Tratamiento exitoso con fondaparinux en trombocitopenia inducida por heparina y trombosis / Successful treatment with fondaparinux in heparin-induced thrombocytopenia and thrombosis

La trombocitopenia inducida por heparina (TIH) es una reacción adversa inmunológica caracterizada por trombocitopenia y la asociación paradojal de trombosis arterial o venosa. Es causada por la formación de anticuerpos IgG contra el complejo multimolecular de heparina-factor plaquetario 4 (FP4). Fondaparinux es un inhibidor selectivo del factor Xa que tiene escasa afinidad por el FP4 y posee un menor potencial para inducir una respuesta inmunológica, haciendo del mismo un agente potencialmente útil en el tratamiento de la TIH. Se presenta el caso de una mujer de 73 años con TIH asociada a fenómenos trombóticos arteriales y venosos, que recibió exitosamente fondaparinux, con normalización del recuento plaquetario y sin progresión trombótica.

Heparin induced thrombocytopenia (HIT) is an immune-mediated adverse reaction characterized by thrombocytopenia and paradoxical arterial or venous thrombosis, due to the formation IgG antibodies directed to a multimolecular complex of heparin-platelet factor 4 (PF4). Fondaparinux is a selective factor Xa inhibitor with little affinity for PF4 and thus less likely to induce an immune response, making fondaparinux a potentially useful drug for the treatment of HIT. Herein we report the case of a 73 years old woman with HIT associated with arterial and venous thrombosis that was successfully treated with fondaparinux, with normalization of the platelet countand without progression of thrombosis.

Protocolo de prevenção de tromboembolismo venoso em cirurgia plástica: resultados em 2759 pacientes no Instituto Ivo Pitanguy / Venous thromboemboembolism prevention protocol in plastic surgery: results in 2759 patients at the Ivo Pitanguy Institute

Introdução: A embolia pulmonar é a causa de morte mais previsível em pacientes hospitalizados, sendo isso ainda mais prevalente em pacientes cirúrgicos. 200.000 novos casos ocorrem anualmente, com início súbito e geralmente levando à morte nas primeiras 2 horas. Prevenir é, portanto, mais efetivo que tratar a doença estabelecida. Esse estudo objetiva demonstrar a importância e segurança do protocolo de prevenção do tromboembolismo venoso. Métodos: Conduzimos um estudo retrospectivo no período de maio de 2009 a maio de 2011, quando 2759 pacientes foram submetidos à cirurgia plástica no Instituto Ivo Pitanguy. Todos os pacientes foram submetidos ao protocolo de prevenção e avaliados quanto aos fatores de risco para tromboembolismo venoso. A soma desses fatores gerou um escore que determinou a conduta profilática a ser adotada. Resultados: Houve três casos de tromboembolismo venoso (0,1%), sendo 1 de TEP e 2 de TVP. A quimioprofilaxia com enoxaparina administrada aos 3 pacientes de acordo com o protocolo de prevenção. Nossas taxas permaneceram abaixo das encontradas na literatura, com diferença estatisticamente significativa nos numero total de casos (p < 0,0001). Houve 34 casos de hematoma (1,2%), sendo 55,9% em pacientes submetidos à quimioprofilaxia e 44,1% em pacientes que usaram apenas o dispositivo de compressão pneumática intermitente apenas. As taxas totais de hematoma também permaneceram abaixo das encontradas na literatura, também com diferença estatisticamente significativa (p < 0,001). Conclusão: O protocolo de prevenção do tromboembolismo venoso do Instituto Ivo Pitanguy se provou seguro e importante na prevenção dos casos de TEV, com taxas de hematoma abaixo do descrito na literatura.

Introduction: Pulmonary embolism is the most predictable cause of death in hospitalized patients, even more in surgical patients. 200.000 new cases occur annually, with sudden onset and generally leading to death in the first 2 hours. Preventing is most effective than treating stablished disease. This study aims to show the importance and safety of the venous thromboembolism prevention protocol. Methods: We conducted a retrospective study in the period between May 2009 and May 2011 at The Ivo Pitanguy Institute, where 2759 patients underwent plastic surgery (aesthetic and reconstructive). All patients were assessed for predisposing and exposing risk factors for venous thromboembolism and the sum of those factors generated a score determining the prophylactic procedure to be adopted according to the protocol. Results: There were three cases of venous thromboembolism (0.1%): one case of pulmonary embolism and two cases of deep venous thrombosis. Chemoprophylaxis with heparin was administered in the three patients according to the venous thromboembolism prevention protocol. Our rates remained below those found in the literature, with a statistically significant difference in total cases (p < 0.0001). There were 34 cases of hematoma (1.2%): 55.9% in patients submitted to pharmacological prophylaxis with heparin and 44,1% in patients who used sequential compression devices only. The total rates of hematoma also remained below those found in the literature with a statistically significant difference (p < 0,001). Conclusion: The venous thromboembolism prevention protocol of the Ivo Pitanguy Institute proved to be important and safe, preventing the occurrence of venous thromboembolism cases with low rates of hematoma.

Utilidad de la terapia trombolítica con estreptokinasa a dosis baja en infarto agudo del miocardio / Usefulness of thrombolytic therapy with low doses of streptokinase in acute myocardial infarction

Background: The optimal dose of Streptokinase in the treatment of acute myocardial infarction is not well established. Apparently, the thrombolytic efficacy would not increase with doses over 750.000 units. Aim: To compare the effectiveness and safety of treatment with low doses of Streptokinase, ranging from 500.000 to 750.000 units, in patients with ST elevation acute myocardial infarction. Patients and methods: From September 1993 to September 1998, the GEMI register of patients with acute myocardial infarction, was carried out in 37 hospitals, incorporating 4,938 patients. Of these, 1,631 patients received streptokinase. According to the administered dose of Streptokinase, patients were divided in two groups: 1,465 patients who received 1.5 millions U in 60 minutes (classical therapy group), and 166 patients with ischemic chest discomfort and either ST-segment elevation or left bundle-branch block on the electrocardiogram, who received 500.000 to 750.000 U streptokinase administered in no more than 30 minutes, with heparin, within 0 to 6 hours of symptom onset. Successful reperfusion, mortality, complications, and hospital outcome was evaluated in both groups. Results: The low dose group of patients had a better reperfusion criteria profile. No differences between groups were observed in patient evolution, mortality, maximum Killip classification, post myocardial infarction heart failure, ischemic complications, arrhythmias or mechanical complications. Conclusions: These results suggest that streptokinase in low doses is at least as effective as classical therapy, in the treatment of ST elevation acute myocardial infarction.

Protesis valvular cardiaca y embarazo: II. Resultados perinatales / Heart valve prothesis and pregnancy: II. Perinatal results

Se reportan 32 casos de pacientes con antecedentes de protesis valvular cardíaca, que se han embarazado en 56 ocasiones. Treinta y dos de estas gestaciones fueron atendidas en el InPer. En dos casos, se han conrolado dos embarazos consecutivos. Se comenta la experiencia obstétrica derivada del manejo y se discuten los criterios y repercusiones maternas, fetales y neonatales de los coagulantes administrados