Evaluation of the Hemochron 8000 Rx/Dx system for heparin management.

The Hemochron Rx/Dx uses an ACT and a heparin response tube to calculate the heparin dose to identify heparin sensitive/resistant patients. We evaluated the Rx/Dx system in 37 patients to determine if the ACT after the predicted heparin loading dose was adequate to initiate CPB. The mean heparin dose calculated by the Rx/Dx was 31,700 IU +/- 8,700 IU (370 IU/kg) with a mean post ACT of 463 +/- 124 sec. Our standard heparin dose (400 IU/kg) would have given an additional 2,800 IU over the Rx/Dx. Four patients (6.5%) were predicted to be heparin sensitive and all four achieved an ACT over 450 sec. Twenty-one patients (56.8%) were predicted to be resistant and yet failed to raise the ACT over 450 sec in 17 (81.0%). Twelve patients (32.4%) were predicted to have a normal heparin response, and four (33.3%) did not achieve an ACT over 450 sec. In all, 21 patients (56.8%) did not achieve an ACT greater than 450 sec. Each institution should evaluate their heparin loading dose and the resultant ACT. In this study, we found the number of times the Rx/Dx system did not raise the ACT over 450 sec too great to justify the additional expense.

Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index.

In severe traumatic injuries to the lower extremity, it is often a difficult decision to attempt heroic efforts aimed at limb salvage or to amputate primarily. To answer this question, the authors performed a 5-year review of 70 limbs in 67 patients. Patients were identified as presenting with major lower extremity trauma and an associated arterial injury. Nineteen (27%) of the 70 limbs were amputated. Limb salvage was not related to the presence or absence of shock and order of repair (orthopedic or vascular). No statistical difference was noted between the time of injury to operative repair in either the amputated or limb salvage group. Limb salvage was related to warm ischemia time and the quantitative degree of arterial, nerve, bone, muscle, skin, and venous injury. A limb salvage index (LSI) was formulated based on the degree of injury to these systems. All 51 patients with an LSI score of less than 6 had successful limb salvage (p less than 0.001). All 19 patients with an LSI score of 6 or greater had amputations (p less than 0.001). Although statistics cannot replace clinical judgment, this index can be a valuable objective tool in the evaluation of the patient with a severely traumatized extremity.