Argatroban/heparin/sodium-bicarbonateBleeding, systemic alkalosis and thrombocytopenia: case report A 41‐year‐old woman developed multiple episodes of bleeding and heparin-induced thrombocytopenia following treatment with heparin and argatroban as an anticoagulant therapy. She also developed systemic alkalosis following treatment with sodium-bicarbonate [route not stated].The woman had a history of polysubstance abuse and poorly managed type I diabetes. She presented with severe chest pain. Upon investigation, it was found that she had non‐ST‐elevation myocardial infarction with a peak troponin of 26 ng/mL with 60% of left ventricular ejection fraction (LVEF). Hence, left heart catheterisation was performed which showed severe three‐vessel coronary artery disease. Later, she underwent pump coronary artery bypass with endarterectomy and an Impella 5.5 was placed through a graft on the ascending aorta. She was started with a traditional heparin purge solution to manage the Impella 5.5. After the operation echocardiogram was performed; it showed LVEF of 13% with proper placement of Impella 5.5. right ventricular (RV) systolic function was also moderately decreased. However, she was moved to the quaternary facility because of the severity of her heart failure. In the quaternary facility, she received advanced mechanical circulatory support and transplant evaluation. At the time of presentation, thrombocytopenia was noted, hence due to the possibility of heparin-induced thrombocytopenia (HIT), all heparin products were withdrawn. Subsequently, the purged solution was replaced with argatroban 50mg in 1L of 5% dextrose. However, upon further investigation, HIT was found to be negative. Therefore, after 17 days, when the platelet count rebounded, the heparin purge solution was restarted again. Later, in the hospital, she needed aggressive renal replacement therapy due to the development of acute kidney injury (AKI) and RV systolic dysfunction. The patient was recovered from AKI with the help of dialysis and careful fluid management. During this whole time, she remained on centrally placed Impella 5.5. On day 33, for the formation of a tracheostomy, the Impella 5.5 device was situated to right axillary approach. However, the patient experienced severe bleeding from central line sites on heparin and argatroban purge solutions. Despite no additional systemic anticoagulation, her partial thromboplastin time (aPTT) was labile. Hence, on day 56 of the operation, he was put on a novel bicarbonate‐based purge solution (BBPS) of 25 mEq sodium bicarbonate in 1L of 5% dextrose. She did not experience any bleeding, pump thrombosis or hypernatraemia on bicarbonate‐based purge solution; however, she had mild systemic alkalosis. She was on bicarbonate‐based purge solution until it was dislodged. Later, she required an intra‐aortic balloon pump. Gradual recovery was not in volume optimisation and RV. On postoperative day 75, she was placed on intracorporeal VAD [no all outcomes state...
