COMPARATIVE EVALUATION OF TREATMENT OF ACUTE PULMONARY EMBOLISM (ACCORDING TO DATA CLINICAL HOSPITAL OF ALMATY #7)

В статье представлены результаты сравнительного анализа 50 больных тромбоэмболии легочной артерии (ТЭЛА), которые по способу лечения были разделены на 3 группы: I группа - с антикоагулянтной терапией (гепарин). II группа - с селективной катетерной тромболитической (альтеплаза) и антикоагулянтной терапией. III группа - с катетерной аспирационной тромбоэкстракцией; Установлено, что на фоне комплексной терапии, включающую тромболитическую и антикоагулянтную терапии наблюдалась лучшая выживаемость пациентов с острой ТЭЛА. The article presents results of a comparative analysis of 50 patients with pulmonary embolism (PE), which were divided into 3 groups according to the method of treatment: Group I - with anticoagulant therapy (heparin); Group II - with catheter thrombolytic (alteplase) and anticoagulant therapy. Group III - with catheter embolectomy (aspiration thromboextraction); It was found against the background of complex therapy, including thrombolytic and anticoagulant therapy, there was a better survival rate for patients with acute PE.

Line Thrombosis in Patient on Maintenance Hemodialysis with use of Trisodium Citrate 4% V/S Heparin at Sheikh Zayed Hospital Rahim Yar Khan

Background: Conventional Heparin and Tri-sodium citrate 4% are used for locking double lumen catheter after dialysis to prevent line thrombosis. Objectives: To compare the line thrombosis after use of heparin and tri-sodium citrate 4%. Methodology: Randomized controlled trial study involving patient who develop line thrombosis after use of heparin and tri-sodium citrate 4% from February 2020 to August 2020. The study was done on a group of 200 patients who had poor blood flow in double lumen catheter during dialysis. After informed consent first detailed clinical history was taken from patient. Inclusion criteria waspatient of age 14 year of above either gender who presented with renal failure, whom dialysis was performed via temporary catheter or permanent catheter. Conventional heparin and tri-sodium citrate are used as line blocking agents and line thrombosis was observed in patients. The data was entered and analyzed SPSS 20. Results: During this research work 200 double lumen were paced in patients. Out of these, in 100 patients heparin was used as locking solution and locking period was 45-60 days. In remaining 100 patients tri-sodium citrate was used as locking solution in the locking period was 45-60 days. There was no difference in patient’s comorbid conditions in both groups of the patients (Figure1). The catheter change rate was greater in patients whose catheter were locked with heparin (52 patients) as compared to tri-sodium citrate (42 patients). The proportion of the patient who needs replacement of the double lumen were 81% in conventional heparin sulphate and 65% with 4% tri-sodium citrate groups. There was longer insertion time for requiring double lumen for line thrombosis related poor blood flow in patients in which 4% tri-sodium citrate were used for catheter locked with comparison to the group in which heparin sulphate were used for locking (Figure2). The average hospitalization for line related thrombosis was longer in heparin group (10.5 days) as compared to citrate group 3.2 days. (P=0.02) The hospitalization rate was 6% in heparin group as compared to 2.5% in tri-sodium citrate group (P=045%). Conclusion: Tri-sodium citrate 4% is equally effective cheap and beneficial with comparison to heparin sulphate. It showed good outcome as far as change of double lumen or double lumen related infection or hospital admission when compared with heparin sulphate. Randomized trials while using tri-sodium citrate with other anti-coagulant would definitely will decide the better double lumen catheter locking agent. Key Words: End stage kidney failure, Advanced renal disease, Dialysis, double lumen blood flow.

Can Heparin Improve Clinical Outcomes in Cardiac Arrest? A Retrospective Cohort Study from the EICU Collaborative Research Database

Background: Studies indicate that heparin can improve survival in patients with out-of-hospital cardiac arrest. Thus, we aimed to investigate the effect of heparin on hospitalized patients with cardiac arrest.Methods: Clinical data of cardiac arrest patients from the eICU Collaborative Research Database V2.0 were retrospectively analyzed. We compared neurological prognosis and primary outcomes in a heparin group that received unfractionated heparin or low molecular weight heparin with a non-heparin group. Additionally, we compared the two heparin sub-groups. Results: After propensity score matching, there were 673 patients in the heparin group and 1346 patients in the non-heparin group. The Glasgow Coma Scale score was significantly better in the heparin group (P<0.05). There were no significant differences in terms of spontaneous respiratory function recovery, dementia, or vegetative state between the two groups (P>0.05). Intensive care unit (ICU) mortality and hospital mortality rates were significantly lower in the heparin group (P<0.05). The duration of mechanical ventilation, length of stay in ICU, and length of stay in hospital were significantly longer in the heparin group (P<0.05). Median survival time was significantly longer in the heparin group (P<0.001). In the comparison of patients who received unfractionated heparin and low molecular weight heparin (267 in each group), there were no significant differences in Glasgow Coma Scale score, ICU mortality, hospital mortality, or median survival time between the two groups (P>0.05).Conclusions: Heparin administration may be beneficial in reducing the mortality rate and prolonging the survival time of in-hospital patients with cardiac arrest. It may also improve the prognosis of neurological function to a certain extent. Outcomes were not significantly different between patients who received unfractionated heparin and those who received low molecular weight heparin.

Efficacy of Low Molecular Heparin on Preeclampsia by Inhibiting Apoptosis of Trophoblasts via the p38MAPK Signaling Pathway

Objective. To explore the efficacy of low molecular heparin on preeclampsia by inhibiting apoptosis of trophoblasts via the p38MAPK signaling pathway. Methods. A preeclampsia rat model was established, and the effects of low molecular heparin on preeclampsia via the p38MAPK signaling pathway were analyzed based on intervention of the rats with different combinations of low molecular heparin and p38MAPK signaling pathway activator. Furthermore, a hypoxia/reoxygenation model of trophoblasts in vitro was established to explore the effects of low molecular heparin on trophoblasts via the p38MAPK signaling pathway. Results. After treatment with low molecular heparin, pregnant rats in the heparin group showed significantly decreased blood pressure, 24 h proteinuria, and p38MAPK protein levels in placenta tissues and decreased apoptosis rate of placenta tissue cells (all P < 0.05 ) and showed more fetal rats and lowered weight of them (both P < 0.05 ) but showed no significant change in the weight of placenta (all P > 0.05 ). Pregnant rats treated with low molecular heparin and p38MAPK activator showed significantly higher blood pressure, 24 h proteinuria, and p38MAPK protein levels in placenta tissues and apoptosis rate of placenta tissue cells than those of pregnant rats in the heparin group (all P < 0.05 ) and also showed less fetal rats and lighter fetal rats than those in the heparin group (both P < 0.05 ) but showed no difference with them in the weight of placenta ( P > 0.05 ). Further analysis revealed that low molecular heparin could protect the survival and migration of trophoblasts under hypoxia/reoxygenation conditions and reduce apoptosis of them (all P < 0.05 ). Conclusion. Low molecular heparin can alleviate preeclampsia by inhibiting the p38MAPK signaling pathway and can inhibit apoptosis of trophoblasts and promote proliferation and migration of them.

Use of bivalirudin for anticoagulation in pediatric extracorporeal membrane oxygenation (ECMO)

This study describes the use of bivalirudin in children on extracorporeal membrane oxygenation (ECMO). Pediatric patients receiving bivalirudin were compared to patients receiving heparin as the anticoagulant on ECMO. Data was collected for children under 18 years of age supported by ECMO from January 2016 to December 2019. Data collected included demographics, diagnosis, ECMO indication, type, and duration, indication for bivalirudin use, dose range, activated partial thromboplastin time (aPTT) levels, minor and major bleeding, hemolysis, and mortality. Forty pediatric patients received ECMO; eight received bivalirudin primarily for anticoagulation. The median age was 4 months (IQR 0.5, 92) in the heparin cohort, 0.6 months (IQR 0.0, 80.0) in the primary bivalirudin cohort. The indication for ECMO was respiratory in 5 patients (18%) in the heparin group versus 6 (75%) in the primary bivalirudin group, cardiac in 18 (67%) in heparin versus 1 (12.5%) in primary bivalirudin, and extracorporeal-cardiopulmonary resuscitation (E-CPR) in 4 (15%) in heparin versus 1 (12.5%) in primary bivalirudin. Bivalirudin was the initial anticoagulant for eight patients (66.6%) while three (25%) were switched due to concern for heparin-induced thrombocytopenia (HIT) and one (8%) for heparin resistance. The median time to achieve therapeutic aPTT was 14.5 hours compared to 12 hours in the heparin group. Sixty-five percent of aPTT values in the bivalirudin and 44% of values in the heparin group were in the therapeutic range in the first 7 days. Patients with primary bivalirudin use had significantly lower dose requirement at 12 (p = 0.003), 36 (p = 0.007), and 48 (p = 0.0002) hours compared to patients with secondary use of bivalirudin. One patient (12.5%) had major bleeding, and two patients (25%) required circuit change in the primary bivalirudin cohort. Bivalirudin may provide stable and successful anticoagulation in children. Further large, multicenter studies are needed to confirm these findings.

Heparin for Moderately Ill Patients with Covid-19

Background Heparin, in addition to its anticoagulant properties, has anti-inflammatory and potential anti-viral effects, and may improve endothelial function in patients with Covid-19. Early initiation of therapeutic heparin could decrease the thrombo-inflammatory process, and reduce the risk of critical illness or death. Methods We randomly assigned moderately ill hospitalized ward patients admitted for Covid-19 with elevated D-dimer level to therapeutic or prophylactic heparin. The primary outcome was a composite of death, invasive mechanical ventilation, non-invasive mechanical ventilation or ICU admission. Safety outcomes included major bleeding. Analysis was by intention-to-treat. Results At 28 days, the primary composite outcome occurred in 37 of 228 patients (16.2%) assigned to therapeutic heparin, and 52 of 237 patients (21.9%) assigned to prophylactic heparin (odds ratio, 0.69; 95% confidence interval [CI], 0.43 to 1.10; p=0.12). Four patients (1.8%) assigned to therapeutic heparin died compared with 18 patients (7.6%) assigned to prophylactic heparin (odds ratio, 0.22; 95%-CI, 0.07 to 0.65). The composite of all-cause mortality or any mechanical ventilation occurred in 23 (10.1%) in the therapeutic heparin group and 38 (16.0%) in the prophylactic heparin group (odds ratio, 0.59; 95%-CI, 0.34 to 1.02). Major bleeding occurred in 2 patients (0.9%) with therapeutic heparin and 4 patients (1.7%) with prophylactic heparin (odds ratio, 0.52; 95%-CI, 0.09 to 2.85). Conclusions In moderately ill ward patients with Covid-19 and elevated D-dimer level, therapeutic heparin did not significantly reduce the primary outcome but decreased the odds of death at 28 days.

Efficacy of intravenous eptifibatide in primary percutaneous coronary intervention patients

Early and complete restoration of blood flow in closed coronary arteries is the main goal in treating patients with myocardial infarction. Primary angioplasty is not always successful in establishing myocardial blood flow. Although the strategy of adding eptifibatide leads to better blood flow, its value as part of a routine strategy is questionable. Therefore, this study was performed to evaluate the efficacy of intravenous eptifibatide in primary percutaneous coronary intervention (PCI) patients. This clinical, randomized, double-blind trial was performed on patients aged 20-80 years undergoing primary PCI. The patients were selected for study by convenience sampling and were randomly divided into two equal groups. The first group was treated with intravenous eptifibatide immediately before angioplasty with heparin. The second group received only coronary angioplasty with heparin. After data collection, statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software, version 16. A total of 104 patients were enrolled in the study, and there were no statistically significant differences in terms of age (P=0.188), gender (P=0.345), risk factor (P>0.05), or history of PCI (P=0.199). Mean thrombolysis in myocardial infarction (TIMI) score was not significant between the two groups after receiving the drug and performing angioplasty (P>0.05), and the rate of ejection fraction was 46.33±6.69 in patients receiving eptifibatide and 47.54±4.67 in the heparin group, which was not statistically significant (P=0.884). We found that eptifibatide improves clinical indexes in patients undergoing primary PCI, but these differences were not significant in the two groups.

Low vs standardized dose anticoagulation regimens for extracorporeal membrane oxygenation: A meta-analysis

Background To compare the safety and efficacy of low-dose anticoagulation (LA) with that of standardized dose anticoagulation (SA) for patients supported with extracorporeal membrane oxygenation (ECMO). Methods PubMed, MEDLINE, the Cochrane Library, and Web of Science were screened for original articles. Screening was performed using predefined search terms to identify cohort studies reporting the comparison of LA with SA in patients supported with ECMO from Nov 1990 to Jun 2020. The effect size was determined by the odds ratio (OR) with the 95% confidence interval (CI). Results An analysis of 7 studies including a total of 553 patients was performed. LA (Low-heparin group) was administered to 255 patients, whereas the other 298 patients received SA (Full-heparin group). The incidence of gastrointestinal tract hemorrhage (OR 0.36, 95% CI 0.20–0.64) and surgical site hemorrhage (OR 0.43, 95% CI 0.20–0.94) were significantly lower in patients who underwent LA compared with that in those who underwent SA. The rates of hospital mortality (OR 0.81, 95% CI 0.42–1.56), successfully weaning off of ECMO (OR 0.80, 95% CI 0.30–2.14), pulmonary embolism (OR 0.79, 95% CI 0.24–2.65), intracardiac thrombus (OR 0.34, 95% CI 0.09–1.30), intracranial hemorrhage (OR 0.62, 95% CI 0.22–1.74), and pulmonary hemorrhage (OR 0.77, 95% CI 0.30–1.93) were similar between the two groups. Conclusions This meta-analysis confirms that LA is a feasible and safe anticoagulation strategy in patients supported by ECMO. Future studies should focus on the long-term benefits of LA compared with SA.

The Effect of Preparing Dialysis Machine Using Normal Saline-Heparin on the Dialysis Adequacy of Hemodialysis Patients: A Crossover, Two-Group, and Randomized Clinical Trial

Background: Patients with end-stage renal disease (ESRD) need adequate dialysis. Thus, identification of the ways to enhance dialysis adequacy is very important. Objectives: The present study was conducted to examine the effect of preparing a dialysis machine using a normal saline heparin method on the dialysis adequacy of hemodialysis patients. Methods: This study was conducted in Hamadan in 2019. A total of 36 patients with hemodialysis were selected using convenience sampling who were assigned to the control and intervention groups. The hemodialysis machine was primed for one month using a routine method (control) and one month using a normal saline-heparin method (intervention). Urea reduction ratio (URR) and Kt/V indices were calculated at the beginning and end of each month in the intervention and control groups. Data were analyzed using paired and independent t-test. Results: In the normal saline-heparin group, KT/V showed a statistically significant difference before and after the treatment (P = 0.013), as well as an increase in the KT/V. The URR as the mean dialysis adequacy showed a statistically significant difference (P = 0.004) between the normal saline group and the normal saline-heparin group before and after the treatment. Moreover, URR in the normal saline-heparin group increased after the treatment. In the normal saline treatment group, KT/V and URR decreased after the treatment. In the normal saline group, URR decreased after the treatment. Conclusions: Applying the hemodialysis machine preparation with a normal saline-heparin method increased dialysis adequacy in the patients who underwent hemodialysis.

Low-molecular-weight heparin administered by subcutaneous catheter is a safe and effective anti-coagulation regimen in selected inpatient infants and children with complex congenital heart disease

Background/hypothesis: Disadvantages of intravenous therapeutic unfractionated heparin, the first-line anti-coagulant agent in children with complex congenital heart disease, include unpredictable pharmacokinetics requiring frequent phlebotomies and the need for continuous intravenous access. Objective: To compare efficacy and safety of low-molecular-weight heparin administered by a subcutaneous indwelling catheter with intravenous unfractionated heparin. Materials and methods: Clinical data from 31 inpatients prospectively enrolled to receive subcutaneous low-molecular-weight heparin were compared with those from a historical group of 44 inpatients receiving intravenous unfractionated heparin. Investigation of parents’ satisfaction by telephone survey. Results: The percentage of anti-factor Xa levels outside therapeutic range was lower in the subcutaneous low-molecular-weight heparin group compared with the percentage of activated partial thromboplastin times outside therapeutic range in the intravenous unfractionated heparin group (40% versus 90%, p < 0.001). Neither group had a major complication. Transient local reactions occurred in 19% of patients of the subcutaneous low-molecular-weight heparin group. The number of needle punctures and that of placement of indwelling catheters were significantly lower in the subcutaneous low-molecular-weight heparin compared with the intravenous unfractionated heparin group (p < 0.001). In total, 84.2% of parents in the subcutaneous low-molecular-weight heparin group reported a positive experience when asked about comparison with prior intravenous unfractionated heparin treatment. Conclusion: Subcutaneous low-molecular-weight heparin offers a safe anti-coagulation regimen for children with complex congenital heart disease providing more efficient therapeutic anti-coagulation and a reduction in needle punctures, thus causing less pain and anxiety in this children.