Management of hemostasis in a patient with liver cirrhosis in the perioperative period.

Для пациентов с циррозом печени характерны существенные изменения в системе гемостаза. Описан клинический случай ведения пациента с циррозом печени, портальной гипертензией, варикозными венами желудка, оперированного на высоте желудочно-кишечного кровотечения, на фоне выявленных тромбоэмболических осложнений (тромбоэмболия легочной артерии и тромбоз глубоких вен голеней). В предоперационном периоде был установлен кава-фильтр. В первые двое суток послеоперационного периода в качестве антикоагулянта вводили концентрат антитромбина III (АТ-III) по 1000 ЕД в связи с исходным его дефицитом (64%) и для дальнейшего обеспечения эффективности терапии низкомолекулярными гепаринами (НМГ). По мере увеличения уровня тромбоцитов с 66×109/л до 200×109/л в качестве антикоагулянта был назначен парнапарин натрия в лечебной дозе. Эффективность терапии НМГ оценивали с помощью тромбоэластографии (ТЭГ). На 9-е сутки после операции диагностировано развитие гепаринорезистентности на фоне тромбоцитоза более 1 млн, гиперфибриногенемии, высокой активности фактора VIII и вновь выявленного дефицита АТ-III (53%). Клинически гепаринорезистентность проявилась образованием флотирующего тромба в правой бедренной вене. К максимальной лечебной дозе парнапарина (17000 анти- Ха) добавлен антиагрегант клопидогрел (75 мг) и начато введение концентрата АТ-III по 1000 МЕ в течение 3 сут. Преодолена гепаринорезистентность с нормализацией уровня АТ-III (89%), достигнута дезагрегация тромбоцитов. Через 7 сут диагностирован полный лизис флотирующего тромба в правой бедренной вене. В дальнейшем пациент в течение 1 мес амбулаторно находился на терапии парнапарином (17000 анти- Ха активность в сутки) и клопидогрелом (75 мг/сут). По данным компьютерной ангиопульмонографии: полный лизис тромба в легочной артерии, кава-фильтр удален. Заключение. Мониторинг системы гемостаза у пациента с циррозом печени позволил контролировать адекватность проводимой антикоагулянтной терапии и использовать арсенал имеющихся в распоряжении клинициста препаратов. Patients with liver cirrhosis are characterized by significant hemostasis changes. A clinical case is described of patient management with liver cirrhosis, portal hypertension, stomach varicose veins, operated at the height of gastrointestinal bleeding, with revealed thromboembolic complications (pulmonary embolism and deep vein thrombosis of the lower legs). Cava filter was installed in preoperative period. In the first 2 days of the postoperative period, antithrombin III (AT-III) concentrate was administered as an anticoagulant, 1000 units each due to its initial deficiency (64%) and to further ensure the therapy efficacy with low molecular weight heparins (LMWH). By increasing the platelet count from 66×109/L to 200×109/L, a therapeutic dose of parnaparin sodium was prescribed as an anticoagulant. The efficacy of LMWH therapy was assessed by thromboelastography (TEG). On the day 9 after surgery heparin resistance was diagnosed with thrombocytosis (more than 1 million), hyperfibrinogenemia, high activity of VIII factor and re-identified AT-III deficiency (53%). Clinically, heparin resistance was manifested by floating thrombus in the right femoral vein. The antiaggregant clopidogrel (75 mg) was added to the maximum therapeutic dose of parnaparin (17,000 anti- Xa), and the administration of AT-III concentrate (1000 IU) was started for 3 days. Heparin resistance was overcome with normalization of AT-III level (89%), platelet disaggregation was achieved. Complete lysis of floating thrombus in the right femoral vein was diagnosed after 7 days. Later the patient was treated with parnaparin (17,000 anti- Xa activity per day) and clopidogrel (75 mg/day) during 1 month outpatiently. According to computer pulmonary angiography, complete thrombus lysis in the pulmonary artery was revealed, the cava filter was removed. Conclusions. Hemostasis monitoring in patient with liver cirrhosis made it possible to control the adequacy of the anticoagulant therapy and to use the arsenal of drugs available to the clinician.

Management of heparin resistance due to antithrombin deficiency in a Chinese pregnant woman: a case report

Untreated individuals with antithrombin (AT) deficiency are at higher risk of thrombosis and adverse pregnancy outcomes. The present recommendations are mostly empirical for treating patients with AT deficiency during pregnancy because of the absence of guidelines. We report a rare case of heparin resistance due to AT deficiency in a pregnant 32-year-old Chinese woman. We also reviewed the English medical literature for AT deficiency and its association with thromboembolism and treatment. This patient suffered two early miscarriages because of thrombosis due to AT deficiency. The patient was administered the combination of adequate low molecular weight heparin with fresh frozen plasma and warfarin because of her heparin resistance. She delivered a healthy female newborn without any adverse effects of the anticoagulation therapy. Our findings suggest that the combination of adequate low molecular weight heparin with fresh frozen plasma and warfarin is effective for preventing thrombus during pregnancy.

Arterial Thrombosis Induced By Coagulopathy Due To Coronavirus Infection Concomitant With Heparin Resistance: A Case Report

Background : A newly emerging pandemic of Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory coronavirus 2 is responsible for significant morbidity and mortality worldwide. As one of the effects is hematological changes related to the COVID-19 infection causing patient tend to thrombosis than hemorrhagic. Current review of evidence and statements on management of coagulopathy and thrombotic complications related to this novel disease is needs to be explored Case : Male 53 years old referred from Private Hospital, due to Severe pneumonia due to COVID-19 and Acute Limb Ischemia. This patient was assessed as Pneumonia COVID-19 severe with acute limb ischemia bilateral grade IIB and performed bilateral surgical thrombectomy with antegrade approach using fogarty catheter with the result was thrombus 10cm along the left femoral artery and thrombus 2cm in the right femoral artery. Discussion : With consideration of atherosclerotic diseases in this patient, we decided to give rivaroxaban as an anticoagulant combined with aspilet and statin high dose. But due to lack of source in our hospital, and patient also denied for further management, treatment for the patient cannot be optimal, so the patient discharge with unresolved limb ischemia. Conclusion : This case showed that the increase risk of heparin resistance in SARS-CoV-2 patient, it is recommend- ed to monitor heparin activity of UFH treatment based on anti-Xa levels instead of aPTT alone.

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.

Off Target: Case Report of Heparin Resistance in a Neurosurgical Intensive Care Unit Patient

Introduction Heparin resistance was discovered in a patient in the surgical intensive care unit who underwent emergency endovascular coiling and later an anterior communicating artery clipping procedure to treat subarachnoid hemorrhage due to rupture of an anterior communicating artery aneurysm. Clinical Findings On intensive care unit day 17/postoperative day 3, the patient experienced shortness of breath, persistent tachycardia, and hypoxia. Bilateral pulmonary emboli, a saddle embolus, and lower-extremity and upper-extremity deep vein thrombi were diagnosed. The patient received high-dose unfractionated heparin (>35 000 U/24 h), and activated partial thromboplastin times remained subtherapeutic over the next 72 hours. Diagnosis Factor VIII activity, fibrinogen, antithrombin activity, antithrombin antigen, and platelet factor 4 were measured. The results demonstrated an increase in factor VIII activity to 342% (reference range, 50%-200%), elevated fibrinogen level of 441 mg/dL (reference range, 200-400 mg/dL), antithrombin antigen level of 92% (reference range, 80%-130%), elevated antithrombin activity of 108% (reference range, 80%-100%), and negative platelet factor 4 result, indicating that the patient did not have heparin-induced thrombocytopenia and confirming the diagnosis of heparin resistance. Conclusions Risk factors for heparin resistance include antithrombin deficiency, elevation of factor VIII or fibrinogen level, elevation in heparin-binding proteins, increased heparin clearance, sepsis, trauma, and burns. The astute critical care nurse may be the first to recognize this condition in a patient, preventing a potentially fatal complication.

Role of combining anticoagulant and antiplatelet agents in COVID-19 treatment: a rapid review

Although primarily affecting the respiratory system, COVID-19 causes multiple organ damage. One of its grave consequences is a prothrombotic state that manifests as thrombotic, microthrombotic and thromboembolic events. Therefore, understanding the effect of antiplatelet and anticoagulation therapy in the context of COVID-19 treatment is important. The aim of this rapid review was to highlight the role of thrombosis in COVID-19 and to provide new insights on the use of antithrombotic therapy in its management. A rapid systematic review was performed using preferred reporting items for systematic reviews. Papers published in English on antithrombotic agent use and COVID-19 complications were eligible. Results showed that the use of anticoagulants increased survival and reduced thromboembolic events in patients. However, despite the use of anticoagulants, patients still suffered thrombotic events likely due to heparin resistance. Data on antiplatelet use in combination with anticoagulants in the setting of COVID-19 are quite scarce. Current side effects of anticoagulation therapy emphasise the need to update treatment guidelines. In this rapid review, we address a possible modulatory role of antiplatelet and anticoagulant combination against COVID-19 pathogenesis. This combination may be an effective form of adjuvant therapy against COVID-19 infection. However, further studies are needed to elucidate potential risks and benefits associated with this combination.

Heparin Resistance in ECMO and the Role of Direct Thrombin Inhibitors: A Case Report

Extracorporeal membrane oxygenation (ECMO) is a potentially life-saving technology that can provide timely support to those failing to oxygenate their blood, either due to cardiac or respiratory related illnesses. However, ECMO also requires a careful hemostatic balance due to the thrombotic nature of the external circuit and the potential for bleeding events while anticoagulated. Current standard procedure for anticoagulating patients on ECMO is the use of unfractionated heparin. Despite its widespread use, many patients still face bleeding and/or clotting complications during their admission, some resulting in disastrous consequences. One possible etiology for this ineffectiveness is due to the mechanism by which heparin works via antithrombin (AT) and the AT deficiency of a critically ill patients. In this case study, we discuss the use of an alternative anticoagulant, a direct-thrombin inhibitor (DTI) in a patient cannulated to ECMO, which is independent of AT. The case study follows their course while on ECMO, focusing on relevant hemostatic measures. We further demonstrate the therapeutic potential for DTIs in place of UFH in ECMO patients, and the need for further research into anticoagulation strategies in critically ill patients.