Use of Argatroban for anticoagulation during cardiopulmonary bypass in a patient with heparin allergy

Smith, Alan; Stroud, Robert E.; Damiani, P.; Vaynblat, Mikhail

doi:10.1016/j.ejcts.2008.07.035

Cited by 20 publications

(12 citation statements)

References 3 publications

(3 reference statements)

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“…Prior reports have noted moderate 3,14 to massive 5,10 transfusion requirements with the use of argatroban in CPB, including prolonged coagulopathies that seem to outlast the reported t 1/2 of the drug. As there are no clinical assays in widespread use for determining argatroban concentrations directly, we decided to save plasma samples for postoperative testing to better understand our patient's coagulopathy.…”

Section: Discussionmentioning

confidence: 94%

Prolonged elevation of plasma argatroban in a cardiac transplant patient with a suspected history of heparin‐induced thrombocytopenia with thrombosis

et al. 2010

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BACKGROUND: Direct thrombin inhibitors (DTIs) provide an alternative method of anticoagulation for patients with a history of heparin-induced thrombocytopenia (HIT) or HIT with thrombosis (HITT) undergoing cardiopulmonary bypass (CPB). In the following report, a 65-year-old critically ill patient with a suspected history of HITT was administered argatroban for anticoagulation on bypass during heart transplantation. The patient required massive transfusion support (55 units of red blood cells, 42 units of fresh-frozen plasma, 40 units of cryoprecipitate, 40 units of platelets, and three doses of recombinant Factor VIIa) for severe intraoperative and postoperative bleeding. STUDY DESIGN AND METHODS: Plasma samples from before and after CPB were analyzed postoperatively for argatroban concentration using a modified ecarin clotting time (ECT) assay. RESULTS: Unexpectedly high concentrations of argatroban were measured in these samples (range, 0-32 mg/mL), and a prolonged plasma argatroban half life (t1/2) of 514 minutes was observed (published elimination t1/2 is 39-51 minutes [Յ181 minutes with hepatic impairment]). CONCLUSIONS: Correlation of plasma argatroban concentration versus the patient's coagulation variables and clinical course suggest that prolonged elevated levels of plasma argatroban may have contributed to the patient's extended coagulopathy. Because DTIs do not have reversal agents, surgical teams and transfusion services should remain aware of the possibility of massive transfusion events during anticoagulation with these agents. This is the first report to measure plasma argatroban concentration in the context of CPB and extended coagulopathy.

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Section: Discussionmentioning

confidence: 94%

Prolonged elevation of plasma argatroban in a cardiac transplant patient with a suspected history of heparin‐induced thrombocytopenia with thrombosis

et al. 2010

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“…[17] During CPB using argatroban, there have been concerns with inadequate anticoagulation resulting in clotting of the extracorporeal circuit and at the same time concerns about increased bleeding in the postoperative period because of the latency in normalization of the ACT. Clots in the oxygenator have been reported in the postbypass period after discontinuation of argatroban,[9–11] but more disconcerting is the fact that people have reported clot formation even during CPB at an ACT of 495 s.[18] Based on these reports, Follis et al . have recently proposed a strategy to keep the ACT between 500 and 600 s.[18]…”

Section: Discussionmentioning

confidence: 99%

“…required very high doses of argatroban (initial bolus of 0.3 mg/kg followed by infusion of 40 mcg/kg/min) to maintain ACTs above 400 s in their 70-year-old patient undergoing mitral valve replacement, despite adding 4.2 mg of argatroban into the pump prime. [11] The surgery was complicated with mild coagulopathy after discontinuation of argatroban, but no clots were seen in the CPB circuit. On the other hand, in the case reported by Furkukawa et al ., a small clot was seen in the reservoir upon termination of CPB.…”

Section: Discussionmentioning

confidence: 99%

Challenges encountered with argatroban anticoagulation during cardiopulmonary bypass

Agarwal

Ullom

Al-Baghdadi

et al. 2012

J Anaesthesiol Clin Pharmacol

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Use of argatroban as an alternative to heparin during cardiopulmonary bypass (CPB) in patients with heparin-induced thrombocytopenia has gained some attention in the past two decades. Dosing of argatroban during CPB is complex due to lack of complete understanding of its pharmacokinetic profile and the various elements during CPB that may alter its plasma levels. We report a case where the challenges in dosing argatroban led to failure to provide adequate anticoagulation during CPB, as evidenced by clot formation in the oxygenator, and extensive bleeding in the postoperative period.

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“…[74][75][76][77][78] In two cases, moderate bleeding was treated with supportive infusions of RBCs, FFP, and platelets. 74,75 The authors of these reports comment that these supportive transfusions did not necessarily cause an immediate reversal of the coagulopathy. In the remaining three cases, massive hemorrhage was encountered.…”

Section: Case Reports On Blood Product/coagulation Factor Dosing For mentioning

confidence: 99%

Pathology Consultation on Monitoring Direct Thrombin Inhibitors and Overcoming Their Effects in Bleeding Patients

Winkler

Tormey

2013

American Journal of Clinical Pathology

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Routine coagulation assays (eg, the prothrombin time) show a relatively poor correlation with the degree of anticoagulation and DTI drug concentrations. Newer assays, such as the ecarin clotting time and dilute thrombin time, may be more useful in assessing DTI anticoagulation, but these assays are not yet widely available. Low-grade DTI-associated bleeds are best managed with cessation of the drug and supportive care, while higher-grade and/or life-threatening bleeds may best be reversed by active drug removal (eg, via the administration of activated charcoal or hemodialysis). At present there is little evidence to suggest that transfusion products such as factor concentrates or thawed plasma are of any particular benefit in DTI reversal; however, these products may play a supportive role in the management of bleeding.

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Use of Argatroban for anticoagulation during cardiopulmonary bypass in a patient with heparin allergy

Cited by 20 publications

References 3 publications

Prolonged elevation of plasma argatroban in a cardiac transplant patient with a suspected history of heparin‐induced thrombocytopenia with thrombosis

Prolonged elevation of plasma argatroban in a cardiac transplant patient with a suspected history of heparin‐induced thrombocytopenia with thrombosis

Challenges encountered with argatroban anticoagulation during cardiopulmonary bypass

Pathology Consultation on Monitoring Direct Thrombin Inhibitors and Overcoming Their Effects in Bleeding Patients

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