Fondaparinux as a safe alternative for managing heparin-induced thrombocytopenia in postoperative cardiac surgery patients.

OBJECTIVE: Heparin-induced thrombocytopenia (HIT) is a rare but severe prothrombotic disorder of heparin treatment that leads to a decline in platelet count and thrombotic complications. If HIT is suspected, then heparin should be stopped and an alternative anticoagulant started. Fondaparinux is a factor Xa-inhibitor that is not FDA-approved for this condition, but preliminary experience in HIT patients has been reported in the literature. The present study describes an experience of anticoagulation management with fondaparinux in postoperative cardiac surgery patients. DESIGN: Retrospective study. SETTING: Tertiary hospital. PARTICIPANTS: Patients who had undergone cardiac surgery from October 2009 to June 2012. INTERVENTIONS: After HIT was suspected clinically, PaGIA and ELISA test were performed in all patients to diagnose HIT. In the patients included, anticoagulation was managed with a low dose of fondaparinux and daily monitoring of platelet count and anti-Xa level. MEASUREMENTS AND MAIN RESULTS: Of a total of 1,338 postoperative cardiac surgery patients, 15 patients were included (1.1%). Twelve of the 15 patients with HIT presented with renal failure and were under continuous renal replacement therapy. Two major bleeding events occurred during fondaparinux treatment, although platelet count and anti-Xa activity remained within the normal range. No thrombotic episodes were diagnosed. CONCLUSION: With daily monitoring of anti-Xa activity, fondaparinux appeared to be a good alternative to heparin in the study group; however, randomized clinical trials are needed to establish the safety and efficacy of this drug in critically ill, previously HIT patients.

Toma de decisiones al final de la vida y ante el diagnóstico de muerte encefálica / Decision making at the end of life and after brain death diagnosis

Introducción. Actualmente las técnicas de mantenimiento de las funciones vitales pueden retrasar la muerte y esta en ocasiones acontece después de múltiples intervenciones médicas. Los facultativos que asisten al paciente en el periodo cercano a la muerte deben manejar adecuadamente las particularidades médico-legales de este contexto clínico. Descripción médico-forense. Varón de 31 años que evoluciona desfavorablemente tras cirugía urgente por fístula aurículo-esofágica como complicación de crioablación de venas pulmonares. Se alcanza el diagnóstico de muerte encefálica, decidiéndose la retirada del tratamiento de soporte vital con reticencias familiares. Discusión. Durante la asistencia se suceden las controversias médico-legales relativas a la toma de decisiones que, aunque responden a criterios médicos, pueden precisar el consentimiento del paciente o por representación. Se revisan las figuras del Documento de Voluntades Anticipadas y el consentimiento por representación, especialmente en las situaciones de limitación o retirada del tratamiento de soporte vital, en contraposición al manejo de la situación de diagnóstico de muerte encefálica (AU)

Introduction. The maintenance of life support can currently delay death and sometimes death can occur after multiple medical interventions. Physicians who care for patients at the end of their lives should properly manage the medical-legal specifics of this clinical context. Medical-legal case description. Unfavourable evolution of a 31-year-old man admitted for emergency surgery because of an atrio-oesophageal fistula as a complication of pulmonary vein cryoablation. Despite the reluctance of the family, life support was withdrawn after diagnosing brain death. Discussion. During patient-care, medical-legal issues regarding decision-making are frequent, and although the discretion of the treating physician takes precedence, certain actions may require the consent of the patient or their family. We review the figures of advance directives and consent by representation, specifically concerning the withholding or withdrawal of life support, and compare them to the situation of brain death diagnosis (AU)