Use of continuous venovenous hemofiltration for reversal of anticoagulation with lepirudin post-cardiopulmonary bypass in a patient with heparin-induced thrombocytopenia after heart transplantation.

and a suitable organ became available 5 days after discontinuation of heparin. Anesthesia was induced with incremental doses of midazolam up to 4 mg and fentanyl up to 500 g, and paralysis was achieved with pancuronium, 10 mg. Anesthesia was maintained with an infusion of propofol at 3 mg/kg/h and isoflurane at an end-tidal concentration up to 0.5% in an oxygen and air mixture. The patient received immunosuppressive and antibiotic treatment according to standard institutional protocol. An autologous blood collection unit (Dideco Electa Cell Saver; Sorin, Mirandola, Italy) was used to salvage shed blood. The patient was given 2 million kallekrein inhibiting units (KIU) of aprotinin intravenously as a bolus over 30 minutes after induction followed by an infusion of 0.5 million KIU/h until the completion of the procedure. Another 2 million KIU of aprotinin were added to the priming volume of the CPB circuit. Recombinant hirudin (lepirudin) was used for anticoagulation. Before aortic cannulation, a bolus of 0.25 mg/kg was given intravenously followed by an infusion of 0.5 mg/min. An additional bolus of 0.2 mg/kg was added to the priming volume of the CPB circuit. Anticoagulation was monitored hourly by using the ecarin coagulation time (ECT) starting from the administration of the first bolus dose. CPB was established when the plasma lepirudin concentration had been confirmed to be 5 g/mL. The authors tried to maintain the ECT at a therapeutic range of 3.5 to 4.5 g/mL of lepirudin during bypass. CPB lasted for 101 minutes, with the ECT remaining above 5 g/mL throughout. Urine output on bypass was 1,000 mL. The lepirudin infusion was stopped shortly after the aortic cross-clamp had been removed and reperfusion of the donor organs commenced. The patient was weaned from CPB without problems on infusions of dopamine at 5 g/kg/min and isoproterenol at 0.04 g/kg/min. One adult therapeutic dose of fresh frozen plasma (FFP) (12-15 mL/kg) was transfused after coming off bypass. However, the ECT remained at levels higher than 5 g/mL even at 2 hours after weaning from CPB. Throughout this time, anticoagulation was monitored by using the ECT, and no ACT data were obtained. Despite using the autologous blood collection unit to salvage the shed blood while waiting for the ECT to normalize, it was necessary to transfuse 15 units of red blood cells in addition to the processed blood from the blood collection unit to maintain hemodynamic stability. This was mainly because of loss from the sternal wound into the drapes. The clotting tests at that time showed a prolonged prothrombin time of 40.4 seconds, an activated partial thromboplastin time of 240 seconds, and a fibrinogen level of 0.5 g/L. The platelet count was 21 109/L. As a result of these findings, the patient was given 10 bags of cryoprecipitate, another adult therapeutic dose of FFP, and 2 bags of apheresis platelets. Additionally, it was decided to attempt elimination of lepirudin by continuous venovenous hemofiltration (CVVH). After percutaneous insertion of a dialysis catheter into the right femoral vein by the surgeon, a circuit with a polyethylsulphone membrane filter (Edwards Lifesciences, Irvine, CA) was used