Article
Low-dose versus therapeutic range intravenous unfractionated heparin administration in the treatment of patients with severe aneurysmal SAH
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Authors
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Mathias Kunz
- Neurochirurgische Klinik Großhadern LMU, München, Deutschland
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Carolina Nell
- Neurochirurgische Klinik und Poliklinik, Campus Grosshadern, Ludwig-Maximilians Universität, München, Deutschland
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Roman Schniepp
- Ludwig-Maximilians-Universität München, Deutsches Schwindel- und Gleichgewichtszentrum (DSGZ), Neurologie, München, Deutschland
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Franziska Dorn
- Klinikum der Universität München – Campus Großhadern, Institut für Klinische Radiologie, Abteilung für Neuroradiologie, München, Deutschland
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Jörg-Christian Tonn
- Klinikum Grosshadern, Klinikum Grosshadern, Neurochirurgische Klinik und Poliklinik, München, Deutschland
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Hans-Walter Pfister
- Ludwig-Maximilians-Universität München, Campus Großhadern, Neurologische Klinik & Friedrich-Baur-Institut, München, Deutschland
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Christian Schichor
- Klinikum der Ludwig-Maximilians-Universität München, Neurosurgical Clinic, Campus Grosshadern, München, Deutschland
| Published: | June 9, 2017 |
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Outline
Text
Objective: After severe aneurysmal subarachnoid hemorrhage (SAH) intensive care treatment necessitates intravenous heparin administration to prevent thromboembolic events. However, data on optimized administration dosages of heparin to prevent thrombembolism but also to avoid the risk of bleeding complications are still lacking. Aim of our study was to compare two cohorts of patients harboring severe SAH, treated with low-dose (activated partial thromboplastin time aPTT <40 sec.) unfractionated heparin (UFH) versus therapeutic range (aPTT in the range of 50-60 sec.) UFH with regard on thrombembolic or bleeding complications. Special focus was set on patients with additional intracerebral hemorrhage (ICH) at admission.
Methods: Data analysis of 410 patients with acute SAH Fisher Grade III and IV treated at the neurological or neurosurgical intensive care units (ICU) between 2005 and 2015 was conducted. Retrospective data analysis was done on the basis of medical and radiological records. Cut-off point between low-dose/therapeutic range UFH administration was aPTT of 40 sec..
Results: 298 patients were treated with low-dose (median aPTT 30 sec.) and 112 patients with therapeutic range UFH (aPTT 47 sec.; p<0.001). 136 patients (33%) presented with SAH associated relevant ICH at admission – 89 (30%) of patients treated with low-dose and 48 (43%) of patients treated with therapeutic range UFH (p=0.02). An increasing ICH was radiologically proven in 3 patients under low-dose and in 9 patients under therapeutic range UFH (p=0.006). New cerebral hemorrhage in general occurred in 58 patients (14%) – in 37 patients (12%) treated with low-dose and in 21 patients (19%) treated with therapeutic range UFH (p=0.2) with no significant difference between treatment modalities. Bleeding complications were associated with relevant mortality (p=0.03) and worse outcome (mRS) (p=0.007). Thrombembolic events occurred in 23 patients (6%) – in 16 patients (5%) treated with low-dose and in 7 (6%) patients with therapeutic range UFH (p=0.9). Bleeding and thrombembolic complications delayed significantly length of stay at the ICU and inhospital stay (p=0.01). Independent risk factors for bleeding complications in overall in the multivariate analysis were the presence of SAH associated ICH at admission (p=0.035, OR 1.9) and values of the highest reached aPTT of more than 55 sec. (p=0.046; OR 1.8); for respective thromboembolic events the positive detection of a HIT (p<0.001; OR 6.6) revealed to be a risk factor.
Conclusion: Compared to low-dose, therapeutic range UFH application in critically ill patients after acute aneurysmal SAH does not prevent thrombembolic events. Bleeding complications were associated with relevant mortality and worse outcome. Especially in case of SAH associated intracerebral hemorrhage at admission therapeutic range UFH application should be avoided.
