![]() ![]() Antidotes were statistically significantly more frequently given in Canada as compared to other participating countries. The use of antidotes was comparable for initial and long-term treatment. Vitamin K was given to 23 (1.2%) patients, one (0.05%) patient received protamin sulfate and seven (0.4%) patients received fresh frozen plasma. Of the patients with at least one major hemorrhage, 19 (41.3%) received an antidote. Some form of antidote was given to 26 (14.4%) patients with a hemorrhage. We investigated 1877 patients treated for venous thromboembolism included in three large clinical trials, of which 181 (9.6%) had a total of 225 adjudicated bleeding episodes 46 hemorrhages being designated as major. Interestingly, it is unknown how often the use of an antidote is necessary in clinical practice. Several new anticoagulants have been developed that are likely to have some risk of bleeding complications, for which no specific antidotes are available. Prophylactic anticoagulation with subcutaneous enoxaparin (40 mg) was reintroduced 2 days after surgery without any bleeding and the patient was discharged from the hospital 2 months after admission.When a bleeding complication occurs during therapy with heparin or vitamin K antagonists, there is an option to give a specific antidote. In order to confirm heparin indication, both a chest CT scan and a lower extremity Doppler examination were performed and revealed no venous thromboembolism. The day after this second surgical procedure, complete normalization of coagulation tests was observed ( T 5, Table 1). The surgery went well, the patient was extubated a few hours after surgery and physical examination showed partial regression of hemiplegia. All routine laboratory-based coagulation tests (aPTT, TT, and anti-Xa assays) from T 0 to T 4 (Table 1) were obtained at least 1 h after each corresponding blood sampling. Protamine administration was repeated (50 mg), complete heparin reversal was confirmed by normalization of TEG trace ( T 4) and surgery could start. TEG showed a reappearance of the heparin effect, evidenced as a prolonged r time >11 min. 2 One hour after protamine infusion and just before incision, a repeat TEG trace along with aPTT and TT measurements ( T 3) were performed (Table 1). ![]() As the half-life of protamine is much shorter than that of heparin, the need for a repeated infusion of protamine after the first administration was expected. Blood sample T 2, 15 min after protamine infusion, was collected: r value of TEG was now normal and the patient was admitted to the operating theatre. 20 min after blood sampling, based on the first results of TEG analysis while standard coagulation tests were still pending. A first dose of 50 mg protamine was slowly given i.v. Blood sample T 1 (Table 1) was obtained 3 h after discontinuation of heparin infusion: TEG with native blood showed heparin effect with prolonged r (reaction) time >240 min (normal 4–10 min). A head CT scan was immediately performed revealing an intracranial haematoma at the operation site and the patient was admitted to the intensive care unit before surgical revision. Rapidly thereafter, the patient exhibited right-sided hemiplegia and impaired consciousness (Glasgow Coma Scale 10/15). A blood sample was obtained for standard coagulation tests: results were obtained 60 min later and showed heparin concentration of 4.5 U ml −1 using an anti-Xa heparin assay ( T 0, Table 1). After 12 h of infusion, the patient presented with bleeding from different puncture sites and heparin infusion was stopped. continuous UFH at a dose of 50 000 U per 24 h after a bolus dose of 50 U kg −1. A resident in neurosurgery prescribed i.v. On the postoperative day 2, the patient exhibited chest pain, dyspnoea, and mild hypoxaemia related to subsegmental pulmonary embolism on a computed tomography (CT) scan. 1–3 Herein, we present a case in which thromboelastography (TEG) 4–6 was used to quickly restore normal coagulation immediately before an emergency procedure for intracranial haemorrhage in a context of heparin overdose.Ī 51-yr-old woman without any medical history except obesity was admitted for elective removal of an intracranial hemangiopericytoma. The required dose of protamine to neutralize unfractionated heparin (UFH) is difficult to predict and use of standard coagulation tests such as activated partial thromboplastin time (aPTT) to assess the effectiveness of reversal may delay surgery, compromising patient safety. Editor-Reversing heparin-induced anticoagulation quickly and effectively can be challenging in bleeding patients undergoing emergency surgery. ![]()
0 Comments
Leave a Reply. |