients with low antithrombin III activity may have resistance to heparin therapy, leading to insufficient anticoagulation during the acute phase of thromboembolism. This case suggests that direct oral anticoagulants, such as rivaroxaban, may be effective first-line agents for treating venous thromboembolism in patients with antithrombin III deficiency. .
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Affiliation(s)
- Junji Yamaguchi
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
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36
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Jones AJ, O'Mara KL, Kelly BJ, Samraj RS. The Impact of Antithrombin III Use in Achieving Anticoagulant Goals in Pediatric Patients. J Pediatr Pharmacol Ther 2017; 22:320-325. [PMID: 29042831 DOI: 10.5863/1551-6776-22.5.320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine the percentage of patients with >10% reduction in heparin infusion rate within 48 hours of antithrombin III (ATIII) administration. Secondary objectives include the achievement of therapeutic anticoagulation and determining the days of subtherapeutic infusion prior to supplementation. METHODS Retrospective chart review of 12 patients younger than 18 years of age who received ATIII concentrate supplementation while on continuous heparin infusion. Specific indications for heparin infusion therapy included extracorporeal membrane oxygenation (ECMO), treatment of thrombus, and post implantation of ventricular assist device(s). RESULTS From time of heparin initiation to ATIII supplementation, patients spent a mean 4.9 ± 2.6 days of subtherapeutic infusion and required uptitration from a mean of 15.3 ± 4.4 units/kg/hr to a mean rate of 40.7 ± 9.5 units/kg/hr. 58.3% of the patients (n = 7) had a ≥10% reduction from the baseline heparin infusion rate within 48 hours of ATIII administration. Those patients considered responders (≥10% reduction from baseline rate) had a slightly higher mean baseline antithrombin level (76.3% ± 22.0% vs. 58.6% ± 2.7% in non-responders, p = 0.1) and were administered comparable doses of ATIII. ATIII supplementation did appear to increase the time of therapeutic anticoagulation within the 48 hours. CONCLUSIONS Administration of ATIII is associated with >10% decrease in heparin requirements in more than half of the patients identified. In those patients deemed non-responders, there was a trend towards lower baseline antithrombin serum levels. Further studies are warranted to determine if the lack of response in some patients is due to inadequate dosing of ATIII or any patient-related factors.
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Affiliation(s)
- Allison J Jones
- Department of Pharmacy (AJJ), Norton Children's Hospital, Louisville, Kentucky, Department of Pharmacy (KLO, BJK) and Department of Pediatrics (RSS), University of Florida Health Shands Hospital, Gainesville, Florida
| | - Keliana L O'Mara
- Department of Pharmacy (AJJ), Norton Children's Hospital, Louisville, Kentucky, Department of Pharmacy (KLO, BJK) and Department of Pediatrics (RSS), University of Florida Health Shands Hospital, Gainesville, Florida
| | - Brian J Kelly
- Department of Pharmacy (AJJ), Norton Children's Hospital, Louisville, Kentucky, Department of Pharmacy (KLO, BJK) and Department of Pediatrics (RSS), University of Florida Health Shands Hospital, Gainesville, Florida
| | - Ravi S Samraj
- Department of Pharmacy (AJJ), Norton Children's Hospital, Louisville, Kentucky, Department of Pharmacy (KLO, BJK) and Department of Pediatrics (RSS), University of Florida Health Shands Hospital, Gainesville, Florida
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37
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Management of Venous Thromboembolism in Patients with Hereditary Antithrombin Deficiency and Pregnancy: Case Report and Review of the Literature. Case Rep Hematol 2017; 2017:9261351. [PMID: 28168066 PMCID: PMC5259678 DOI: 10.1155/2017/9261351] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/14/2016] [Accepted: 11/24/2016] [Indexed: 02/02/2023] Open
Abstract
Background. Hereditary antithrombin deficiency is a thrombogenic disorder associated with a 50–90% lifetime risk of venous thromboembolism (VTE), which is increased during pregnancy and the puerperium in these patients. We present a case of a woman with antithrombin (AT) deficiency who presented with a VTE despite therapeutic low molecular weight heparin (LMWH). Though the pregnancy was deemed unviable, further maternal complications were mitigated through the combined use of therapeutic anticoagulation and plasma-derived antithrombin concentrate infusions to normalize her functional antithrombin levels. Methods. A review of the literature was conducted for studies on prophylaxis and management of VTE in pregnant patients with hereditary AT deficiency. The search involved a number of electronic databases, using combinations of keywords as described in the text. Only English language studies between 1946 and 2015 were included. Conclusion. Antithrombin concentrate is indicated in pregnant women with hereditary AT deficiency who develop VTE despite being on therapeutic dose anticoagulation. Expert opinion suggests AT concentrate should be used concomitantly with therapeutic dose anticoagulation. However, further high-quality studies on the dose and duration of treatment in the postpartum period are required. Use of AT concentrate for prophylaxis is controversial and should be based on individual VTE risk stratification.
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38
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Beyer JT, Schoeppler KE, Zanotti G, Weiss GM, Mueller SW, MacLaren R, Fish DN, Kiser TH. Antithrombin Administration During Intravenous Heparin Anticoagulation in the Intensive Care Unit: A Single-Center Matched Retrospective Cohort Study. Clin Appl Thromb Hemost 2016; 24:145-150. [PMID: 27624738 DOI: 10.1177/1076029616668407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Unfractionated heparin (UFH) is a frequently utilized indirect anticoagulant that induces therapeutic effect by enhancing antithrombin (AT)-mediated procoagulant enzyme inhibition. In suspected heparin resistance (HR) during cardiopulmonary bypass, AT activity may be decreased and AT supplementation helps restore UFH responsiveness. The benefit of AT supplementation in HR over longer durations of UFH therapy is unclear. The objective of this study was to describe and evaluate the use of AT III concentrate in the intensive care units (ICUs) at our institution for improving UFH therapy response over 72 hours. A total of 44 critically ill patients were included in the analysis-22 patients received at least 1 dose of AT and 22 patients received no AT. Thirty (68.2%) of the 44 patients were receiving mechanical circulatory support. Baseline characteristics were similar between groups. The average AT activity prior to AT supplementation was 57.9% in the treatment group, and the median cumulative dose of AT was 786.5 U (9.26 U/kg) per patient. There were no significant differences observed in proportion of time spent in therapeutic range (31.9% vs 35.2%, P = .65), time to therapeutic goal (16.5 vs 15.5 hours, P = .97), or patients who experienced a bleeding event (5 vs 5, P = .99) between groups. In conclusion, AT supplementation had minimal impact on anticoagulant response in this cohort of ICU patients with mild to moderate HR receiving a prolonged UFH infusion. Additional research is needed to define AT activity targets and to standardize AT supplementation practices in patients receiving prolonged heparin infusion.
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Affiliation(s)
- Jacob T Beyer
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Kelly E Schoeppler
- 2 Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | - Giorgio Zanotti
- 3 Department of Surgery, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Gregory M Weiss
- 4 Department of Anesthesiology, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Scott W Mueller
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Robert MacLaren
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Douglas N Fish
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Tyree H Kiser
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Anticoagulation and Thrombolysis. Pediatr Crit Care Med 2016; 17:S77-88. [PMID: 26945332 DOI: 10.1097/pcc.0000000000000623] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Thrombotic complications are increasingly being recognized as a significant cause of morbidity and mortality in pediatric and congenital heart disease. The objective of this article is to review the medications currently available to prevent and treat such complications. DATA SOURCES Online searches were conducted using PubMed. STUDY SELECTION Studies were selected for inclusion based on their scientific merit and applicability to the pediatric cardiac population. DATA EXTRACTION Pertinent information from each selected study or scientific review was extracted for inclusion. DATA SYNTHESIS Four classes of medications were identified as potentially beneficial in this patient group: anticoagulants, antiplatelet agents, thrombolytic agents, and novel oral anticoagulants. Data on each class of medication were synthesized into the follow sections: mechanism of action, pharmacokinetics, dosing, monitoring, reversal, considerations for use, and evidence to support. CONCLUSIONS Anticoagulants, antiplatelet agents, and thrombolytic agents are routinely used successfully in the pediatric patient with heart disease for the prevention and treatment of a wide range of thrombotic complications. Although the novel oral anticoagulants have been approved for a limited number of indications in adults, studies on the safety and efficacy of these agents in children are pending.
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40
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Jao YTFN, Fang CC. Intraprocedural stent thrombosis, antithrombin-III dependent heparin resistance and crush technique for bifurcation lesions: the "Devil's Triangle". Int J Cardiol 2015; 199:71-4. [PMID: 26188821 DOI: 10.1016/j.ijcard.2015.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 07/02/2015] [Indexed: 11/29/2022]
Affiliation(s)
| | - Ching-Chang Fang
- Department of Cardiology, Tainan Municipal Hospital, Tainan, Taiwan.
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41
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King AB, O'Duffy AE, Kumar AB. Heparin Resistance and Anticoagulation Failure in a Challenging Case of Cerebral Venous Sinus Thrombosis. Neurohospitalist 2015; 6:118-21. [PMID: 27366296 DOI: 10.1177/1941874415591500] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
We report a challenging case of cerebral venous sinus thrombosis (multiple etiologic factors) that was complicated by heparin resistance secondary to suspected antithrombin III (ATIII) deficiency. A 20-year-old female previously healthy and currently 8 weeks pregnant presented with worsening headaches, nausea, and decreasing Glasgow Coma Scale/Score (GCS), necessitating mechanical ventilatory support. Imaging showed extensive clots in multiple cerebral venous sinuses including the superior sagittal sinus, transverse, sigmoid, jugular veins, and the straight sinus. She was started on systemic anticoagulation and underwent mechanical clot removal and catheter-directed endovascular thrombolysis with limited success. Complicating the intensive care unit care was the development of heparin resistance, with an inability to reach the target partial thomboplastin time (PTT) of 60 to 80 seconds. At her peak heparin dose, she was receiving >35 000 units/24 h, and her PTT was subtherapeutic at <50 seconds. Deficiency of ATIII was suspected as a possible etiology of her heparin resistance. Fresh frozen plasma was administered for ATIII level repletion. Given her high thrombogenic risk and challenges with conventional anticoagulation regimens, we transitioned to argatroban for systemic anticoagulation. Heparin produces its major anticoagulant effect by inactivating thrombin and factor X through an AT-dependent mechanism. For inhibition of thrombin, heparin must bind to both the coagulation enzyme and the AT. A deficiency of AT leads to a hypercoagulable state and decreased efficacy of heparin that places patients at high risk of thromboembolism. Heparin resistance, especially in the setting of critical illness, should raise the index of suspicion for AT deficiency. Argatroban is an alternate agent for systemic anticoagulation in the setting of heparin resistance.
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Affiliation(s)
- Adam B King
- Division of Critical Care, Department of Anesthesiology, Vanderbilt University, Nashville, TN, USA
| | - Anne E O'Duffy
- Department of Neurology, Vanderbilt University, Nashville, TN, USA
| | - Avinash B Kumar
- Division of Critical Care, Department of Anesthesiology, Vanderbilt University, Nashville, TN, USA
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42
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McNair E, Marcoux JA, Bally C, Gamble J, Thomson D. Bivalirudin as an adjunctive anticoagulant to heparin in the treatment of heparin resistance during cardiopulmonary bypass-assisted cardiac surgery. Perfusion 2015; 31:189-99. [PMID: 25934498 DOI: 10.1177/0267659115583525] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Heparin resistance (unresponsiveness to heparin) is characterized by the inability to reach acceptable activated clotting time values following a calculated dose of heparin. Up to 20% of the patients undergoing cardiothoracic surgery with cardiopulmonary bypass using unfractionated heparin (UFH) for anticoagulation experience heparin resistance. Although UFH has been the "gold standard" for anticoagulation, it is not without its limitations. It is contraindicated in patients with confirmed heparin-induced thrombocytopenia (HIT) and heparin or protamine allergy. The safety and efficacy of the use of the direct thrombin inhibitor bivalirudin for anticoagulation during cardiac surgery has been reported. However, there have been no reports on the treatment of heparin resistance with bivalirudin during CPB. In this review, we report the favorable outcome of our single-center experience with the alternative use of bivalirudin in the management of anticoagulation of heparin unresponsive patients undergoing coronary artery bypass graft surgery.
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Affiliation(s)
- E McNair
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada Department of Surgery, Division of Cardiac Surgery, Saskatoon Health Region, Saskatoon, SK, Canada
| | - J-A Marcoux
- Department of Surgery, Division of Cardiac Surgery, Saskatoon Health Region, Saskatoon, SK, Canada
| | - C Bally
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - J Gamble
- Department of Anesthesiology and Pain Management, College of Medicine and Saskatoon Health Region, Saskatoon, SK, Canada
| | - D Thomson
- Department of Surgery, Division of Cardiac Surgery, Saskatoon Health Region, Saskatoon, SK, Canada
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Sniecinski RM, Levy JH. Anticoagulation management associated with extracorporeal circulation. Best Pract Res Clin Anaesthesiol 2015; 29:189-202. [PMID: 26060030 DOI: 10.1016/j.bpa.2015.03.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 03/20/2015] [Indexed: 11/25/2022]
Abstract
The use of extracorporeal circulation requires anticoagulation to maintain blood fluidity throughout the circuit, and to prevent thrombotic complications. Additionally, adequate suppression of hemostatic activation avoids the unnecessary consumption of coagulation factors caused by the contact of blood with foreign surfaces. Cardiopulmonary bypass represents the greatest challenge in this regard, necessitating profound levels of anticoagulation during its conduct, but also quick, efficient reversal of this state once the surgical procedure is completed. Although extracorporeal circulation has been around for more than half a century, many questions remain regarding how to best achieve anticoagulation for it. Although unfractionated heparin is the predominant agent used for cardiopulmonary bypass, the amount required and how best to monitor its effects are still unresolved. This review discusses the use of heparin, novel anticoagulants, and the monitoring of anticoagulation during the conduct of cardiopulmonary bypass.
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Affiliation(s)
- Roman M Sniecinski
- Emory University School of Medicine, Department of Anesthesiology, 1364 Clifton Rd, NE, Atlanta, GA 30322, USA.
| | - Jerrold H Levy
- Cardiothoracic Anesthesia and Critical Care, Duke University Medical Center, 2301 Erwin Road, 5691H HAFS, Durham, NC 27710, USA.
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Morshuis M, Özpeker C, Schulz U, Gummert J, Koster A. Herzunterstützungssysteminduzierte Störungen der Gerinnung. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-013-1050-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Clinical use and the Italian demand for antithrombin. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2014; 11 Suppl 4:s86-93. [PMID: 24333319 DOI: 10.2450/2013.014s] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Tanaka K, Esper S, Bolliger D. Perioperative factor concentrate therapy. Br J Anaesth 2013; 111 Suppl 1:i35-49. [DOI: 10.1093/bja/aet380] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Lilly KJ, Pirundini PA, Fox AA, Body SC, Shaw C, Rizzo RJ. Restoration of the coagulation cascade on CPB: a case report. Perfusion 2013; 29:272-4. [DOI: 10.1177/0267659113507471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Coagulopathy can sometimes be observed when CPB times are prolonged. Correction of coagulopathy post CPB can present the surgical team with a number of challenges, including right ventricular volume overload, hemodilution, anemia and excessive cell salvage with further loss of coagulation factors. Restoration of the coagulation cascade on CPB may help to avoid these issues. This case report is of a 64-year-old male with a delayed diagnosis of aortic dissection. The patient presented to the cardiac surgery operating room with hepatic and renal shock/failure, with the resulting coagulopathy. The described technique is representative of a technique that we sometimes employ to restore the clotting mechanism before separating from bypass.
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Affiliation(s)
- KJ Lilly
- Division of Cardiac Surgery, Brigham & Women’s/Cape Cod Hospital, Harvard Medical School, Boston, MA, USA
| | - PA Pirundini
- Division of Cardiac Surgery, Brigham & Women’s/Cape Cod Hospital, Harvard Medical School, Boston, MA, USA
| | - AA Fox
- Division of Cardiac Surgery, Brigham & Women’s/Cape Cod Hospital, Harvard Medical School, Boston, MA, USA
| | - SC Body
- Division of Cardiac Anesthesiology, Brigham & Women’s/Cape Cod Hospital, Harvard Medical School, Boston, MA, USA
| | - C Shaw
- Division of Cardiac Surgery, Brigham & Women’s/Cape Cod Hospital, Harvard Medical School, Boston, MA, USA
| | - RJ Rizzo
- Division of Cardiac Surgery, Brigham & Women’s/Cape Cod Hospital, Harvard Medical School, Boston, MA, USA
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Gadhinglajkar S, Sreedhar R, Varma P, Pal S. Plasma exchange transfusion for management of altered heparin responsiveness before cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2013; 27:e58-60. [PMID: 24054198 DOI: 10.1053/j.jvca.2013.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Shrinivas Gadhinglajkar
- Department of Anesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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