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Inge A. van Erp, Apostolos Gaitanidis, Mohamad El Moheb, Haytham M. A. Kaafarani, Noelle Saillant, Ann-Christine Duhaime, and April E. Mendoza

either low-molecular-weight heparin (LMWH) or unfractionated heparin (UH). 10 The Eastern Association for the Surgery of Trauma recommends using LMWH over UH in children older than 15 years of age with an ISS greater than 25. 8 However, this recommendation largely reflects current clinical practice, as there is a paucity of evidence supporting the use of either in pediatric patients. Because of its shorter half-life and ease of reversal, UH is preferred over LMWH by many clinicians, especially in high-risk TBI patients. 10 However, recent experimental studies have

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Robert F. James, Nicolas K. Khattar, Zaid S. Aljuboori, Paul S. Page, Elaine Y. Shao, Lacey M. Carter, Kimberly S. Meyer, Michael W. Daniels, John Craycroft, John R. Gaughen Jr., M. Imran Chaudry, Shesh N. Rai, D. Erik Everhart, and J. Marc Simard

dysfunction. 2 Recent studies have shown the potential benefit of unfractionated heparin in antagonizing mechanisms responsible for DND associated with aSAH. 44–46 Unfractionated heparin is a mixture of glycosaminoglycans of variable lengths and molecular weights ranging from 3 to 30 kD. 23 As the most negatively charged biological molecule known, heparin has a strong ability to interfere with the functioning of positively charged molecules. Due to the difference in charges, heparin has been documented to interact with over 100 proteins. 57 Interleukins, cytokines, and

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Kiyoyuki Yanaka, Stephen R. Spellman, James B. McCarthy, Theodore R. Oegema Jr., Walter C. Low, and Paul J. Camarata

/kg, Group II); treatment with low-molecular-weight heparin (total 9 mg/kg; total 300 United States Pharmacopoeia (USP) U/kg; Group III); treatment with unfractionated heparin (total 4 mg/kg; total 300 USP U/kg; Group IV); treatment with heparan sulfate (total 4 mg/kg; Group V); treatment with chondroitin sulfate C (total 4 mg/kg; Group VI); or treatment with dextran sulfate (total 4 mg/kg; Group VII). The animals in Groups II to VII received two intravenously administered doses of 100 µl saline containing each sulfated polysaccharide, one at the time of reperfusion and

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Samuel R. Browd, Brian T. Ragel, Gary E. Davis, Amy M. Scott, Elaine J. Skalabrin, and William T. Couldwell

The incidence of deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE) in patients undergoing neurosurgery has been reported to be as high as 25%, with a mortality rate from PE between 9 and 50%. Even with the use of pneumatic compression devices, the incidence of DVT has been reported to be 32% in these patients, making prophylactic heparin therapy desirable. Both unfractionated and low-molecular-weight heparin have been shown to reduce the incidence of DVT consistently by 40 to 50% in neurosurgical patients. The baseline rate for major intracranial hemorrhage (ICH) following craniotomy has been reported to be between 1 and 3.9%, but after initiation of heparin therapy this rate has been found to be as high as 10.9%. Therefore, neurosurgeons must balance the risk of PE against the increased risk of postoperative ICH from prophylactic heparin for DVT. The authors review the literature on the incidence of DVT and PE in neurosurgical patients, focusing on the incidence of ICH related to the use of unfractionated and low-molecular-weight heparin in this patient population

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Kiyoyuki Yanaka, Stephen R. Spellman, James B. McCarthy, Walter C. Low, and Paul J. Camarata

/kg; total 100 United States Pharmacopoeia (USP) U/kg) (Group III); treatment with intravenous administration of heparin (total 2.67 mg/kg; total 200 USP U/kg) (Group IV); or treatment with intravenous administration of heparin (total 4 mg/kg; total 300 USP U/kg) (Group V). The animals in Group I were the same as those used in Part I of this study. 21 The animals in Groups II to V received two intravenously administered doses of 100 µl saline containing unfractionated heparin, one at the time of reperfusion and one 24 hours after reperfusion. Commercial unfractionated

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David D. Gonda, Jared Fridley, Sheila L. Ryan, Valentina Briceño, Sandi K. Lam, MD MBA, Thomas G. Luerssen, and Andrew Jea

inpatient costs and length of stay in young trauma patients. 4 , 8 Current therapy for management of VTEs in children is extrapolated from clinical experience and trials with adult patients. It usually consists of therapy with unfractionated heparin, low-molecular-weight heparin (LMWH), oral anticoagulants, or a combination of these medications. 1 , 10 Poor venous access, unpredictable pharmacokinetics requiring serial monitoring, increased risk of bleeding related to primary disorders, and the influence of disease, diet, or medications adversely influence the safe

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Michael L. Levy, Robert C. Granville, David Hart, and Hal Meltzer

DVT in the control group. 5 Cerrato, et al., 4 reported that the administration of mini-dose heparin (5000 IU three times daily) in 50 adult patients reduced the incidence of DVT from 34% in the control group to 6%, although there was a concomitant doubling in the rate of hemorrhage. Adjusted-dose unfractionated heparin therapy is based on the activated partial thromboplastin time (60–80 seconds) and, although more specific, requires serial blood testing and remains the mainstay of therapeutic and prophylactic therapy in adults. Estimates of bleeding and

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Omar Tanweer, Akwasi Boah, and Paul P. Huang

chemical prophylaxis (low-dose unfractionated heparin [LDUH], enoxaparin, or none), time to initiation of the prophylactic agent, time to next CT scan, and occurrence of VTE. All patients had intermittent compression devices placed at the time of admission. During the patients' hospital stay, ultrasonography or contrast CT scans of the lower extremities were obtained if the treating physician clinically suspected deep vein thrombosis or a pulmonary embolus. For drain placement, a standard frontal approach was used. 7 An antibiotic-coated, 2.8-mm

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Spontaneous spinal hematomas and low-molecular-weight heparin

Report of four cases and review of the literature

Peter A. Heppner, Stephen J. Monteith, and Andrew J. J. Law

has in the past been associated with spinal anesthetic—related hematomas. This dose has been shown in several trials to be at least as effective as unfractionated heparin in the treatment of unstable CAD, 3, 11, 16 deep venous thrombosis, 12 and pulmonary embolus. 25 As such, its use has increased and will continue to increase in the foreseeable future. It may be, however, that this higher dose confers a risk of spinal hematoma absent when the lower dose is chosen. In a large trial involving the treatment of acute ischemic stroke with low

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Brandon W. Smith, Jacob R. Joseph, and Paul Park

present a case of HIT with extensive thrombosis in a patient who had undergone a recent spine operation with exposure to postoperative unfractionated heparin prophylaxis. This patient went on to develop compartment syndrome that caused acute lower-extremity paralysis, renal failure, deep venous thromboses (DVTs), and pulmonary embolisms (PEs) causing respiratory failure. The purpose for presenting this case is to increase the awareness that HIT can develop in spine patients after prophylactic dosing of unfractionated heparin, and that this can present as acute weakness