Safety and potential anticoagulant effects of nebulised heparin in burns patients with inhalational injury at Singapore General Hospital Burns Centre

Yip, Lian Yee; Lim, Yen Fang; Chan, Hong Ngee

doi:10.1016/j.burns.2011.07.006

Cited by 39 publications

(46 citation statements)

References 23 publications

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“…Indeed, no differences were seen between the groups on coagulation tests or platelet counts consistent with other studies using similar doses of inhaled heparin. [33][34][35] The lack of any anti-inflammatory effect of inhaled heparin with severe pneumonia has been seen in animal models. [36] We did find that ARDS was more common in the nebulized 0.9% sodium chloride group but this group also had a higher prevalence of infections on admission to the ICU.…”

Section: Discussionmentioning

confidence: 99%

Is inhaled prophylactic heparin useful for prevention and Management of Pneumonia in ventilated ICU patients?

Bandeshe

Dulhunty

Dunlop

et al. 2016

Journal of Critical Care

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Word Length: 242Word length excluding abstract, tables and references: 2654 Keywords: nebulization, ventilator associated complication, ventilator associated pneumonia, unfractionated heparin, Corresponding Author:Associate Professor Rob Boots Department of Intensive Care Medicine Royal Brisbane and Women's HospitalButterfield Street, Herston.Queensland. AUSTRALIA. 4029Email: r.boots@uq.edu.au Udy, Andrew BHB MB ChB PGCert(AME) FCICM PhD 6 White, Hayden FCICM 7 A C C E P T E D M A N U S C R I P T ACCEPTED MANUSCRIPTA C C E P T E D M A N U S C R I P T Conclusion:Nebulized heparin cannot be recommended for prophylaxis against VAP or to hasten recovery from pneumonia in patients receiving MV.

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Section: Discussionmentioning

confidence: 99%

Is inhaled prophylactic heparin useful for prevention and Management of Pneumonia in ventilated ICU patients?

Bandeshe

Dulhunty

Dunlop

et al. 2016

Journal of Critical Care

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“…Details regarding article selection are presented in Figure 1. Compared to our previous review published in 2012, the updated search found six additional articles reporting on preclinical studies (36,37,(42)(43)(44)(45), and eight new articles reporting on human trials of nebulized anticoagulants (50,51,(53)(54)(55)(56)60,61).…”

Section: Search Resultsmentioning

confidence: 99%

“…While an animal study showed that nebulized heparin indeed affects systemic coagulation (49), results from clinical trials are less consistent with regards to systemic effects of nebulized heparin. The only trial evaluating safety of nebulized heparin in inhalation trauma patients did not detect differences in systemic coagulation or systemic bleedings between intervention and control group (53). However, this trial used a relative low heparin dosage of 30,000 U/day.…”

Section: Discussionmentioning

confidence: 99%

“…Nebulized heparin was associated with shorter duration of ventilatory support in two trials (50,55), and with reduced mortality in two trials (50,52), both retrospective trials using historical controls. Nebulization of heparin did neither affect systemic coagulation nor resulted in more systemic bleedings (53,55). Of note, in one prematurely stopped randomized controlled trial, the incidence of blood-tinged sputum and increased systemic clotting times was high (personal communication) (56).…”

Section: Trials In Patients With Inhalation Traumamentioning

confidence: 99%

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Nebulized anticoagulants in lung injury in critically ill patients—an updated systematic review of preclinical and clinical studies

et al. 2017

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Pneumonia, inhalation trauma and acute respiratory distress syndrome (ARDS), typical causes of lung injury in critically ill patients, are all three characterized by dysregulated inflammation and coagulation in the lungs. Nebulized anticoagulants are thought to have beneficial effects as they could attenuate pulmonary coagulopathy and maybe even affect pulmonary inflammation. A systematic search of the medical literature was performed using terms referring to aspects of the condition ('pneumonia', 'inhalation trauma' and 'ARDS'), the intervention ('nebulized', 'vaporized', and 'aerosolized') and anticoagulants limited to agents that are commercially available and frequently given or tested in critically ill patients ['heparin', 'danaparoid', 'activated protein C' (APC), 'antithrombin' (AT) and 'tissue factor pathway inhibitor' (TFPI)].The systematic search identified 16 articles reporting on preclinical studies and 11 articles reporting on human trials. All nebulized anticoagulants attenuate pulmonary coagulopathy in preclinical studies using various models for lung injury, but the effects on inflammation are less consistent. Nebulized heparin, danaparoid and TFPI, but not APC and AT also reduced systemic coagulation. Nebulized heparin in lung injury patients shows contradictory results, and there is concern over systemic side effects of this strategy.Future studies need to focus on the way to nebulize anticoagulants, as well as on efficient but safe dosages, and other side effects.

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“…A combination of aerosolized heparin and N-acetylcysteine has been used in the management of inhalation injuries. [103][104][105] Animal models of acute smoke inhalation lung injury have produced somewhat mixed results. In a sheep model of smoke inhalation injury along with sepsis induced by pulmonary instillation of Pseudomonas aeruginosa, subsequent treatment with heparin, either aerosolized (10,000 units) or intravenous (5,300 units/kg) reduced histologic changes, including pulmonary edema and cast formation.…”

Section: Aerosolized Anticoagulants and Oxygen Radical Scavengersmentioning

confidence: 99%

Adjunct Therapies During Mechanical Ventilation: Airway Clearance Techniques, Therapeutic Aerosols, and GasesDiscussion

Kallet

2013

Respir Care

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Mechanically ventilated patients in respiratory failure often require adjunct therapies to address special needs such as inhaled drug delivery to alleviate airway obstruction, treat pulmonary infection, or stabilize gas exchange, or therapies that enhance pulmonary hygiene. These therapies generally are supportive in nature rather than curative. Currently, most lack high-level evidence supporting their routine use. This overview describes the rationale and examines the evidence supporting adjunctive therapies during mechanical ventilation. Both mechanistic and clinical research suggests that intrapulmonary percussive ventilation may enhance pulmonary secretion mobilization and might reverse atelectasis. However, its impact on outcomes such ICU stay is uncertain. The most crucial issue is whether aerosolized antibiotics should be used to treat ventilatorassociated pneumonia, particularly when caused by multi-drug resistant pathogens. There is encouraging evidence from several studies supporting its use, at least in individual cases of pneumonia non-responsive to systemic antibiotic therapy. Inhaled pulmonary vasodilators provide at least short-term improvement in oxygenation and may be useful in stabilizing pulmonary gas exchange in complex management situations. Small uncontrolled studies suggest aerosolized heparin with N-acetylcysteine might break down pulmonary casts and relieve airway obstruction in patients with severe inhalation injury. Similar low-level evidence suggests that heliox is effective in reducing airway pressure and improving ventilation in various forms of lower airway obstruction. These therapies generally are supportive and may facilitate patient management. However, because they have not been shown to improve patient outcomes, it behooves clinicians to use these therapies parsimoniously and to monitor their effectiveness carefully. Key words: high-frequency percussive ventilation; intrapulmonary percussive ventilation; inhaled nitric oxide; aerosolized prostacyclin; aerosolized heparin; metered-dose inhalers; heliox.

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Safety and potential anticoagulant effects of nebulised heparin in burns patients with inhalational injury at Singapore General Hospital Burns Centre

Cited by 39 publications

References 23 publications

Is inhaled prophylactic heparin useful for prevention and Management of Pneumonia in ventilated ICU patients?

Is inhaled prophylactic heparin useful for prevention and Management of Pneumonia in ventilated ICU patients?

Nebulized anticoagulants in lung injury in critically ill patients—an updated systematic review of preclinical and clinical studies

Adjunct Therapies During Mechanical Ventilation: Airway Clearance Techniques, Therapeutic Aerosols, and GasesDiscussion

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