[HSF] Heparin Induced Thrombocytopenia and CABG

[V. Aldrete, M.D.]

Indications for surgery aside I just wanted to let you know that the  
Swan Ganz catheters have bonded heparin. It will leach after insertion.

I had the horrible experience of having a patient with true allergy  
to heparin (bronchospasm) and all, for which I used Ancrod for CPB  
anticoagulation as described by:

Zulys VJ.  Teasdale SJ.  Michel ER.  Skala RA.  Keating SE.  Viger  
JR.  Glynn MF.
  Department of Anaesthesia, Toronto General Hospital, Ontario, Canada.
Ancrod (Arvin) as an alternative to heparin anticoagulation for  
cardiopulmonary bypass.
Anesthesiology.  71(6):870-7, 1989 Dec.

Good luck,

Victor


On Oct 15, 2007, at 5:52 PM, Cysmd613 at aol.com wrote:

> 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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