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Heparin-induced thrombocytopenia and coagulopathy in an elderly patient: case report A 65-year-old woman developed heparin-induced thrombocytopenia (HIT) while receiving heparin; she later developed coagulopathy after receiving argatroban during coronary bypass surgery [some routes not stated]. The woman started receiving a heparin infusion [dosage not stated] for a myocardial infarction. On day 3 of heparin, her platelet count decreased by more than 50%. HIT was suspected. Heparin was withdrawn, and the woman started receiving an argatroban 0.8–1.5 µg/kg/min infusion (target aPTT 48–78s). Prior to undergoing urgent coronary bypass grafting surgery, she received a bolus of argatroban 6.5mg (0.1 mg/kg), followed by a 5 µg/kg/min infusion (target activated clotting time (ACT) >500s). Thirty minutes after receiving the argatroban bolus, her ACT was 313s, and she received a further bolus of argatroban 3mg, and her infusion was increased to 7.5 µg/kg/min. The cardiopulmonary bypass (CPB) circuit was then started. About 15 minutes later, a clot was observed in the venous reservoir and she received a further bolus of argatroban 3mg. About 12 minutes later, she had a haematocrit value of 20%, and packed RBCs were added to the circuit. As her ACT values showed only marginal increases, another bolus of argatroban 1.5mg was administered, and her infusion was increased to 10 µg/kg/min. Bypass surgery was then completed, with the use ultrafiltration. The argatroban infusion was stopped 15 minutes after recovery of her native rhythm. Due to difficulties in achieving haemostasis, CPB was continued for a further 40 minutes. Her postoperative period was complicated by significant difficulties in achieving haemostasis. She received transfusions of plasma, platelets and packed RBCs before leaving the operating room and during the next 24 hours in an ICU. On postoperative day 1, her coagulation parameters and bleeding stabilised. She was later discharged with no neurological deficits. Author comment: "[T]he challenges in dosing argatroban led to the failure to provide adequate anticoagulation, as evidenced by the clot formation in the oxygenator, and extensive bleeding in the postoperative period." Agarwal S, et al. Challenges encountered with argatroban anticoagulation during cardiopulmonary bypass. Journal of Anaesthesiology Clinical Pharmacology 28: 106-110, No. 1, Jan-Mar 2012. Available from: URL: http:// 803070433 dx.doi.org/10.4103/0970-9185.92458 - USA

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Reactions 19 May 2012 No. 1402