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Bleeding after intermittent or continuous r-hirudin during CVVH
1Department of Anaesthesiology and Operative Intensive Care, University Hospital Charité, Humboldt-University Berlin, Germany. hartmut.kern@charite.de
Objective:
To demonstrate bleeding complications encountered in patients after cardiac surgery on continuous venovenous haemofiltration (CVVH) treated with continuous versus intermittent r-hirudin for heparin-induced thrombocytopenia (HIT) type II.
Design:
Case description.
Setting:
Cardiothoracic intensive care unit at a university hospital.
Patients:
5 consecutive patients with proven HIT type II on CVVH after major cardiac surgery.
Interventions:
Recombinant hirudin (r-hirudin) was given continuously at a dose of 0.01 mg/kg per h in three patients or in repeated bolus administration of 0.05 mg/kg in two patients.
Measurements And Results:
Since the ecarin clotting time assay was not available at that time to monitor hirudin effects on coagulation, the activated partial thromboplastin time (normal range 26-38 s, target range 50-60 s) was used. The continuously treated patients suffered from major bleeding complications. Therefore, the regimen was changed to repeated bolus administration, reducing the incidence of bleeding complications probably due to a threefold diminished cumulative hirudin dose per day in comparison to continuous administration.
Conclusions:
If ecarin clotting time, the most suitable monitor for hirudin activation, is not available, we would prefer to give r-hirudin in repeated boluses to avoid major bleeding complications in cardiac surgery patients on CVVH.