Management of Microsurgical Patients using Intraoperative Unfractionated Heparin and Thromboelastography

Zavlin, Dmitry; Chegireddy, Vishwanath; Jubbal, Kevin T.; Agrawal, Nikhil; Spiegel, Aldona J.

doi:10.1055/s-0038-1670683

Cited by 15 publications

(27 citation statements)

References 48 publications

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“…Thromboelastography could be an interesting method to identify these high-risk patients. 8 The intraluminal application of heparin has also shown to reduce the thrombosis rate of anastomoses in an animal study. 9 Pérez et al 10 reported that local subcutaneous injection of heparin to be an effective alternative in improving flap venous congestion.…”

mentioning

confidence: 99%

The Influence of Topically Administered Heparin on Peripheral Microcirculation of the Skin: A Double-Blind, Randomized, Controlled Preliminary Study on 50 Healthy Subjects

Denzinger¹,

Held

Amr

et al. 2021

J Reconstr Microsurg

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Background Venous thrombosis is the most common cause of flap failure in the first days after surgery. Although heparin is one of the most important antithrombotic substances and is implemented in the therapy of various diseases, there are only a few studies addressing its topical administration in the field of flap surgery. Especially, very little is known about the effects of topical heparin and its impact on microcirculation. In this study we evaluated to what extent topically administered heparin influences skin microcirculation (capillary venous oxygen saturation SO2, blood filling of microvessels, blood flow, and velocity) in healthy subjects. Methods Skin perfusion parameters on the forearm were measured with the O2C device in a double-blinded, controlled, and randomized study with 50 healthy subjects after administration of heparin ointment in three different concentrations and a control ointment (dexpanthenol). Results Topically administrated heparin slightly increased SO2 (max. 187 ± 285 SD or standard deviation % vs. 145 ± 129 SD %), flow (max. 264 ± 427 SD % vs. 151.74 ± 111 SD %), and velocity (max. 153 ± 149 SD % vs. 122 ± 56 SD %) after an incubation time of 60 minutes in comparison to control. No statistically significant difference could be detected regarding heparin concentration. Conclusion As a first important step in possible future implementing of heparin as a topical administration in flap surgery, our data—although not statistically significant—indicate that heparin can improve microcirculation (SO2, flow) in healthy subjects. Nevertheless, further research in subjects with impaired microcirculation is necessary.

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mentioning

confidence: 99%

The Influence of Topically Administered Heparin on Peripheral Microcirculation of the Skin: A Double-Blind, Randomized, Controlled Preliminary Study on 50 Healthy Subjects

Denzinger¹,

Held

Amr

et al. 2021

J Reconstr Microsurg

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“…Platelet levels, activated PTT (aPTT), and prothrombin time did not have predictive values for flap loss. 35 In patients undergoing free flap reconstruction for posttraumatic defects, higher flap loss rates have been observed in patients with pathological findings on preoperative rotational thromboelastometry (ROTEM), a similar measurement (13.6 vs. 4.3%). 36 Further analysis is needed to determine if these measurements can be combined with intraoperative evaluation of the local vasculature to further stratify patients at risk.…”

Section: Discussionmentioning

confidence: 91%

Does Anticoagulation Improve Flap Outcomes in Hypercoagulable Patients? A Systematic Review

Kotamarti

Shiah

Rezak

et al. 2019

J reconstr Microsurg

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Background Despite improvements in microsurgical techniques, hypercoagulable patients remain a reconstructive challenge. Thrombophilias are a relatively common problem with potentially catastrophic results including free flap loss. The aim of this study was to assess the available literature on free tissue transfer in patients with known hypercoagulability to develop recommendations for management. Methods A systematic review of the PubMed, EBSCO, and Cochrane databases was performed in June 2018. Inclusion criteria were assessment of outcomes of free tissue transfer in patients with established hypercoagulability. Exclusion criteria were review articles, case reports, and studies lacking detailed discussion of anticoagulation regimens and surgical outcomes. Data collected included the number of hypercoagulable patients, anticoagulation regimens, thrombotic complications, flap success, and bleeding complications. Statistical analysis was performed using independent samples t-tests. Results Of 147 total results, four articles were included for analysis. One relevant article published after search completion was included. In total, 185 free tissue transfers were performed in 155 thrombophilic patients. Anticoagulation regimens varied widely but often included intraoperative continuous heparin, with or without additional bolus, followed by postoperative and outpatient anticoagulation. Hypercoagulable patients often developed late postoperative thromboses. Of the intraoperative thromboses, 36.4% were successfully salvaged. No flaps with postoperative thrombosis were salvaged. Preemptive therapeutic anticoagulation improved outcomes but increased the bleeding risk. Conclusion Free tissue transfer may be successful in hypercoagulable patients. High-risk patients identified preoperatively should receive therapeutic anticoagulation initiated intraoperatively unless contraindicated. Salvage after postoperative thrombosis is poor. Ultimately, the benefits of free tissue transfer must be considered with the potential morbidity of bleeding complications on a case-by-case basis when developing a reconstructive plan. Initiating anticoagulation based on the presence of intraoperative risk factors may prevent unnecessary intervention.

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“…Thromboelastography [27], as a coagulation-monitoring method, which was widely used in the field of transplantation and blood vasculature operations [13, 28], monitors the dynamic process of coagulation and fibrinolysis. Zavlin et al [14] concluded that TEG is more dynamic compared to the APTT or PT, and is exceedingly reflective of real-time coagulation status changes. While these traditional coagulation tests were not able to identify patients with thrombosis in the fields of microsurgery.…”

Section: Discussionmentioning

confidence: 99%

“…Thromboelastography (TEG), as a blood clotting test, which can monitor coagulation changes from clotting to fibrinolysis dynamically, was widely used in the field of transplantation and blood vasculature operations [11–13]. TEG can simulate the whole process of coagulation and fibrinolysis in the human body environment, which is more sensitive than conventional coagulation assays in the evaluation of hypercoagulation, low coagulation, and fibrinolysis [14–16].…”

Section: Introductionmentioning

confidence: 99%

Application of thromboelastography to evaluate the effect of different routes administration of tranexamic acid on coagulation function in total hip arthroplasty

Jiang

Liu

et al. 2019

J Orthop Surg Res

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BackgroundTranexamic acid (TXA) is widely used to reduce blood loss and transfusion rates in total hip arthroplasty(THA). Thromboelastography, which can monitor coagulation changes from clotting to fibrinolysis dynamically. In this study, thromboelastography was used to assess the dynamic changes in the coagulation of patients who underwent THA with the administration of TXA.MethodsThis randomized controlled trial consisted of 207 consecutive patients who underwent primary total hip arthroplasty. Patients were randomized into three groups: topical-TXA group received a topical application of TXA, IV-TXA group received an intravenous injection of TXA, and control group. Thromboelastography was performed 1 day before surgery and first, fourth, seventh days after surgery. The primary outcomes were thromboelastography parameters, the rates of deep vein thrombosis(DVT), and pulmonary embolism(PE). Secondary outcomes included perioperative blood loss, transfusion rates, and other perioperative complications.ResultsThe mean calculated total blood loss in the Topical-TXA group were 832.7 ± 279.84 ml and 834.8 ± 322.94 ml in the IV-TXA group, which were significantly reduced (p < 0.05) compared with control groups at 1093.3 ± 379.7 ml. There were no significant differences between topical-TXA and IV-TXA groups in total blood loss or transfusion rates. K and R have reached a nadir from preoperative levels to 4th day postoperatively and then began to increase.α angle and CI peaked from preoperative levels to the fourth day postoperatively and then began to decline.IV-TXA significantly (p < 0.05) promoted coagulation levels compared with topical-TXA and control groups in the early postoperative period. Almost no significant differences were observed between topical-TXA and control groups in thromboelastography parameters.No significant differences were observed in the incidence of thromboembolic complications and other perioperative complications.ConclusionsThe topical administration of TXA had the same hemostatic effect as intravenous injection tranexamic acid. Coagulation function peaked on 4th day postoperatively and then began to decline. IV-TXA was more enhanced coagulation functions compared with topical-TXA.

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Management of Microsurgical Patients using Intraoperative Unfractionated Heparin and Thromboelastography

Cited by 15 publications

References 48 publications

The Influence of Topically Administered Heparin on Peripheral Microcirculation of the Skin: A Double-Blind, Randomized, Controlled Preliminary Study on 50 Healthy Subjects

The Influence of Topically Administered Heparin on Peripheral Microcirculation of the Skin: A Double-Blind, Randomized, Controlled Preliminary Study on 50 Healthy Subjects

Does Anticoagulation Improve Flap Outcomes in Hypercoagulable Patients? A Systematic Review

Application of thromboelastography to evaluate the effect of different routes administration of tranexamic acid on coagulation function in total hip arthroplasty

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