PMID- 28789610
OWN - NLM
STAT- MEDLINE
DCOM- 20181001
LR  - 20181001
IS  - 1477-111X (Electronic)
IS  - 0267-6591 (Linking)
VI  - 33
IP  - 3
DP  - 2018 Apr
TI  - Management of refractory bleeding post-cardiopulmonary bypass in an acute 
      heparin-induced thrombocytopenia type II renal failure patient who underwent 
      urgent cardiac surgery with bivalirudin (Angiox((R))) anticoagulation.
PG  - 235-240
LID - 10.1177/0267659117723457 [doi]
AB  - Acute heparin-induced thrombocytopenia (HIT) patients present a myriad of 
      anticoagulation management challenges, in clinical settings where unfractionated 
      heparin (UFH) is the traditional drug of choice. UFH use in cardiac surgery is a 
      known entity that has been subject to rigorous research. Research has, thus, led 
      to its unparalleled use and the development of well-established protocols for 
      cardiac surgery. In comparison to UFH, bivalirudin use for acute HIT patients 
      requiring urgent cardiac surgery with cardiopulmonary bypass (CPB) is still in 
      its infancy. We describe the tailored post-CPB management of refractory bleeding 
      in a 65-year-old infective endocarditis, acute HIT patient with renal failure who 
      underwent urgent aortic valve replacement and mitral valve repair with 
      bivalirudin anticoagulation. A management approach that entailed a combination of 
      continuous venovenous haemofiltration (CVVH), 4-Factor prothrombin complex 
      concentrate (PCC) (Beriplex), recombinant factor VIIa (rFactor VIIa) and 
      desmopressin (DDAVP) were consecutively used post-operatively in theatre. Based 
      on this case study experience, two modifications to institutional protocols are 
      recommended. The first is the use of CVVH in theatre to eliminate bivalirudin in 
      renal failure patients or in patients where bivalirudin elimination is prolonged. 
      Secondly, a 'rescue therapy/intervention' algorithm for the swift identification 
      of refractory bleeding post-CPB is also recommended. Rescue therapy agents, such 
      as a 4-Factor PCCs and rFactor VIIa, should be incorporated into the protocol 
      after a robust evidence-based search and agreement with the haematologist. The 
      aim of these recommendations is to reduce the risk of bleeding associated with 
      bivalirudin use for inexperienced institutions and experienced institutions 
      alike, until larger randomized, controlled studies provide more in-depth 
      knowledge to expand our clinical practice.
FAU - Hassen, Kimberly
AU  - Hassen K
AD  - 1 Department of Clinical Perfusion, Essex Cardiothoracic Centre, Basildon 
      University Hospital, Basildon, UK.
FAU - Maccaroni, Maria R
AU  - Maccaroni MR
AD  - 2 Department of Anaesthesia, Essex Cardiothoracic Centre, Basildon University 
      Hospital, Basildon, UK.
FAU - Sabry, Haytham
AU  - Sabry H
AD  - 3 Department of Surgery, Essex Cardiothoracic Centre, Basildon University 
      Hospital, Basildon, UK.
FAU - Mukherjee, Smitangshu
AU  - Mukherjee S
AD  - 4 Department of Anaesthesia, Hammersmith Hospital, Imperial College Healthcare 
      NHS Trust, London, UK.
FAU - Serumadar, Shankari
AU  - Serumadar S
AD  - 5 Department of Haematology, Essex Cardiothoracic Centre, Basildon University 
      Hospital, Basildon, UK.
FAU - Birdi, Inderpaul
AU  - Birdi I
AD  - 3 Department of Surgery, Essex Cardiothoracic Centre, Basildon University 
      Hospital, Basildon, UK.
LA  - eng
PT  - Case Reports
PT  - Journal Article
DEP - 20170808
PL  - England
TA  - Perfusion
JT  - Perfusion
JID - 8700166
RN  - 0 (Anticoagulants)
RN  - 0 (Blood Coagulation Factors)
RN  - 0 (Hemostatics)
RN  - 0 (Hirudins)
RN  - 0 (Peptide Fragments)
RN  - 0 (Recombinant Proteins)
RN  - 37224-63-8 (prothrombin complex concentrates)
RN  - 9005-49-6 (Heparin)
RN  - AC71R787OV (recombinant FVIIa)
RN  - EC 3.4.21.21 (Factor VIIa)
RN  - ENR1LLB0FP (Deamino Arginine Vasopressin)
RN  - TN9BEX005G (bivalirudin)
SB  - IM
CIN - Perfusion. 2018 Apr;33(3):241-242. PMID: 29064332
MH  - Acute Disease
MH  - Aged
MH  - Anticoagulants/*adverse effects/therapeutic use
MH  - Aortic Valve/surgery
MH  - Blood Coagulation Factors/*therapeutic use
MH  - Cardiac Surgical Procedures/adverse effects/methods
MH  - Cardiopulmonary Bypass/adverse effects/methods
MH  - Deamino Arginine Vasopressin/*therapeutic use
MH  - Factor VIIa/*therapeutic use
MH  - Hemorrhage/*drug therapy
MH  - Hemostatics/*therapeutic use
MH  - Heparin/*adverse effects/therapeutic use
MH  - Hirudins
MH  - Humans
MH  - Male
MH  - Mitral Valve/surgery
MH  - Peptide Fragments/therapeutic use
MH  - Recombinant Proteins/therapeutic use
MH  - Renal Insufficiency/complications
MH  - Thrombocytopenia/*chemically induced/complications
OTO - NOTNLM
OT  - HIT
OT  - HIT positive
OT  - acute heparin-induced thrombocytopenia
OT  - bivalirudin
OT  - cardiac surgery
OT  - cardiopulmonary bypass
OT  - direct thrombin inhibitors
OT  - heparin-induced thrombocytopenia
OT  - refractory bleeding
OT  - renal failure
EDAT- 2017/08/10 06:00
MHDA- 2018/10/03 06:00
CRDT- 2017/08/10 06:00
PHST- 2017/08/10 06:00 [pubmed]
PHST- 2018/10/03 06:00 [medline]
PHST- 2017/08/10 06:00 [entrez]
AID - 10.1177/0267659117723457 [doi]
PST - ppublish
SO  - Perfusion. 2018 Apr;33(3):235-240. doi: 10.1177/0267659117723457. Epub 2017 Aug 
      8.