title: Management of anticoagulation during cardiopulmonary bypass in a patient with allergy to heparin and heparin-like compounds: a case-report.
abstract: Hypersensitivity to heparin and heparin-like compounds is a rare condition that represents therapeutic challenges for patients requiring a cardiopulmonary bypass (CPB). We here report the case of a woman with a combined allergy to heparins (fractionated and unfractionated), danaparoid and fondaparinux. She underwent a mitral valve replacement under CBP using lepirudin for systemic anticoagulation. The use of lepirudin instead of unfractionated heparin (UFH) in this setting has many important implications. Lepirudin therapeutic index is narrow and so, overdosing can lead to catastrophic bleeding, whereas underdosing can result in clotting in the CPB tubing. Monitoring of lepirudin activity is essential. The usual activated clotting time monitoring is not a reliable method to monitor anticoagulation with lepirudin in the operating theater. Our experience suggests that the diluted thrombin time provides a valuable alternative during CPB.
authors.affiliation: aDivision of Anaesthesiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium bDivision of Anaesthesiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada cDivision of Haematology, Haemostasis and Thrombosis Unit dDivision of Pneumology and Allergology Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
authors.forename: Séverine
authors.initials: S
authors.lastname: Balthazar
authors.forename: Christine
authors.initials: C
authors.lastname: Watremez
authors.forename: Louise
authors.initials: L
authors.lastname: Vigneault
authors.forename: Stéphane
authors.initials: S
authors.lastname: Eeckhoudt
authors.forename: Françoise
authors.initials: F
authors.lastname: Pirson
authors.forename: Cédric
authors.initials: C
authors.lastname: Hermans
mesh_terms: D000328:Adult; D000925:Anticoagulants / Q000627:therapeutic use*; D001777:Blood Coagulation / Q000187:drug effects; D002315:Cardiopulmonary Bypass; D004342:Drug Hypersensitivity; D016903:Drug Monitoring; D005260:Female; D006493:Heparin / Q000009:adverse effects*; D006629:Hirudins; D006801:Humans; D008943:Mitral Valve / Q000637:transplantation; D008944:Mitral Valve Insufficiency / Q000097:blood* / Q000473:pathology / Q000601:surgery; D011994:Recombinant Proteins / Q000627:therapeutic use; D013918:Thrombin Time; D013927:Thrombosis / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants; D006629:Hirudins; D011994:Recombinant Proteins; D006493:Heparin; C083544:lepirudin