Rush desensitization in heparin hypersensitivity: a case report

Among all the known drug intolerances, adverse reactions to heparin are not very common. No desensitization in patients with heparin hypersensitivity has ever been attempted. We report the case of a 55–year-old female patient with mitral stenosis and insufficiency, and tricuspid and aortic insufficiency. The patient underwent heparin treatment, and urticaria occurred with either s.c. calcium heparin or i.v. sodium heparin. Allergy testing (skin tests and patch tests) was negative. A pseudoallergic intolerance was diagnosed. Mitral valve replacement with the extracorporeal circulation method was necessary; therefore, heparin treatment was administered. A heparin rush desensitization together with antihistamine drugs (4 mg clorpheniramine maleate for 3 d) was started: 50 UI (0.5 mg) s.c. sodium heparin were first administered; within 4 d, 5000 UI (50 mg) sodium heparin was administered i.v. with no side-effects. A full-dosage heparin treatment was then administered and heart surgery was easily performed. During the postsurgical course, i.v. sodium heparin was smoothly replaced with s.c. calcium heparin (25000 UI s.c. per day) and with oral anticoagulants (sodium warfarin).     

Red blood cell energy metabolism during cardiopulmonary bypass

BACKGROUND: During cardiopulmonary bypass (CPB) an intracellular ATP deficit could theoretically play a role in changes of erythrocyte shape and deformability caused by mechanical trauma. We therefore studied erythrocyte energy metabolism in 12 patients undergoing normothermic CPB for myocardial revascularization. METHODS: Blood samples were collected prior to and 45 minutes after CPB beginning and analyzed for erythrocyte ATP, ADP, and AMP and their metabolites, erythrocyte NAD and NADP, plasma and whole blood lactate (Lact(p) and Lact(b) respectively), and whole blood pyruvate (Pyr(b)). RESULTS: Values were expressed as mean +/- standard deviation or median (lower and higher quartiles) on the ground of a test for normality. During CPB erythrocyte nucleotides and their metabolites did not change significantly (ATP: 60.2+/-12.1 vs. 68.3+/-13.0; ADP: 12.2+/-3.6 vs. 12.0+/-3.1; AMP: 0.43+/-24 vs. 0.44+/-0.26; adenosine: 0.063 (0.034-0.203) vs. 0.77 (0.032-0.221); inosine: 0.064 (0.023-0.072) vs. 0.075 (0.025-0.111); hypoxanthine: 0.330+/-0.272 vs. 0.367+/-0.223; xanthine: 0.193+/-0.090 vs. 0.220+/-0.095; NAD: 3.149+/-0.743 vs. 3.358+/-0.851; values in microM/mM packed red blood cell hemoglobin) while NADP increased (2.110+/-0.390 vs. 2.433+/-0.288 microM/mM packed red blood cell hemoglobin; p<0.05). Ringer lactate, with which the extracorporeal circuit was primed, caused Lact(p) to increase (1.87+/-0.81 vs. 3.27+/-1.15 mM/l; p<0.01). Some lactate entered erythrocytes since Lact(p)/Lact(b) ratio did not change (1.09+/-0.25 vs. 1.07+/-0.23) and some was transformed into pyruvate since Pyr(b) increased [62.9 (30.3-73.3) vs. 100.5 (61.0-146.9) microM/l; p<0.01]. Lact(b)/Pyr(b) ratio did not change significantly [22.6 (16.1-40.5) vs. 27.9 (17.5-35.2)] so that NAD/NADH ratio and, consequently, the rate of glycolysis were unlikely to change too. CONCLUSIONS: Erythrocyte energy metabolism is not affected by CPB, at least during the period of time taken into account in this study.     

Topical use of tranexamic acid in coronary artery bypass operations: a double-blind, prospective, randomized, placebo-controlled study

OBJECTIVES: We sought to investigate the effect of topical application of tranexamic acid into the pericardial cavity in reducing postoperative blood loss in coronary artery surgery. METHODS: A prospective, randomized, double-blind investigation with parallel groups was performed. Forty consecutive patients undergoing primary coronary surgery were randomly assigned to group 1 (tranexamic acid group) or group 2 (placebo group). Tranexamic acid (1 g in 100 mL of saline solution) or placebo was poured into the pericardial cavity and over the mediastinal tissues before sternal closure. The drainage of mediastinal blood was measured hourly. RESULTS: Chest tube drainage in the first 24 hours was 485 +/- 166 mL in the tranexamic acid group and 641 +/- 184 mL in the placebo group (P =.01). Total postoperative blood loss was 573 +/- 164 mL and 739 +/- 228 mL, respectively (P =.01). The use of banked donor blood products was not significantly different between the two groups. Tranexamic acid could not be detected in any of the blood samples blindly collected from 24 patients to verify whether any systemic absorption of the drug occurred. There were no deaths in either group. None of the patients required reoperation for bleeding. CONCLUSIONS: Topical application of tranexamic acid into the pericardial cavity after cardiopulmonary bypass in patients undergoing primary coronary bypass operations significantly reduces postoperative bleeding. Further studies must be carried out to clarify whether a more pronounced effect on both bleeding and blood products requirement might be seen in procedures with a higher risk of bleeding.     

Relapse in medulloblastoma: what can be done after abandoning high-dose chemotherapy? A mono-institutional experience

Purpose

We retrospectively report strategies used for medulloblastoma patients progressing after craniospinal irradiation where we aimed for: symptom control, a satisfactory quality of life, accrual in phase 1–2 trials, when available, and the first two conditions could no longer be satisfied by already experienced second-line strategies.

Methods

Surgery was used in cases of doubtful relapse or when only one site was affected. Radiotherapy was given whenever possible, especially to relieve symptoms. The main chemotherapy regimens were oral temozolomide/etoposide, intravenous (iv.) cisplatin/etoposide, iv. gemcitabine/oxaliplatin, an oral sonic hedgehog pathway inhibitor and oral melphalan.

Results

Between 1998 and 2011, we treated 18 patients relapsed after median 20 months. Nine had relapsed locally, four had dissemination, three single metastases, and two had one synchronous local and metastatic recurrence. Responses to chemotherapy were seen in 32 % of cases. The median hospital stay for treatments/complications was 19 days. The 1- and 3-year progression-free survival (PFS) rates were 28?±?10 % and 0 %, respectively, for OS, they were 44?±?12 % and 22?±?10 % but no patient was cured. The median PFS after a first relapse was 7 months (range 1–29); the median OS was 7 months (range 4–44). No patients died due to treatment toxicity. Late recurrence (more than 1–2 years after diagnosis) and involvement of single sites were favorable prognostic factors.

Conclusions

Without succeeding in patients cure, we ensured them further treatment with short hospital stay thus affording low personal and social costs. The chances of cure may emerge from tailored therapies according to genetic stratification.     

Normothermia does not improve postoperative hemostasis nor does it reduce inflammatory activation in patients undergoing primary isolated coronary artery bypass

BACKGROUND: Despite its common acceptance in clinical practice, the effective benefits of normothermic systemic perfusion during coronary artery bypass operations are far from established. METHODS: A total of 113 patients undergoing primary isolated coronary artery bypass were randomly assigned to normothermic (37 degrees C) or hypothermic (26 degrees C) systemic perfusion. The clinical course of the patients was prospectively recorded, and several inflammatory and fibrinolytic markers (C-reactive protein, fibrinogen, interleukin 6, plasminogen activator inhibitor 1, prothrombin time, activated partial thromboplastin time, platelets, and white blood cell counts) were determined before surgical intervention; 24, 48, and 72 hours thereafter; and at hospital discharge. RESULTS: Postoperatively, 2 in-hospital deaths occurred in the normothermic series and none in the hypothermic series. Four patients had a myocardial infarction, 1 had respiratory insufficiency, 1 had to be reoperated on for graft malfunction, and none had renal insufficiency in the hypothermic group versus 1 patient with each of these complications in the normothermic series. Mean blood loss in the first 24 hours was 766 +/- 223 mL in the normothermic group and 740 +/- 220 mL in the hypothermic group. None of these differences was statistically significant. Similarly, no significant difference in the postoperative level of any of the measured variables at any time point was evident between the patients in the normothermic and hypothermic groups. CONCLUSION: Normothermic systemic perfusion does not influence the clinical course or the extent of inflammatory and hemostatic activation in patients undergoing primary isolated coronary artery bypass.     

Manual removal of the placenta and postcesarean endometritis

OBJECTIVE: To determine if manual vs. spontaneous delivery of the placenta at cesarean section affects the rate of postoperative endometritis and amount of blood loss. STUDY DESIGN: A prospective, randomized study was carried out on patients who had cesarean delivery assigned either to spontaneous delivery of the placenta (group 1) or manual removal (group 2). We excluded patients undergoing emergency cesareans and those with possible placenta accreta or evidence of preexisting infection. Outcome measures (frequency of endometritis and quantitative decrease in hemoglobin) were compared for the two groups. RESULTS: Study criteria were met for 375 subjects: 177 in group 1 and 198 in group 2. Endometritis was diagnosed in 1.7% of the former and 2.5% of the latter. The change in hemoglobin, reflecting operative blood loss, was similar in both groups (-1.81 and -1.72 g/dL, respectively). CONCLUSION: We found no significant difference in either postoperative endometritis or blood loss regardless of the means used to effect delivery of the placenta. The frequency of febrile morbidity in our study cases was considerably lower than heretofore reported.     

Genetic control of postoperative systemic inflammatory reaction and pulmonary and renal complications after coronary artery surgery

BACKGROUND: Although some data suggest that the individual genetic predisposition for developing major or minor degrees of postoperative systemic inflammatory reaction may influence postoperative morbidity, this hypothesis has not been clinically tested to date.Methods and results The -174 G/C polymorphism of the promoter of the interleukin 6 gene was determined preoperatively in 111 consecutive patients submitted to primary isolated coronary artery bypass. The results of the genetic analysis were then correlated with the postoperative interleukin 6 levels and the development of postoperative renal and pulmonary complications. G homozygotes had significantly higher interleukin 6 levels postoperatively (P <.0001 for the difference between areas under the curve). These patients also had worse postoperative pulmonary and renal function. The mean perioperative difference in serum creatinine, potassium, and nitrogen was 0.82 +/- 0.34, 0.99 +/- 0.44, and 10.1 +/- 7.8 mg/dL versus 0.18 +/- 0.14, 0.15 +/- 0.48, and 2.6 +/- 4.1 mg/dL for GG versus non-GG carriers (P <.0001), respectively. The mean respiratory index at 6 and 12 hours was 2.9 +/- 0.8 and 2.8 +/- 0.3 versus 2.1 +/- 0.5 and 1.3 +/- 0.1, respectively (P <.0001). The mean duration of mechanical ventilation was 22.5 +/- 2.1 versus 12.7 +/- 6.7 hours (P <.01). A correlation was found between postoperative interleukin 6 levels and renal and pulmonary complications. CONCLUSION: The interleukin 6 -174 G/C polymorphism modulates postoperative interleukin 6 levels and is associated with the degree of postoperative renal and pulmonary dysfunction and in-hospital stay after coronary surgery.     

Pregnancy outcomes in urban teenagers.

OBJECTIVES: To compare pregnancy outcomes for teenagers with those for older gravidas. METHODS: A retrospective case control study was undertaken to compare teenagers who delivered between January 1996 and October 1999 at a public urban hospital with a group of older gravidas. RESULTS: Young pregnant teenagers were more likely to be nulliparous. They weighed less and gained less in pregnancy. More teen pregnancies occurred among Hispanics than other ethnic groups. The younger the teenager, the more likely for her infant to be of low or very low birth weight or growth restricted. There were fewer postmature deliveries, macrosomic fetuses and cesarean deliveries in young gravidas. Perinatal mortality was unaffected by maternal age. CONCLUSIONS: This investigation demonstrates that, while pregnancy outcomes in teenagers have improved in recent years relative to historical patterns, teenagers face continuing problems requiring special attention by care givers.     

Is Early Tracheostomy a Risk Factor for Mediastinitis after Median Sternotomy?

Abstract   Early tracheostomy may increase the risk of mediastinitis after median sternotomy. Patients who had postoperative tracheostomy after cardiac surgery in the period 2000-2005 were retrospectively analyzed (total: 5095 patients) to evaluate the incidence of mediastinitis and sternal wound infections. Fifty-seven cases (1.1% of all operated patients) had postoperative tracheostomy at an average 5.6 ± 0.7 days postoperatively. None of these patients had mediastinitis. Eleven cases of aseptic sternal instability and ten cases of mild-to-moderate infection limited to subcutaneous planes were observed. There was no correlation between the time to performance of tracheostomy and the isolation of bacteria from the thoracic wounds (p = 0.61). The bacterial strains isolated from subcutaneous infection were qualitatively and quantitatively different from those isolated from bronchial secretions. We conclude that in this study there is no demonstrable link between early tracheostomy after sternotomy and mediastinitis. Early tracheostomy should not be denied due to concerns of increasing the risk of mediastinitis.