Heparin induced thrombosis: an important complication of heparin prophylaxis for thromboembolic disease in surgery.

Abstract

Possible criteria for audit of urinary tract infection care 1 The accuracy of the diagnosis-that is, was an appropriately taken midstream urine specimen used to make the diagnosis, and was the result consistent with the diagnosis? 2 Was the infection appropriately investigated and followed up? 3 Was a suitable antibiotic used?Structure-We may want to look at how good our children's facilities are. The best judges of that are the children and their parents, so it is best to find out how we are doing from a patient satisfaction survey. If worded properly, such a survey could use the parents' comments to create ideas to change the existing arrangements to be more "child friendly." Process-We could choose an important topic such as urinary tract infection in childhood. The sort of criteria of concern might be those shown opposite.All these criteria need to be fully discussed, justified by good published work, and then have standards applied to them. For example, the standard for taking a midstream urine specimen before treating a child with a suspected urinary tract infection would probably be agreed by most reasonable general practitioners to be 1 00%.Outcome-This is the most difficult subject to assess in the small populations that we deal with in general practice. However, it is possible to find a few examples. One could be to look at emergency admissions of children with asthma as a criterion of control outcome. Having sampled a group, the number of emergency admissions in a year can be measured. Having created whatever change was in mind for the children's care, the audit can be run again to see if emergency admissions have reduced.Audit is particularly useful in primary care for assessing the effectiveness of clinics. For example, auditing various aspects of asthma care before and after instituting an asthma clinic will help ascertain whether or not the clinic is worthwhile.L Peter is a general practitioner, Harrow, Middlesex.

Heparin-induced thrombocytopenia: natural history, diagnosis, and management

“…Venous thrombosis is more common than arterial thrombosis in HIT patients, especially in those who receive heparin for postoperative deep venous thrombosis prevention. 13,25 Extremity deep vein thrombosis is the most frequently encountered venous thrombotic complication in HIT patients followed in frequency by pulmonary embolism and cerebral sinus thrombosis.…”

Heparinassoziierte Thrombocytopenie (HAT) Typ II Eine unterschätzte Komplikation der Thromboembolieprophylaxe mit Heparin

“…Es spielt keine Rolle, ob das verabreichte Heparin von Schweinen oder Rindern gewonnen wurde [1,4], was von Killer et al [18] [1,15,20,28]. Beschrieben ist das ¹white-clot syndromeª [1,23] mit thrombotischen, arteriellen und venösen Gefäûverschlüssen und entsprechenden Komplikationen: hämorrhagische Nebennierennekrosen [13,20,24], arterielle Gefäûverschlüsse [15,23], tiefe Beinvenenthrombose [15], Lungenembolie, Herzinfarkt [21,29], Apoplex [3] sowie neurologische Ausfälle [20].…”

“…Ein idealer Standardtest steht derzeit nicht zur Verfügung [10,21], weswegen therapeutische Maûnahmen, nämlich das sofortige Absetzen der Heparinmedikation, schon aufgrund des klinischen Verdachts (Thrombocytenabfall) auf HAT empfohlen werden [1,3,5,10,14,15,18,20,23,25,26]. Zuvor sollten andere Ursachen für eine Thrombocytopenie, wie DIC (disseminierte intravasale Gerinnung), Sepsis oder Nebenwirkungen anderer Medikamente, ausgeschlossen werden [2,13,19,21].…”

“…Den o. g. Testen kommt danach die Aufgabe zu, die Diagnose laborchemisch zu bestätigen [9,13,14,19,25]. Bei negativen Labortesten zeigt der Thrombocytenanstieg nach Absetzen des Heparins die Richtigkeit der Diagnose [1,4,15,17,21].…”

“…Weiterhin finden sich hohe Raten von Kreuzreaktivität (80 % [3], 30 % [15], ¹fast vollständigª [14]) der Heparine. Daher sind niedermolekulare Heparine ungeeignet zur Therapie einer HAT [4,20,25,27] oder machen zumindest die vorherige In-vitro-Testung bei Patienten mit nachgewiesenen Antikörpern (HAAb) notwendig [14,17,21].…”