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Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJ, Schlimp CJ, Vandermeulen E, Volk T, von Heymann C, Wolmarans M, Afshari A. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100-132. [PMID: 34980845 DOI: 10.1097/eja.0000000000001600] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, Valencia, Spain (RF), Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris (AG), INSERM UMRS-1140 Paris University, Paris, France (AG), Department of Anaesthesiology and Critical Care, Doctor Peset University Hospital (JL), Department of Surgery, Valencia University, Valencia, Spain (JL), Serviço de Anestesiologia Hospital das Forças Armadas, Pólo Porto, Porto, Portugal (CL), Department of Anaesthesia Pain Medicine and Critical Care, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK (AM), Department of Anaesthesia and Intensive Care Medicine, AUVA Trauma Centre Linz, Linz (CJS); Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria (CJS), Department of Anaesthesia, University Hospitals Leuven. Catholic University of Leuven, Leuven, Belgium (EV), Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar (TV), Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany (CVH), Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK (MW), and Department of Pediatric and Obstetric Anesthesia, Juliane Marie Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA)
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Elmofty DH, Tucker A, Wuenstel AM, Cheng PK, Fox E, Knoebel R, Liao C, Scavone B. Varying Dosages of Subcutaneous Unfractionated Heparin and Activated Partial Thromboplastin Time in Hospitalized Antepartum Patients: A Retrospective Cohort Analysis. Anesth Analg 2022; 134:1028-1034. [PMID: 35020621 DOI: 10.1213/ane.0000000000005866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a leading cause of maternal morbidity and mortality in the United States. Subcutanous unfractionated heparin (UFH) has been used for decades for VTE prophylaxis and under many obstetric quality of care initiatives, hospitalized antepartum patients now receive doses as high as 10,000 units every 12 hours. This practice increases the likelihood of UFH administration around the time that epidural labor analgesia is requested or neuraxial analgesia for cesarean delivery is needed. To clarify the effect of UFH on coagulation, we reviewed the care of hospitalized antepartum patients receiving VTE prophylaxis with UFH to determine the incidence of concurrent abnormal activated partial thromboplastin time (aPTT) values and associated risk factors. METHODS This retrospective cohort study used data from the University of Chicago Pharmacy database to identify hospitalized antepartum patients receiving subcutaneous UFH from June 1, 2016 to July 1, 2019. Our institutional protocol states that all patients hospitalized for antepartum conditions should receive pharmacologic prophylaxis empirically unless contraindicated. For patients receiving UFH, dosing was based on gestational age: 5000 units every 12 hours for first trimester antepartum patients, 7500 units every 12 hours for second trimester patients, and 10,000 units every 12 hours for patients in the third trimester. As per protocol, aPTT values were obtained 2 hours after the third dose of heparin, and platelet counts after 4 days. Data collection included demographics, comorbidities, heparin doses, aPTT values, platelet counts, creatinine if available, and anesthetic type and complications. Logistic regression was performed to determine the association between elevated aPTT >40 seconds and study variables. RESULTS Of the 321 antepartum patients who received subcutaneous UFH, 33 (10.3%) had an aPTT >40 seconds, 4 of those 33 patients (12.1%) received 5000 units every 12 hours, 14 (42.2%) received 7500 units every 12 hours, and 15 (45.5%) received 10,000 units every 12 hours. The likelihood of a patient having aPTT >40 seconds was 2.8% with 5000 units every 12 hours, 18.9% with 7500 units every 12 hours, and 14.6% with 10,000 units every 12 hours. CONCLUSIONS Elevated aPTT values are likely with total daily doses of 15,000 or 20,000 units subcutaneous UFH in hospitalized antepartum patients.
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Affiliation(s)
- Dalia H Elmofty
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Andrew Tucker
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Andrew M Wuenstel
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Paul K Cheng
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Edward Fox
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Randall Knoebel
- Department of Pharmacy, University of Chicago, Chicago, Illinois
| | - Chuanghong Liao
- Department of Public Health Sciences,University of Chicago, Chicago, Illinois
| | - Barbara Scavone
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois.,Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
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Incidence and risk factors for PTT prolongation in patients receiving low-dose unfractionated heparin thromboprophylaxis. J Thromb Thrombolysis 2020; 52:331-337. [PMID: 33006065 DOI: 10.1007/s11239-020-02294-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/22/2022]
Abstract
Low-dose unfractionated heparin (LDUH) prophylaxis decreases the incidence of venous thromboembolism (VTE) in hospitalized patients, but increases the risk of bleeding events. Patients who develop a prolonged activated partial thromboplastin time (aPTT) while on LDUH may be at higher risk for bleeding complications. To determine the incidence and risk factors for aPTT prolongation in hospitalized patients receiving LDUH thromboprophylaxis, we performed a retrospective pharmacoepidemiologic cohort study of adult patients admitted to an academic medical center from September 2013 through September 2015. Among 3857 patients with at least one aPTT checked within 24 h of LDUH administration, aPTT prolongation > 1.5 times the upper limit of normal occurred in 131 (3.4%). Age 68-78 years (OR 1.6, 95% CI 1.01-2.4), age > 78 years (OR 1.9, 95% CI 1.3-2.9), female gender (OR 1.9, 95% CI 1.4-2.5), black race (OR 1.6, 95% CI 1.1-2.3), low BMI (OR 1.8, 95% CI 1.3-2.5), being admitted to a surgical service (OR 0.5, 95% CI 0.3-0.8), and receipt of high-dose (> 10,000 units in a day) unfractionated heparin prophylaxis (OR 1.4, 95% CI 1.003-2.0), were independently associated with aPTT prolongation after LDUH exposure. LDUH VTE prophylaxis is associated with aPTT prolongation in 3.4% of general hospitalized patients. We demonstrated several factors independently associated with aPTT prolongation. Monitoring aPTT levels may be indicated for select patients on LDUH thromboprophylaxis who are at high risk or consequence of bleeding and for aPTT prolongation.
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Thoracic Epidural Anesthesia and Prophylactic Three Times Daily Unfractionated Heparin Within an Enhanced Recovery After Surgery Pathway for Colorectal Surgery. Reg Anesth Pain Med 2018; 42:197-203. [PMID: 28079734 DOI: 10.1097/aap.0000000000000542] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Venous thromboembolism (VTE) is a common cause of preventable harm. Perioperative thoracic epidural analgesia (TEA) presents a challenge to optimal VTE prophylaxis. Our primary aim was to characterize missed doses of VTE prophylaxis associated with epidural catheter placement and removal. Our secondary aim was to measure the effect of an enhanced recovery after surgery (ERAS) pathway on the rate of TEA-associated missed VTE prophylaxis. METHODS We retrospectively reviewed a prospectively collected database of 1264 colorectal surgery patients at a single academic center. Missed preoperative doses between TEA patients and non-TEA patients were compared. Missed postoperative unfractionated heparin (UFH) doses associated with epidural removal were compared before and after implementation of an ERAS program. Other data collected included demographic data, surgical indication, and thrombohemorrhagic complications. RESULTS Of the 445 TEA patients, 12.6% missed their preoperative heparin doses compared with 8.4% of patients without epidurals (P = 0.017). Of the TEA patients prescribed 3 times daily UFH, 22.5% missed one or more doses associated with epidural removal. The percent of patients missing at least one dose of UFH on epidural removal dropped from 28.1% before ERAS to 17.9% after the ERAS program (P = 0.023). Seven patients developed VTEs. There were zero epidural hematomas. CONCLUSIONS Thoracic epidural analgesia was associated with a 1.5-fold increased risk of missed dose of preoperative VTE prophylaxis, which was not affected by implementation of an ERAS program. The implementation of an ERAS program reduced missed doses associated with epidural removal. This study highlights the challenge posed by providing VTE prophylaxis in the setting of perioperative neuraxial analgesia.
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Su J, Soliz JM, Popat KU, Gebhardt R. Epidural Analgesia and Subcutaneous Heparin 3 Times Daily in Cancer Patients With Acute Postoperative Pain. Anesth Analg 2018; 127:e57-e59. [PMID: 29958215 DOI: 10.1213/ane.0000000000003603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The use of epidural analgesia in conjunction with subcutaneous administration of unfractionated heparin 3 times per day could increase the risk of spinal epidural hematoma, but insufficient patient experience data exist to determine this. We retrospectively reviewed the incidence of spinal epidural hematoma in 3705 cases at our institution over a 7-year period of patients receiving acute postoperative epidural analgesia and heparin 3 times per day. No cases of spinal epidural hematoma were reported (95% CI, 0-0.0009952).
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Affiliation(s)
- Jackson Su
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Jose M Soliz
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Keyuri U Popat
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Rodolfo Gebhardt
- Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy. Reg Anesth Pain Med 2018; 43:263-309. [DOI: 10.1097/aap.0000000000000763] [Citation(s) in RCA: 442] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition). Reg Anesth Pain Med 2017; 43:225-262. [DOI: 10.1097/aap.0000000000000700] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Thomas O, Lybeck E, Flisberg P, Schött U. Pre- to postoperative coagulation profile of 307 patients undergoing oesophageal resection with epidural blockade over a 10-year period in a single hospital: implications for the risk of spinal haematoma. Perioper Med (Lond) 2017; 6:14. [PMID: 29034090 PMCID: PMC5628458 DOI: 10.1186/s13741-017-0070-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 09/11/2017] [Indexed: 12/18/2022] Open
Abstract
Background Epidural anaesthesia and analgesia are indicated for oesophageal surgery. A rare but serious complication is spinal haematoma, which can occur on insertion, manipulation or withdrawal of catheters. Evidence and guidelines are vague regarding which tests are appropriate and how to interpret their results. We aimed to describe how routine coagulation test results change during oesophagectomy’s perioperative course. Methods Following ethical approval, we retrospectively identified patients who had undergone oesophagectomy between 2002 and 2012. Blood test results and details of operations, haemorrhage and complications were recorded and analysed with Excel and R. A literature search was conducted using the PubMed terms ‘epidural’ AND ‘coagulation’ AND English language. Relevant articles published in 2000 and after were included. Results Three hundred and seven patients received a thoracic epidural infusion with bupivacaine and morphine while 51 received an intravenous morphine infusion. Tests taken preoperatively and before the planned withdrawal of the epidural catheter demonstrated increases in all three measures: aPTT (activated partial thromboplastin time), PT-INR (prothrombin international normalised ratio) and platelet count (Plc). Postoperative thrombocytopenia was almost non-existent while aPTT or PT-INR was elevated above the reference range in 129/307 patients: aPTT was elevated in 116/307 while PT-INR was elevated in 32/307. This is too small a sample to allow meaningful estimation of risk of spinal haematoma: it may be as high as 2.3%. The literature search returned 275 articles, of which 57 were relevant. Twenty-one concerned the natural history of postoperative coagulation; 16, the incidence of and risk factors for spinal haematoma; and 5, evaluation of specific blood tests. Postoperative coagulation is characterised by thrombocytosis and transient moderately abnormal routine coagulation test results. Viscoelastic tests are not validated in the stable postoperative setting. Conclusions Screening for coagulopathy before removal of epidural catheters is of unclear benefit since elevated aPTT and PT-INR are usual and may not indicate hypocoagulation. A thorough clinical assessment is important. We nevertheless recommend caution when being presented with elevated routine tests of coagulation before withdrawing an epidural catheter: viscoelastic haemostatic tests may have a role in testing before withdrawal of epidural catheters but they are so far not validated. Future research should include advanced coagulation analysis as soon as a patient is unfortunate enough to have a spinal haematoma. Electronic supplementary material The online version of this article (10.1186/s13741-017-0070-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Owain Thomas
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Lund, Medical Faculty, University of Lund, 221 00 Lund, Sweden.,Department of Paediatric Anaesthesia and Intensive Care, SUS Lund University Hospital, 22185 Lund, Sweden
| | | | - Per Flisberg
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Lund, Medical Faculty, University of Lund, 221 00 Lund, Sweden.,Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Södra Vallgatan 5, 254 37 Helsingborg, Sweden
| | - Ulf Schött
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Lund, Medical Faculty, University of Lund, 221 00 Lund, Sweden.,Department of Anaesthesia and Intensive Care, SUS Lund University Hospital, 221 85 Lund, Sweden
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Thomas O, Rein H, Strandberg K, Schött U. Coagulative safety of epidural catheters after major upper gastrointestinal surgery: advanced and routine coagulation analysis in 38 patients. Perioper Med (Lond) 2016; 5:28. [PMID: 27777753 PMCID: PMC5067910 DOI: 10.1186/s13741-016-0053-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 09/26/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The risk of spinal haematoma in patients receiving epidural catheters is estimated using routine coagulation tests, but guidelines are inconsistent in their recommendations on what to do when results indicate slight hypocoagulation. Postoperative patients are prone to thrombosis, and thromboelastometry has previously shown hypercoagulation in this setting. We aimed to better understand perioperative haemostasis by comparing results from routine and advanced tests, hypothesizing that patients undergoing major upper gastrointestinal surgery would be deficient in vitamin K-dependent coagulation factors because of malnutrition, or hypocoagulative because of accumulation of low molecular weight heparin (LMWH). METHODS Thirty-eight patients receiving epidural analgesia for major upper gastrointestinal surgery were included. We took blood at the time of preoperative epidural catheterization and at catheter withdrawal. Prothrombin time-international normalized ratio (PT-INR), activated partial thromboplastin time (aPTT) and platelet count (Plc) were analysed, and also albumin, proteins induced by vitamin K absence (PIVKA-II), rotational thromboelastometry (ROTEM®), multiple electrode aggregometry (Multiplate®) and activities of factors II, VII, IX, X, XI, XII and XIII. RESULTS Postoperative coagulation was characterized by thrombocytosis and hyperfibrinogenaemia. Mean PT-INR increased significantly from 1.0 ± 0.1 to 1.2 ± 0.2 and mean aPTT increased significantly from 27 ± 3 to 30 ± 4 s. Activity of vitamin K-dependent factors did not decrease significantly: FIX and FX activity increased. FXII and FXIII decreased significantly. Mean Plc increased from 213 ± 153 × 106/L while all mean ROTEM-MCFs (maximal clot firmnesses) especially FIBTEM-MCF increased significantly to above the reference interval. All mean ROTEM® clotting times were within their reference intervals both before and after surgery. ROTEM® (HEPTEM minus INTEM) results were spread around 0. There were significant correlations between routine tests and the expected coagulation factors, but not any of the viscoelastic parameters or PIVKA-II. Multiplate® area under curve and EXTEM-MCF correlated significantly to Plc as did EXTEM-MCF to fibrinogen, FIX, FX and FXIII; and FIBTEM-MCF to Plc, FII, FXI and FXIII. CONCLUSIONS The increase in PT-INR may be caused by decreased postoperative FVII while the elevated aPTT may be caused by low FXII. The mild postoperative hypocoagulation indicated by routine tests is not consistent with thromboelastometry. The relevance of ROTEM® and Multiplate® in the context of moderately increased routine tests remains unclear. Trial registration number is not applicable since this is not a clinical trial.
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Affiliation(s)
- Owain Thomas
- Faculty of Medicine, University of Lund, 22100 Lund, Sweden ; Department of Paediatric Anaesthesia and Intensive Care, SUS Lund University Hospital, 22185 Lund, Sweden
| | | | - Karin Strandberg
- Faculty of Medicine, University of Lund, 22100 Lund, Sweden ; Coagulation Laboratory, Department of Clinical Chemistry, Division of Laboratory Medicine, Skåne University Hospital, 21428 Malmö, Sweden
| | - Ulf Schött
- Faculty of Medicine, University of Lund, 22100 Lund, Sweden ; Department of Anaesthesia and Intensive Care, SUS Lund University Hospital, 22185 Lund, Sweden
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Thompson MH, Wilson SH, Toussaint BL, Jordan CL, Hayes GL, McKinzie BP, Wolf BJ, Field LC. Effect of Subcutaneous Unfractionated Heparin Prophylaxis on Activated Partial Thromboplastin Time: A Retrospective Evaluation. J Clin Anesth 2016; 33:346-50. [PMID: 27555191 DOI: 10.1016/j.jclinane.2015.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 09/10/2015] [Accepted: 11/12/2015] [Indexed: 02/01/2023]
Abstract
STUDY OBJECTIVE Characterize the incidence of elevated aPTT results in patients treated with prophylactic, subcutaneous unfractionated heparin (UFH). DESIGN Retrospective, cohort analysis. SETTING Single-center, university hospital. MEASUREMENTS Evaluation of 257 patients with activated partial thromboplastin time (aPTT) testing both prior to and following subcutaneous (SC) unfractionated heparin (UFH) therapy. MAIN RESULTS Evaluated patients received UFH 5000 units every 8 hours. Baseline aPTT values were within the normal range (mean±SD, 32.0±8.5 seconds). After initiation of UFH, aPTT values increased (mean±SD, 37.6±15.2 seconds). After 24 hours of SC UFH, mean aPTT values (mean±SD, 38.6±15.5) exceeded the normal laboratory range (23.3-35.7 seconds). An elevated aPTT result after UFH was associated with baseline aPTT, length of therapy, and weight-based UFH dose. A significant association was not identified between aPTT elevation and age, race, sex, history of liver disease, type of admission, or transfusion of blood products. CONCLUSIONS Treatment with UFH resulted in a small, but significant, increase in aPTT.
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Affiliation(s)
- Molly H Thompson
- Department of Pharmacy Services, Medical University of South Carolina, 150 Ashley Avenue, MSC 584, Charleston, SC, 29425, USA
| | - Sylvia H Wilson
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 167 Ashley Avenue, Suite 301, MSC 912, Charleston, SC, 29425-9120, USA.
| | - Brittany L Toussaint
- Department of Pharmacy Services, Medical University of South Carolina, 150 Ashley Avenue, MSC 584, Charleston, SC, 29425, USA
| | - Cameron L Jordan
- Department of Pharmacy Services, Medical University of South Carolina, 150 Ashley Avenue, MSC 584, Charleston, SC, 29425, USA
| | - Genevieve L Hayes
- Department of Pharmacy Services, Medical University of South Carolina, 150 Ashley Avenue, MSC 584, Charleston, SC, 29425, USA
| | - Brian P McKinzie
- Department of Pharmacy Services, Medical University of South Carolina, 150 Ashley Avenue, MSC 584, Charleston, SC, 29425, USA
| | - Bethany J Wolf
- Department of Public Health Sciences, Medical University of South Carolina, 135 Cannon St, Suite 303, MSC 835, Charleston, SC, 29425, USA
| | - Larry C Field
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 167 Ashley Avenue, Suite 301, MSC 912, Charleston, SC, 29425-9120, USA
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