nicola stigliano, cardioanesthesia department villa verde taranto
4 April 2011
this work is very interesting.I would know what is the clinical strategy used by authors when their patients had a serious thrombocitopenia and is important to use CPFA.
Thank you for attention
Competing interests
None declared
RESPONSE TO THE LETTER
FRANCO TURANI, AURELIA HOSPITAL EUROPEAN HOSPITAL ROME
24 May 2011
Dear Nicola Stigliano , Thank you very much for your attention in our study and your consideration. Control of coagulation, in effect, is an important issue during CPFA. CPFA, as you know, requires a plasma filter, an additional Ultrafiltration filter and the cartridge for plasma adsorption, plus the extracorporeal circuit. So it’s possible, that coagulation may occur despite heparin infusion. Moreover thrombocitopenia, commonly observed during sepsis, may induce to decrease the infusion of heparin. What we observed in our study was a non significant different platelets count compared with standard CRTT treatment, More in detail, the platelets count decreased from 161.467 (basal time) to 116.464 (t1) and to 102.538 (t2). Only one Patient ( with platelets count< 12.000) was transfused with platelets. In our experience, thrombocitopenia is a rare event. Any way, as requested by your letter , in patients with very low platelets count (< 30000 ) we use heparin only for the priming of the circuit (10000 U/L ) and then we monitor ACT, tromboelastogram and filter pressures. In case of ACT decreasing, normalization of MA, TEG and increase of filter pressures we start with very low dosage of heparin infusion (5-7 unit /kg/ hour), as suggested by Formica et al. (1) In some cases HIT can be considered and then Bivalirudin may be used ,instead of heparin. At this moment we don’t have any data with this treatment during CPFA.
In conclusion we can say that in patients suffering HIT or with frank coagulopathies, alternative anticoagulation strategies could be addressed. Among these, the regional anticoagulation with citrate seems to have good premises. No large data about exhaustive experiences exist so far but a first empirical attempt afforded by Mariano et al. (2) New data about the treatment and clinical effects of this anticoagulation are needed.
Thank you very much for your attention
Best regards
FRANCO TURANI AURELIA HOSPITAL / EUROPEAN HOSPITAL- CARDIAC SURGERY DEPARTMENT /- ROME
References 1- Formica M. et al. Intensive Care Med 2003 ; 29:703-708. 2- Mariano F. et al. Blood Purif 2004 ; 22:313-319.
Critical Care
cpfa and serious thrombocitopenia...
4 April 2011
this work is very interesting.I would know what is the clinical strategy used by authors when their patients had
a serious thrombocitopenia and is important to use CPFA.
Thank you for attention
Competing interests
None declared
RESPONSE TO THE LETTER
24 May 2011
Dear Nicola Stigliano ,
Thank you very much for your attention in our study and your consideration.
Control of coagulation, in effect, is an important issue during CPFA.
CPFA, as you know, requires a plasma filter, an additional Ultrafiltration filter and the cartridge for plasma adsorption, plus the extracorporeal circuit. So it’s possible, that coagulation may occur despite heparin infusion.
Moreover thrombocitopenia, commonly observed during sepsis, may induce to decrease the infusion of heparin.
What we observed in our study was a non significant different platelets count compared with standard CRTT treatment, More in detail, the platelets count decreased from 161.467 (basal time) to 116.464 (t1) and to 102.538 (t2). Only one Patient ( with platelets count< 12.000) was transfused with platelets.
In our experience, thrombocitopenia is a rare event. Any way, as requested by your letter , in patients with very low platelets count (< 30000 ) we use heparin only for the priming of the circuit (10000 U/L ) and then we monitor ACT, tromboelastogram and filter pressures. In case of ACT decreasing, normalization of MA, TEG and increase of filter pressures we start with very low dosage of heparin infusion (5-7 unit /kg/ hour), as suggested by Formica et al. (1)
In some cases HIT can be considered and then Bivalirudin may be used ,instead of heparin. At this moment we don’t have any data with this treatment during CPFA.
In conclusion we can say that in patients suffering HIT or with frank coagulopathies, alternative anticoagulation strategies could be addressed. Among these, the regional anticoagulation with citrate seems to have good premises. No large data about exhaustive experiences exist so far but a first empirical attempt afforded by Mariano et al. (2)
New data about the treatment and clinical effects of this anticoagulation are needed.
Thank you very much for your attention
Best regards
FRANCO TURANI
AURELIA HOSPITAL / EUROPEAN HOSPITAL- CARDIAC SURGERY DEPARTMENT /- ROME
References
1- Formica M. et al. Intensive Care Med 2003 ; 29:703-708.
2- Mariano F. et al. Blood Purif 2004 ; 22:313-319.
Competing interests
NO INTERESTS DECLARED