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Evanston Northwestern Healthcare, Feinberg School of Medicine, Northwestern University, Evanston, IL, jmarymont{at}enh.org
To the Editor:
We congratulate Hallman et al. (1) on their use of argatroban during carotid endarterectomy in a patient who developed heparin-induced thrombocytopenia (HIT) 3 yr previously. We wonder if unfractionated heparin (UFH) could also have been an appropriate choice for intraoperative administration. The authors do not give us the needed information to make this decision.
Once HIT develops, HIT antibodies are usually present less than 100 days (2). The HIT antibodies present after the abdominal aortic aneurysm repair 3 yr ago should no longer be a concern at the time of carotid endarterectomy.
To use UFH intraoperatively, there should be no recent UFH (or low molecular weight heparin) exposure. In addition there should be a normal platelet count, and a negative test for HIT antibodies. Our view is consistent with the American College of Chest Physicians Evidenced-Based Guidelines (3). These guidelines also point out that intraoperative UFH has been safely administered to patients with a previous diagnosis of HIT. Use of UFH should only be considered during the operation and not given preoperatively or postoperatively.
We do not want anesthesiologists to believe that intraoperative UFH must always be avoided in a patient with previous HIT. Remote HIT does not automatically preclude UFH. Direct thrombin inhibitors are an option, but UFH still has its place. With a history of HIT, the timing and extent of re-exposure to heparin is important.
Footnotes
Dr. Hallman does not wish to respond.
References
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