Management of the Patient with Acute or Recent HIT

For patients with acute HIT who require heart surgery, or with recent HIT and persistence of circulating HIT antibodies, it is possible to use alternative anticoagulants during cardiopulmonary bypass (CPB) (see Chapter 19). Options for alternative anticoagulation for such patients include bivalirudin and lepirudin (minimal data regarding use of argatroban for this indication precludes recommendations). Unfortunately, the lack of a specific antidote, the need for special intraoperative monitoring, and other considerations mean that none is ideal for managing CPB.

Another approach is to administer heparin together with a potent antiplatelet agent, e.g., tirofiban (GPIIb/IIIa antagonist) or epoprostenol (prostacyclin analogue). Danaparoid is not recommended for anticoagulation during CPB due to its long half-life. This special topic of managing cardiac surgery patients with acute or previous HIT is discussed in detail in Chapter 19, as well as in relation to specific anticoagulant agents in Chapters 13-16.

Danaparoid and lepirudin have also been used to provide intraoperative anticoagulation, as well as to "flush" blood vessels during vascular surgery in patients with acute HIT (for review, see Warkentin, 2004). There is some experience using argatroban for vascular surgery.

Recommendation. Alternative anticoagulation should be used for heart or vascular surgery in a patient with acute or recent HIT with detectable heparin-dependent, platelet-activating antibodies. Either bivalirudin or lepirudin are appropriate alternatives for intraoperative anticoagulation, provided that appropriate, rapid-turnaround laboratory monitoring and blood product support to manage potentially severe bleeding complications are available. Another approach is to give heparin together with a potent antiplatelet agent (grade 2C).

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