Difficult Management of Anticoagulation With Argatroban in a Patient Undergoing On-Pump Cardiac Surgery

Azuma, Kenji; Maruyama, Koichi; Imanishi, Hirokazu; Nakagawa, Hideyuki; Kitamura, Akira; Hayashida, Masakazu

doi:10.1053/j.jvca.2009.12.001

Cited by 8 publications

(8 citation statements)

References 15 publications

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“…Argatroban, a direct thrombin inhibitor that binds avidly and reversibly to the catalytic site of thrombin and that does not require other cofactors to exert its antithrombotic action, is often used in open-heart surgery for patients with HIT II [9,10]. After initial bolus administration at 0.1-0.3 mg/kg and continuous dosing at 5-10 μg/kg/min during cardiopulmonary bypass, additional bolus doses and an increase in the continuous dose are often required to achieve the target ACT [11,12]. Similarly, in our case, additional administration was required to achieve the target ACT after continuous dosing at about 11.3 μg/kg/min after bolus administration of about 0.3 mg/kg.…”

Section: Discussionmentioning

confidence: 99%

“…In all previously reported cases of open-heart surgery in pediatric patients with HIT II, ACT far exceeded the target level after additional administration of argatroban based on ACT [13]. In addition, many reports suggest that 7-26 h are required for ACT to return to the preadministration level, and intra-and postoperative recovery of blood coagulation ability is prolonged, causing increased bleeding and blood transfusion volumes [9,11,14]. This may be because argatroban has an onset time of as long as 30 min, and a similarly long half-life of about 30 min.…”

Section: Discussionmentioning

confidence: 99%

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Use of argatroban in combination with nafamostat mesilate in open-heart surgery for a pediatric patient with heparin-induced thrombocytopenia type II: a case report

2020

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Background Heparin-induced thrombocytopenia type II (HIT II) is a rare, immune-mediated complication of heparin therapy and can cause life-threatening thromboembolism. However, perioperative anticoagulation therapy for patients with a complication of HIT II has not been established. Case presentation A 6-year-old boy with tetralogy of Fallot underwent radical intracardiac repair with administration of argatroban at 1 year old due to positive HIT antibody. Reoperation was scheduled for pulmonary valve insufficiency, using argatroban and nafamostat mesilate as anticoagulants. Argatroban has a long onset time and the activated coagulation time (ACT) requires 7–26 h to return to the preadministration level, making hemorrhage control difficult, while half-life of nafamostat mesilate is shorter than that of argatroban. Celite ACT reflects the effects of both argatroban and nafamostat mesilate, but kaolin ACT reflects only the effect of argatroban. Due to the early termination of argatroban administration based on Celite and kaolin ACTs, ACT recovered to ≤ 200 s at 5 h after the end of argatroban administration. Conclusion Celite and kaolin ACTs can be used as markers to obtain close control of the required dose of argatroban in combination with nafamostat mesilate for the management of HIT II patients.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Use of argatroban in combination with nafamostat mesilate in open-heart surgery for a pediatric patient with heparin-induced thrombocytopenia type II: a case report

2020

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“…However, several reports indicate that this dose is inappropriate for initiating CPB and that additional boluses or an increased infusion rate is required [10,11]. In Case 1, as recommended by Martin and colleagues [9], we administered argatroban 0.3 mg/kg (15 mg) as a bolus dose and subsequently started continuous infusion at 5 μg/kg/min.…”

Section: Discussionmentioning

confidence: 99%

Anticoagulant Managements of Left Ventricular Assist Device Implantation in Two Patients with Heparin-Induced Thrombocytopenia (HIT): Use of Argatroban as an Anticoagulant for Cardiopulmonary Bypass

Toyama¹

2015

J Anesth Clin Res

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Heparin-induced thrombocytopenia (HIT) can cause fatal arterial or venous thrombosis/thromboembolism. In high-risk cases, heparin should be immediately discontinued and an alternative administered; the only alternative permitted in Japan is argatroban, a direct thrombin inhibitor. Anticoagulation in patients with recent HIT requiring cardiopulmonary bypass (CPB) surgery is challenging, because it is sometimes difficult to find out appropriate dosage of argatroban using ACT based monitoring calculation.Two dilated cardiomyopathy patients with HIT were administered argatroban as the anticoagulant for the CPB in left ventricular assist device (LVAD) implantation. After discontinuing argatroban, blood coagulopathy persisted beyond its expected half-life, leading to abnormal haemostasis. Because of severe intraoperative and postoperative bleeding, both patients required massive transfusion support, despite the case 2 performed plasmapheresis to eliminate argatroban at the weaning from CPB. However, blood loss in case 2 (18,159 ml) was significantly lower than that in case 1 (31,292 ml), which might be contributed by the smaller dosage of argatroban (242 mg in case 2 vs. 489 mg in case 1) and plasmapheresis.Prolongation of ACT is multifactorial and affected by platelet count, fibrinogen concentration and, particularly total dose of argatroban. Furthermore, literatures and our experienses revealed that the recovery time to baseline ACT after stopping argatroban was significantly correlated with the total dose of argatroban (r=0.927). But, we could not authenticate the potency of plasmapheresis to eliminate argatroban and HIT antibodies.Because no specific antidotes are available for argatroban, surgical teams should carefully monitor timing of argatroban administration and the total dosage.

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“…1 Le monitorage de son action se fait conventionnellement par la mesure du temps de coagulation activée (ACT). 17 Actuellement l'argatroban a l'AMM pour le traitement des thrombopénies à l'héparine (TIH) aigues ainsi que les interventions coronariennes percutanées. Son utilisation lors d'intervention de chirurgie cardiaque sous CEC reste limitée à quelques séries de cas.…”

Section: Danaparoïde Sodiqueunclassified

“…Son utilisation lors d'intervention de chirurgie cardiaque sous CEC reste limitée à quelques séries de cas. [17][18][19] 8 Aucun antagoniste spécifique à ce traitement n'existe à l'heure actuelle. Chez les patients insuffisants rénaux, l'utilisation de l'hémodialyse s'avère efficace pour l'élimination de la molécule.…”

Section: Danaparoïde Sodiqueunclassified

Les différentes alternatives d’anticoagulation au couple héparine/protamine en chirurgie cardiaque sous circulation extra-corporelle

Bouraghda

Gillois

Albaladéjo

2015

Can J Anesth/J Can Anesth

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Difficult Management of Anticoagulation With Argatroban in a Patient Undergoing On-Pump Cardiac Surgery

Cited by 8 publications

References 15 publications

Use of argatroban in combination with nafamostat mesilate in open-heart surgery for a pediatric patient with heparin-induced thrombocytopenia type II: a case report

Use of argatroban in combination with nafamostat mesilate in open-heart surgery for a pediatric patient with heparin-induced thrombocytopenia type II: a case report

Anticoagulant Managements of Left Ventricular Assist Device Implantation in Two Patients with Heparin-Induced Thrombocytopenia (HIT): Use of Argatroban as an Anticoagulant for Cardiopulmonary Bypass

Les différentes alternatives d’anticoagulation au couple héparine/protamine en chirurgie cardiaque sous circulation extra-corporelle

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