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27.08.2019 | Neurosurgery

Prolonged activated partial thromboplastin time after prophylactic-dose unfractionated heparin in the post-operative neurosurgical setting: case series and management recommendations

verfasst von: Michael Shusterman, Niklas Grassl, Karen Berger, Maria T. De Sancho

Erschienen in: Journal of Thrombosis and Thrombolysis | Ausgabe 1/2020

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Abstract

Primary brain tumors, both benign and malignant, pose a high risk of perioperative venous thromboembolism (VTE) due to the development of a prothrombotic state. Perioperative pharmacologic thromboprophylaxis with subcutaneous (SC) unfractionated heparin (UFH) has significantly reduced VTE associated morbidity. Recent reports suggest an association between prolonged activated partial thromboplastin time (aPTT) due to prophylactic SC UFH and increased bleeding risk. We present three patients with normal baseline coagulation parameters in whom pharmacologic thromboprophylaxis with SC UFH resulted in a marked prolongation of the aPTT, leading to adverse outcomes in two patients. These cases demonstrate the uncertain kinetics of SC UFH and effect on aPTT, suggesting the significance of routine aPTT monitoring in high-risk settings. Given the wide variation in presentations of therapeutic or supratherapeutic values of aPTT in the perioperative neurosurgical setting, we propose a practical standardized approach to the evaluation and management of aPTT prolongation following prophylactic SC UFH administration.
Literatur
1.
Zurück zum Zitat Ganau M et al (2017) Risk of deep vein thrombosis in neurosurgery: state of the art on prophylaxis protocols and best clinical practices. J Clin Neurosci 45:60–66CrossRef Ganau M et al (2017) Risk of deep vein thrombosis in neurosurgery: state of the art on prophylaxis protocols and best clinical practices. J Clin Neurosci 45:60–66CrossRef
2.
Zurück zum Zitat Gerber DE et al (2007) Venous thromboembolism occurs infrequently in meningioma patients receiving combined modality prophylaxis. Cancer 109(2):300–305CrossRef Gerber DE et al (2007) Venous thromboembolism occurs infrequently in meningioma patients receiving combined modality prophylaxis. Cancer 109(2):300–305CrossRef
3.
Zurück zum Zitat Kahn SR et al (2012) Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e195S–e226SCrossRef Kahn SR et al (2012) Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e195S–e226SCrossRef
4.
Zurück zum Zitat Raabe A et al (2001) The risk of haemorrhage associated with early postoperative heparin administration after intracranial surgery. Acta Neurochir (Wien) 143(1):1–7CrossRef Raabe A et al (2001) The risk of haemorrhage associated with early postoperative heparin administration after intracranial surgery. Acta Neurochir (Wien) 143(1):1–7CrossRef
5.
Zurück zum Zitat Fiebig EW et al (2011) Unexpectedly high PTT values after low-dose heparin prophylaxis. Arch Intern Med 171(7):702–703CrossRef Fiebig EW et al (2011) Unexpectedly high PTT values after low-dose heparin prophylaxis. Arch Intern Med 171(7):702–703CrossRef
6.
Zurück zum Zitat Gallus AS et al (1976) Prevention of venous thrombosis with small, subcutaneous doses of heparin. JAMA 235(18):1980–1982CrossRef Gallus AS et al (1976) Prevention of venous thrombosis with small, subcutaneous doses of heparin. JAMA 235(18):1980–1982CrossRef
7.
Zurück zum Zitat Matsubara S et al (2010) Prolonged activated partial thromboplastin time in thromboprophylaxis with unfractionated heparin in patients undergoing cesarean section. J Obstet Gynaecol Res 36(1):58–63CrossRef Matsubara S et al (2010) Prolonged activated partial thromboplastin time in thromboprophylaxis with unfractionated heparin in patients undergoing cesarean section. J Obstet Gynaecol Res 36(1):58–63CrossRef
8.
Zurück zum Zitat Thompson MH et al (2016) Effect of subcutaneous unfractionated heparin prophylaxis on activated partial thromboplastin time: a retrospective evaluation. J Clin Anesth 33:346–350CrossRef Thompson MH et al (2016) Effect of subcutaneous unfractionated heparin prophylaxis on activated partial thromboplastin time: a retrospective evaluation. J Clin Anesth 33:346–350CrossRef
9.
Zurück zum Zitat Nyquist P et al (2017) Prophylaxis of venous thrombosis in neurocritical care patients: an executive summary of evidence-based guidelines—a statement for healthcare professionals from the neurocritical care society and society of critical care medicine. Crit Care Med 45(3):476–479CrossRef Nyquist P et al (2017) Prophylaxis of venous thrombosis in neurocritical care patients: an executive summary of evidence-based guidelines—a statement for healthcare professionals from the neurocritical care society and society of critical care medicine. Crit Care Med 45(3):476–479CrossRef
10.
Zurück zum Zitat Frontera JA et al (2016) Guideline for reversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the neurocritical care society and society of critical care medicine. Neurocrit Care 24(1):6–46CrossRef Frontera JA et al (2016) Guideline for reversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the neurocritical care society and society of critical care medicine. Neurocrit Care 24(1):6–46CrossRef
11.
Zurück zum Zitat Vignon P et al (2013) Intermittent pneumatic compression to prevent venous thromboembolism in patients with high risk of bleeding hospitalized in intensive care units: the CIREA1 randomized trial. Intensive Care Med 39(5):872–880CrossRef Vignon P et al (2013) Intermittent pneumatic compression to prevent venous thromboembolism in patients with high risk of bleeding hospitalized in intensive care units: the CIREA1 randomized trial. Intensive Care Med 39(5):872–880CrossRef
12.
Zurück zum Zitat Arabi YM et al (2019) Adjunctive intermittent pneumatic compression for venous thromboprophylaxis. N Engl J Med 380(14):1305–1315CrossRef Arabi YM et al (2019) Adjunctive intermittent pneumatic compression for venous thromboprophylaxis. N Engl J Med 380(14):1305–1315CrossRef
13.
Zurück zum Zitat Khan NR et al (2018) Chemical venous thromboembolism prophylaxis in neurosurgical patients: an updated systematic review and meta-analysis. J Neurosurg 129(4):906–915CrossRef Khan NR et al (2018) Chemical venous thromboembolism prophylaxis in neurosurgical patients: an updated systematic review and meta-analysis. J Neurosurg 129(4):906–915CrossRef
14.
Zurück zum Zitat King CS et al (2007) Twice vs three times daily heparin dosing for thromboembolism prophylaxis in the general medical population: a metaanalysis. Chest 131(2):507–516CrossRef King CS et al (2007) Twice vs three times daily heparin dosing for thromboembolism prophylaxis in the general medical population: a metaanalysis. Chest 131(2):507–516CrossRef
15.
Zurück zum Zitat Junqueira DR, Zorzela LM, Perini E (2017) Unfractionated heparin versus low molecular weight heparins for avoiding heparin-induced thrombocytopenia in postoperative patients. Cochrane Database Syst Rev 4:CD007557PubMed Junqueira DR, Zorzela LM, Perini E (2017) Unfractionated heparin versus low molecular weight heparins for avoiding heparin-induced thrombocytopenia in postoperative patients. Cochrane Database Syst Rev 4:CD007557PubMed
16.
Zurück zum Zitat Baluwala I, Favaloro EJ, Pasalic L (2017) Therapeutic monitoring of unfractionated heparin: trials and tribulations. Expert Rev Hematol 10(7):595–605CrossRef Baluwala I, Favaloro EJ, Pasalic L (2017) Therapeutic monitoring of unfractionated heparin: trials and tribulations. Expert Rev Hematol 10(7):595–605CrossRef
17.
Zurück zum Zitat Bara L et al (1985) Comparative pharmacokinetics of a low molecular weight heparin (PK 10 169) and unfractionated heparin after intravenous and subcutaneous administration. Thromb Res 39(5):631–636CrossRef Bara L et al (1985) Comparative pharmacokinetics of a low molecular weight heparin (PK 10 169) and unfractionated heparin after intravenous and subcutaneous administration. Thromb Res 39(5):631–636CrossRef
18.
Zurück zum Zitat Baglin T et al (2006) Guidelines on the use and monitoring of heparin. Br J Haematol 133(1):19–34CrossRef Baglin T et al (2006) Guidelines on the use and monitoring of heparin. Br J Haematol 133(1):19–34CrossRef
19.
Zurück zum Zitat Newman RS, Fagin AR (1995) Heparin contamination in coagulation testing and a protocol to avoid it and the risk of inappropriate FFP transfusion. Am J Clin Pathol 104(4):447–449CrossRef Newman RS, Fagin AR (1995) Heparin contamination in coagulation testing and a protocol to avoid it and the risk of inappropriate FFP transfusion. Am J Clin Pathol 104(4):447–449CrossRef
20.
Zurück zum Zitat Garcia DA et al (2012) Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e24S–e43SCrossRef Garcia DA et al (2012) Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e24S–e43SCrossRef
21.
Zurück zum Zitat Wolzt M et al (1995) Studies on the neutralizing effects of protamine on unfractionated and low molecular weight heparin (Fragmin) at the site of activation of the coagulation system in man. Thromb Haemost 73(3):439–443CrossRef Wolzt M et al (1995) Studies on the neutralizing effects of protamine on unfractionated and low molecular weight heparin (Fragmin) at the site of activation of the coagulation system in man. Thromb Haemost 73(3):439–443CrossRef
22.
Zurück zum Zitat Dawes J et al (1986) Relationship between biological activity and concentration of a low-molecular-weight heparin (PK 10169) and unfractionated heparin after intravenous and subcutaneous administration. Haemostasis 16(2):116–122PubMed Dawes J et al (1986) Relationship between biological activity and concentration of a low-molecular-weight heparin (PK 10169) and unfractionated heparin after intravenous and subcutaneous administration. Haemostasis 16(2):116–122PubMed
23.
Zurück zum Zitat Hirsh J et al (2008) Parenteral anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest 133(6 Suppl):141 s–159CrossRef Hirsh J et al (2008) Parenteral anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest 133(6 Suppl):141 s–159CrossRef
Metadaten
Titel
Prolonged activated partial thromboplastin time after prophylactic-dose unfractionated heparin in the post-operative neurosurgical setting: case series and management recommendations
verfasst von
Michael Shusterman
Niklas Grassl
Karen Berger
Maria T. De Sancho
Publikationsdatum
27.08.2019
Verlag
Springer US
Erschienen in
Journal of Thrombosis and Thrombolysis / Ausgabe 1/2020
Print ISSN: 0929-5305
Elektronische ISSN: 1573-742X
DOI
https://doi.org/10.1007/s11239-019-01936-4

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