Bleeding complications after cardiac surgery, before anticoagulation start and then with argatroban or heparin in the early postoperative setting

Abstract

Objectives: After elective cardiac surgery a postoperative anticoagulation is obligatory. With critically ill patients the conventional anticoagulation standard heparin is sometimes impossible, e.g. based on HIT II. Then, argatroban is currently a possible alternative, however, due to its impaired metabolism in critically ill patients, anticoagulation effect is harder to anticipate, thus resulting in higher bleeding risk. Furthermore, to date no antidote is available. Hence, severe postoperative bleeding incidents under anticoagulation are commonly mono-causal attributed to the anticoagulation itself. This study concentrates on the number of well-defined postoperative bleeding incidents before any anticoagulation started, then actually under argatroban as well as compared to those under heparin (or switched from heparin to argatroban). Material and methods: Retrospective study including 215 patients undergoing elective cardiac surgery with a postoperative stay in ICU ≥48 h. Postoperative bleeding complications before and after start of anticoagulation were evaluated. Definition of bleeding complications were: decrease of hemoglobin by more than 2 g/dl without dilution (mean value of volume balance plus one standard deviation) and/or increased need of red blood cell transfusion/day (average transfusion rate + 2 standard deviations). Results: Within the study group of 215 patients, 143 were treated with heparin, 43 with argatroban, 29 switched from heparin to argatroban. Overall, 26.5% (57/215) postoperative bleeding complications occurred. In 54.4% (31/57) bleeding complications occurred before start of anticoagulation; in 43.6% (26/57) after. Of these, 14 bleeding incidents occurred under heparin 9.8% (14/143), 6 under argatroban 14% (6/43) and 6 switched 20.7% (6/29). Higher bleeding complications before start of anticoagulation was related to concomitant factors influencing the overall bleeding risk; e.g. score of severity of illness. These observations further correlate with postoperative, but not anticoagulation induced mortality rate of 2.8% of then given heparin, 20.9% then argatroban, 20.7% then switched. Conclusions: Postoperative bleeding complications cannot simply be attributed to anticoagulation since occurring often before anticoagulation was started. The risk for bleeding complications after start of anticoagulation was quite comparable for argatroban and heparin. Accordingly, the influence of argatroban on bleeding complications in the postoperative period may be less significant than previously thought.

The Antithrombotic Effect of Recombinant Neorudin on Thrombi

“…However, some moderate bleeding often occurs accompanying their applications in clinic. 10 , 11 The license of Rivaroxaban, a representative of direct oral anticoagulants (DOACs), brings more options to the anticoagulant market. Nevertheless, moderate or minor bleeding of rivaroxaban still puzzles doctors, especially for patients with high bleeding risk.…”

Between a Rock and a Hard Place: Anticoagulating an Adolescent with Post-Tonsillectomy Massive PE: A Case Report

“…The relative risk of bleeding has been described for elective orthopedic and cardiovascular procedures with similar bleeding risks as tonsillectomy. 14,15 Unlike many cardiac or orthopedic patients, however, tonsillectomy patients are often young and very rarely require anticoagulation for any reason, which explains the lack of data on this topic.…”

Thromboprophylaxis with argatroban in critically ill patients with sepsis: a review

“…In comparison with heparins such as LMWH or UFH, a retrospective study in critically ill patients diagnosed with HIT showed that argatroban used at doses less than 0.4 mg/kg/min was not associated with an increase in transfusion requirement and furthermore was associated with reduced overall treatment cost as compared to heparin [179]. Although risk factors for bleeding during argatroban are known [180], several retrospective studies have demonstrated that argatroban is well tolerated with bleeding rates comparable to those of heparin in critically ill patients suffering from various diseases other than HIT [181][182][183][184].…”