[HSF] Heparin Induced Thrombocytopenia and CABG

[Cysmd613 at aol.com]

Need advice on a case which I cancelled today.  64 yo morbidly obese  
diabetic woman with chronic renal insufficiency admitted 11 days ago with  angina.  
Did not have an MI.  Stress test positive.  Cath showed  50-60% distal left 
main, 60% ostial circ, 70% RCA with good LV.  History of  thrombocytopenia with 
negative bone marrow biopsy in past.  Platelet count  on admission 97,000 which 
slowly dropped to 67,000.  She had been on IV  heparin.  Yesterday morning 
when I made rounds she was still on  heparin.  Hematologist ordered platelet 
transfusions on call to OR.   This morning, I got a call from the 
anesthesiologist who was lining the patient  in the OR, saying that the patient is on 
Refludan, and what was my plan for  anticoagulation on bypass.  You can imagine my 
surprise!!  Yesterday  evening, the cardiologist, without calling me first, 
stopped the patient's  heparin and switched to Refludan because of the 
thrombocytopenia.  No  heparin antibody had been done yet.  Just from the neck sticks for 
the IJ  central line and swan-ganz, the patient was bleeding significantly.
So, I cancelled the case.  Blood was drawn and the heparin antibody is  
POSITIVE.  
 
Now, how to proceed?  I would not do CABG using Refludan as it is not  
reversible.  Should I use heparin, transfuse platelets as needed and hope  for no 
intravascular thrombosis?
 
Thank you for your input.
 
Carmi Stadlan



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