Laureen L. Hill

Peripartum Substitution of Inhaled for Intravenous Prostacyclin in a Patient with Primary Pulmonary Hypertension

WE report a parturient with severe primary pulmonary hypertension who was receiving chronic intravenous prostacyclin (epoprostenol, PGI 2 , Flolan®; GlaxoSmith-Kline, Research Triangle Park, NC) and changed to inhaled prostacyclin prepartum. Our strategy was to take advantage of the selective pulmonary artery (PA) vasodilation afforded by inhaled prostacyclin to minimize systemic side effects such as arterial hypotension and antiplatelet effects seen with intravenous administration. We theorized that this approach would allow for uninterrupted PA vasodilation while simultaneously minimizing the risk of antiplatelet effects and would thereby permit safer epidural catheter placement necessary for effective analgesia for planned forceps-assisted vaginal delivery.

The occurrence of antibodies to heparin-platelet factor 4 in cardiac and thoracic surgical patients receiving desirudin or heparin for postoperative venous thrombosis prophylaxis

INTRODUCTION This randomized, exploratory study compared the incidence of heparin-dependent antibodies associated with subcutaneous (SC) desirudin or heparin given for deep-vein thrombosis prophylaxis following cardiac and thoracic surgery. MATERIALS AND METHODS Adult patients scheduled for elective cardiac or thoracic surgery received desirudin 15 mg SC twice daily or unfractionated heparin 5000 units SC thrice daily. Duration of thrombosis prophylaxis was determined by the treating physician. Primary outcome measure was the incidence of new antibody formation directed against platelet factor 4 (PF4)/heparin complex. Secondary outcomes included bleeding and thrombotic complications. Blood was tested for anti-PF4/heparin antibodies at baseline, after surgery prior to study drug administration, postdrug day (PDD) 2, PDD 7, and at 1 month. Doppler studies were done before discharge. RESULTS Of 120 patients, 61 received desirudin, 59 received heparin. New PF4/heparin antibodies occurred in 10.2% and 13.6% of desirudin- and heparin-treated patients, respectively. Among desirudin patients with no heparin exposure, none (0/36) developed PF4/heparin antibodies versus 17.1% with heparin exposure. Incidence of deep venous thrombosis was 4.9% and 3.4% in the desirudin and heparin groups, respectively. Two heparin-group patients developed pulmonary embolism. Two patients per group had bleeding events; no patients required re-exploration for bleeding complications. Median chest tube output was similar with desirudin (900 mL) and heparin (692 mL) as was blood transfusion requirements of more than 2 units (5/61, desirudin; 2/59 heparin). CONCLUSIONS The incidence of thrombotic events was low in both groups. There were no safety concerns, and desirudin was not associated with anti-PF4/heparin antibodies.

Use of the Patient State Index (PSI) to assist in the diagnosis of perioperative neurological injury and brain death.

We present a series of three postoperative cases that were admitted to a cardiothoracic intensive care unit (ICU) after major surgery. Due to the possible presence of residual postoperative neuromuscular blockade after surgery, a processed electroencephalograph (EEG) was applied prior to starting sedation. This was markedly abnormal in all three cases, and not in keeping with the residual anesthesia. The patients were immediately transported for a CT scan. In all three cases there was severe neurological injury incompatible with survival and end of life decisions were made. Although the utility of quantitative EEG technology, like the Bispectral index (BIS) or Patient State Analyzer (PSA), is becoming better defined in the operating room, the role in the ICU is less clear. We propose that the ICU use of the PSA 4000 may have affected our decision weighing the risk versus benefit of transporting a fresh postoperative case to the radiology suite, expedited the neurological diagnosis, and may have reduced overall ICU resource utilization.