Bivalirudin fails to prevent atrial thrombus development in heparin-induced thrombocytopaenia and thrombosis syndrome.

An 81-year-old woman presented with acute decompensated heart failure due to new-onset atrial fibrillation and a flail myxomatous mitral valve which necessitated surgical mitral valve repair. No atrial thrombi were noted on transoesophageal echocardiograms performed prior to surgery and intraoperatively. Immediately postoperatively, while treated with unfractionated heparin, the patient developed thrombocytopaenia with positive platelet factor 4 antibodies and an abnormal serotonin functional platelet assay, consistent with heparin-induced thrombocytopaenia. The anticoagulation therapy was changed to the direct thrombin inhibitor bivalirudin with an improvement in the platelet count. Despite bivalirudin therapy, a left atrial layering thrombus was revealed on transoesophageal echocardiogram performed in preparation for cardioversion of the symptomatic atrial fibrillation. Anticoagulation was changed to warfarin, and the patient was discharged without thromboembolic complications neither during her hospital stay nor the 3-year outpatient follow-up.

Citrate versus heparin for apheresis catheter locks: an efficacy analysis.

INTRODUCTION: There is a paucity of medical literature regarding the efficacy of lock solutions in preventing catheter thrombosis. Traditionally, heparin has been used as the anticoagulant of choice for catheter locking, but it has many adverse effects associated with its use. Sodium citrate 4% is an attractive alternative to heparin. METHODS: Our plasmapheresis unit converted to locking all central venous catheters with sodium citrate 4% in place of heparin 100 units/mL in May 2010. We conducted a 2-year period retrospective observational cohort study comparing the outcomes of using heparin versus citrate locks. Outcomes examined were catheter patency, catheter exchanges, alteplase usage, and catheter infections. RESULTS: During the study period, 84 patients who underwent a total of 554 plasmapheresis treatments were identified. Flow problems among the citrate treatments were more frequent than those among the heparin group (6.5% vs. 3.2%, P = 0.11, n = 554) but this did not reach statistical significance. The frequency of more severe flow problems requiring catheter exchange or alteplase infusion was higher among the citrate group than the heparin group (3.2% vs. 1.3%, P = 0.11, n = 554). Subgroup analysis, stratified by diagnosis, demonstrated that there was a statistically significant difference in flow problems when comparing myasthenia gravis (MG) patients to non-MG patients. There was no difference in catheter infections between the groups. CONCLUSIONS: Based on the findings of our study, we conclude that citrate and heparin locks have similar efficacy in maintaining catheter patency in plasmapheresis patients. Further research is needed to examine the differences observed between MG patients versus all other patients.

Medication related nausea and vomiting in palliative medicine.

There are multiple potential states and/or symptoms that may occur in the palliative care population including: pain, nausea/vomiting, fatigue, anorexia, dyspnea, hiccups, cough, constipation, abdominal cramps/bloating, diarrhea, pruritis, depression/anxiety, dysphagia and sleep disturbances. Some of this may be the direct result of medications or drug-drug interactions from agents prescribed to treat the medical conditions that the patient has. Medication-related nausea and vomiting (MRNV) is a significant problem in palliative medicine that is reasonably common likely due to the multiple medications that these patients are often taking.