Use of argatroban: experiences in continuous renal replacement therapy in critically ill patients after cardiac surgery

OBJECTIVES

Acute kidney injury requiring renal replacement therapy (RRT) is a common complication after cardiac surgery, complicated by suspected or proven heparin-induced thrombocytopenia (type II). The present study evaluated the use of argatroban as an anticoagulant during continuous RRT in the early period after cardiac surgery. Argatroban was compared with unfractionated heparin (UH) with respect to bleeding complications and the effectiveness of anticoagulation.

METHODS

Patients requiring RRT after cardiac surgery from March 2007 to June 2009 were identified. The effectiveness of anticoagulation was measured indirectly by the duration of dialysis filter use. Bleeding was defined as clinical signs of blood loss or the need for transfusion.

RESULTS

Of 94 patients, 41 received argatroban, 27 UH, and 26 required conversion from UH to argatroban. In all 3 subgroups, RRT was begun within a median postoperative period of 2.0 days. Similar levels of anticoagulation were achieved with the duration of the circuit and filter changed an average of 1.1 times daily during RRT. Liver function was comparable in all patients. Neither clinically relevant signs of bleeding nor significant differences in the hemoglobin levels or a requirement for transfusion were noted. However, the Simplified Acute Physiology Score II values during dialysis and mortality were significantly greater in the patients initially receiving argatroban compared with those who received UH alone (54 ± 2 vs 43 ± 3, P < .001; 71% vs 44%, P = .04).

CONCLUSIONS

Argatroban can provide effective anticoagulation in postoperative cardiac patients receiving continuous RRT. Close monitoring and dose titration resulted in a comparable risk of bleeding for anticoagulation with both argatroban and heparin, regardless of the disease severity or impaired hepatic function.

Prophylactic fibrinogen administration during complex congenital cardiac surgery leading to thrombosis of a patient's brachial artery and the cardiopulmonary bypass circuit: a case report

Cardiac surgery represents one of the largest consumers of blood products due to the level of blood loss in these patients. As such, there is considerable interest in hemostatic therapies for this patient population. A hemostatic agent that has recently garnered interest is fibrinogen. The conversion of fibrinogen to fibrin by activated thrombin results in clot formation, leading to hemostasis. Currently, a number of studies are underway to evaluate the efficacy of fibrinogen concentrate in cardiac surgery patients. While potentially beneficial in hemostasis for cardiac patients, the current case report provides evidence of the importance of timing in the administration of this product.