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Safety and efficacy of immediate heparin reversal with protamine after complex percutaneous coronary intervention. BMC Cardiovasc Disord 2022; 22:207. [PMID: 35538419 PMCID: PMC9088099 DOI: 10.1186/s12872-022-02650-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/25/2022] [Indexed: 11/21/2022] Open
Abstract
Background Compared to simple percutaneous coronary intervention (PCI), complex PCI is associated with higher bleeding and thrombotic risk. No previous study has evaluated the use of protamine after PCI with contemporary technologies. This study aimed to evaluate the safety and efficacy of manual compression with and without protamine after transfemoral complex PCI.
Methods We retrospectively analyzed 160 patients (protamine group, n = 92; non-protamine group, n = 68) who underwent complex PCI via the femoral artery. The primary outcome was a composite of in-hospital death, myocardial infarction, stent thrombosis, stroke/systemic embolism, bleeding requiring blood transfusion, and vascular access complications. Results The primary outcome was significantly lower in the protamine group than in the non-protamine group (4.3% vs. 17.6%; p = 0.006). This was driven mainly by the lower incidences of hematoma in the protamine group (3.3% vs. 13.2%, p = 0.020). Furthermore, the protamine group had a significantly shorter hospital stay than the non-protamine group (4.8 ± 3.7 days vs. 8.4 ± 8.3 days, p = 0.001). While > 90% of the patients had acute coronary syndrome, there were no incidences of myocardial infarction or stent thrombosis in either group. Conclusions Among patients who underwent complex PCI via transfemoral access, immediate protamine administration was associated with a significantly lower rate of vascular access complications, especially hematoma, and shorter hospital stay than no protamine administration.
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Robinson KJ, Soda Y, Bakker E. Recent improvements to the selectivity of extraction-based optical ion sensors. Chem Commun (Camb) 2022; 58:4279-4287. [PMID: 35201251 PMCID: PMC8972301 DOI: 10.1039/d1cc06636f] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Optical sensors continue to demonstrate tremendous potential across a wide range of applications due to their high versatility and low cost. This feature article will focus on a number of recent advances made in improving the performance of extraction-based optical ion sensors within our group. This includes the progress of anchored solvatochromic transduction to provide pH and sample volume independent optical responses in nanoemulsion-based sensors. A recent breakthough is in polyion sensing in biological fluids that uses a novel indirect transduction mechanism that significantly improves the selectivity of dinonylnaphthalenesulfonate-based protamine sensors and its potential applications beyond polyion sensing. The role of particle stabilizers in relation to the response of emulsified sensors is shown to be important. Current challenges in the field and possible opportunities are also discussed. Selectivity remains a constant challenge in the development of optical extraction-based sensors. Fortunately, there are several mechanistic and compositional changes with the potential to improve selectivity without developing new ionophores.![]()
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Affiliation(s)
- Kye J Robinson
- Department of Inorganic, Analytical Chemistry University of Geneva Quai Ernest-Ansermet 30, 1211 Geneva, Switzerland.
| | - Yoshiki Soda
- Department of Inorganic, Analytical Chemistry University of Geneva Quai Ernest-Ansermet 30, 1211 Geneva, Switzerland.
| | - Eric Bakker
- Department of Inorganic, Analytical Chemistry University of Geneva Quai Ernest-Ansermet 30, 1211 Geneva, Switzerland.
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Wooten JM, Baldwin ST. Pharmacologic Agents Used to Reverse the Anticoagulant Effect of Common Anticoagulants. South Med J 2022; 115:220-226. [PMID: 35237842 DOI: 10.14423/smj.0000000000001372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Numerous oral and parenteral anticoagulant drugs are now available for clinical use. Understanding the precise pharmacologic properties of each anticoagulant is imperative for those practitioners who prescribe these drugs, including knowing the current recommendations for reversing the anticoagulant effect of each anticoagulant. This review provides a brief description of the various anticoagulants used today and also discusses the pharmacologic properties of those drugs used to reverse the anticoagulant action of specific anticoagulants.
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Affiliation(s)
- James M Wooten
- From the Department of Internal Medicine-Clinical Pharmacology, University of Missouri-Kansas City School of Medicine, Kansas City, and Pediatric Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama (Retired)
| | - Steven T Baldwin
- From the Department of Internal Medicine-Clinical Pharmacology, University of Missouri-Kansas City School of Medicine, Kansas City, and Pediatric Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama (Retired)
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Abstract
Continuous renal replacement therapy is an important, yet challenging, treatment of critically ill patients with kidney dysfunction. Clotting within the dialysis filter or circuit leads to time off therapy and impaired delivery of prescribed treatment. Anticoagulation can be used to prevent this complication; however, doing so introduces risk for unintended complications such as bleeding or metabolic derangements in patients who are already critically ill. A thorough understanding of indications, therapeutic options, and monitoring principles is necessary for safe and effective use of this strategy. This review provides clinicians important information regarding when to anticoagulate, differences in pharmacologic agents, recommended doses, routes of drug delivery, and appropriate laboratory monitoring for patients receiving anticoagulation to support continuous renal replacement therapy.
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Pan Y, Zhao Z, Yang T, Jiao Q, Wei W, Ji J, Xin W. A Meta-Analysis of Using Protamine for Reducing the Risk of Hemorrhage During Carotid Recanalization: Direct Comparisons of Post-operative Complications. Front Pharmacol 2022; 13:796329. [PMID: 35281915 PMCID: PMC8914204 DOI: 10.3389/fphar.2022.796329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Protamine can decrease the risk of hemorrhage during carotid recanalization. However, it may cause severe side effects. There is no consensus on the safety and efficacy of protamine during surgery. Thus, we conduct a comprehensive review and meta-analysis to compare the differences between the protamine and the no-protamine group.Method: We systematically obtained literature from Medline, Google Scholar, Cochrane Library, and PubMed electronic databases. All four databases were scanned from 1937 when protamine was first adopted as a heparin antagonist until February 2021. The reference lists of identified studies were manually checked to determine other eligible studies that qualify. The articles were included in this meta-analysis as long as they met the criteria of PICOS; conference or commentary articles, letters, case report or series, and animal observation were excluded from this study. The Newcastle-Ottawa Quality Assessment Scale and Cochrane Collaboration’s tool are used to assess the risk of bias of each included observational study and RCT, respectively. Stata version 12.0 statistical software (StataCorp LP, College Station, Texas) was adopted as statistical software. When I2 < 50%, we consider that the data have no obvious heterogeneity, and we conduct a meta-analysis using the fixed-effect model. Otherwise, the random-effect model was performed.Result: A total of 11 studies, consisting of 94,618 participants, are included in this study. Our analysis found that the rate of wound hematoma had a significant difference among protamine and no-protamine patients (OR = 0.268, 95% CI = 0.093 to 0.774, p = 0.015). Furthermore, the incidence of hematoma requiring re-operation (0.7%) was significantly lower than that of patients without protamine (1.8%). However, there was no significant difference in the incidence of stroke, wound hematoma with hypertension, transient ischemic attacks (TIA), myocardial infarction (MI), and death.Conclusion: Among included participants undergoing recanalization, the use of protamine is effective in reducing hematoma without increasing the risk of having other complications. Besides, more evidence-based performance is needed to supplement this opinion due to inherent limitations.
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Affiliation(s)
- Yongli Pan
- Department of Neurology, Weifang Medical University, Weifang, China
| | - Zhiqiang Zhao
- Department of Neurosurgery, Heji Hospital Affiliated Changzhi Medical College, Changzhi, China
| | - Tao Yang
- Department of Neurosurgery, Heji Hospital Affiliated Changzhi Medical College, Changzhi, China
| | - Qingzheng Jiao
- Second Department of Internal Medicine, Gucheng Country Hospital, Shijiazhuang, China
| | - Wei Wei
- Department of Neurology, Mianyang Central Hospital, Mianyang, China
| | - Jianyong Ji
- Department of Neurosurgery, Liaocheng People’s Hospital, Liaocheng, China
- *Correspondence: Jianyong Ji, ; Wenqiang Xin,
| | - Wenqiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- *Correspondence: Jianyong Ji, ; Wenqiang Xin,
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Recent Progress on Heparin–Protamine Particles for Biomedical Application. Polymers (Basel) 2022; 14:polym14050932. [PMID: 35267754 PMCID: PMC8912589 DOI: 10.3390/polym14050932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 02/01/2023] Open
Abstract
Biomolecules are attractive building blocks with self-assembly ability, structural diversity, and excellent functionality for creating artificial materials. Heparin and protamine, a clinically relevant pair of biomolecules used in cardiac and vascular surgery, have been shown to coassemble into particulate polyelectrolyte complexes in vitro. The resulting heparin–protamine particles exhibit adhesive properties that enable advantageous interactions with proteins, cells, and various other substances and have been employed as functional materials for biomedical applications. In this review article, we summarize recent progress in research on the use of heparin–protamine particles as drug carriers, cell adhesives, and cell labels. Studies have demonstrated that heparin–protamine particles are potentially versatile in biomedical fields from drug delivery and regenerative medicine to plastic surgery.
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Auci E, Vendramin I, Barbariol F, Riccardi I, Gigante A, Baroselli A, Bove T, Bassi F, Vetrugno L, Livi U. Platelet Dysfunction in Cardiac Surgery: When is the Best Time to Assess It? An Observational Single Center Study. Semin Cardiothorac Vasc Anesth 2022; 26:8-14. [PMID: 35156440 DOI: 10.1177/10892532211064041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose. Cardiac surgery is characterized by a high risk of complications related to perioperative bleeding. Guidelines suggest the use of local algorithms based on perioperative point-of-care tests to assess and manage potential coagulation abnormalities. We investigated whether heparin reversal administration affects the adenosine-5-diphosphate (ADP) test values, thus identifying the earliest time point following cardio-pulmonary bypass that permits the promptest detection and treatment of potential platelet dysfunctions. Methods. This was a retrospective, single-center, observational study enrolling cardiac surgery patients requiring cardiac bypass. ADP-tests at 4 different time-points during surgery (T0: baseline, T1: at aortic de-clamping, T2: 10 minutes after protamine administration, and T3: at the end of surgery) were performed. Results. 63 patients undergoing elective cardiac surgery were studied. Baseline ADP-test values were almost constantly greater than intraoperative values, and end of surgery values were often greater than previous intraoperative values. The only difference that proved to be not statistically significant was between T1 and T2, with a clinically insignificant mean difference of -.2 U (95%CI of difference: -6.9 - 6.5 U). There was no correlation between the variation in ADP-test values pre- and post-protamine administration and the protamine-to-heparin ratio. Conclusion. The results of the present study support the hypothesis that the ADP-test could be performed early, at aortic de-clamping before protamine administration. This approach allows for the promptest assessment of a potential impairment in platelet function, and its timely correction.
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Affiliation(s)
| | | | | | | | | | | | - Tiziana Bove
- ASUFC University Hospital of Udine, Udine, Italy.,Department of Medicine, 9316University of Udine, Udine, Italy
| | - Flavio Bassi
- ASUFC University Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- ASUFC University Hospital of Udine, Udine, Italy.,Department of Medicine, 9316University of Udine, Udine, Italy
| | - Ugolino Livi
- ASUFC University Hospital of Udine, Udine, Italy.,Department of Medicine, 9316University of Udine, Udine, Italy
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Singh AA, Boyle JR, Chetter I, Falter F. Protamine for Heparin Reversal After Carotid Endarterectomy is Significantly Underutilised: Results from a UK National Survey. Eur J Vasc Endovasc Surg 2022; 63:657-658. [DOI: 10.1016/j.ejvs.2022.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/07/2022] [Accepted: 01/09/2022] [Indexed: 11/28/2022]
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Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJ, Schlimp CJ, Vandermeulen E, Volk T, von Heymann C, Wolmarans M, Afshari A. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100-132. [PMID: 34980845 DOI: 10.1097/eja.0000000000001600] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, Valencia, Spain (RF), Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris (AG), INSERM UMRS-1140 Paris University, Paris, France (AG), Department of Anaesthesiology and Critical Care, Doctor Peset University Hospital (JL), Department of Surgery, Valencia University, Valencia, Spain (JL), Serviço de Anestesiologia Hospital das Forças Armadas, Pólo Porto, Porto, Portugal (CL), Department of Anaesthesia Pain Medicine and Critical Care, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK (AM), Department of Anaesthesia and Intensive Care Medicine, AUVA Trauma Centre Linz, Linz (CJS); Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria (CJS), Department of Anaesthesia, University Hospitals Leuven. Catholic University of Leuven, Leuven, Belgium (EV), Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar (TV), Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany (CVH), Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK (MW), and Department of Pediatric and Obstetric Anesthesia, Juliane Marie Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA)
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Zharkova MS, Golubeva OY, Orlov DS, Vladimirova EV, Dmitriev AV, Tossi A, Shamova OV. Silver Nanoparticles Functionalized With Antimicrobial Polypeptides: Benefits and Possible Pitfalls of a Novel Anti-infective Tool. Front Microbiol 2021; 12:750556. [PMID: 34975782 PMCID: PMC8719061 DOI: 10.3389/fmicb.2021.750556] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/22/2021] [Indexed: 12/13/2022] Open
Abstract
Silver nanoparticles (AgNPs) and antimicrobial peptides or proteins (AMPs/APs) are both considered as promising platforms for the development of novel therapeutic agents effective against the growing number of drug-resistant pathogens. The observed synergy of their antibacterial activity suggested the prospect of introducing antimicrobial peptides or small antimicrobial proteins into the gelatinized coating of AgNPs. Conjugates with protegrin-1, indolicidin, protamine, histones, and lysozyme were comparatively tested for their antibacterial properties and compared with unconjugated nanoparticles and antimicrobial polypeptides alone. Their toxic effects were similarly tested against both normal eukaryotic cells (human erythrocytes, peripheral blood mononuclear cells, neutrophils, and dermal fibroblasts) and tumor cells (human erythromyeloid leukemia K562 and human histiocytic lymphoma U937 cell lines). The AMPs/APs retained their ability to enhance the antibacterial activity of AgNPs against both Gram-positive and Gram-negative bacteria, including drug-resistant strains, when conjugated to the AgNP surface. The small, membranolytic protegrin-1 was the most efficient, suggesting that a short, rigid structure is not a limiting factor despite the constraints imposed by binding to the nanoparticle. Some of the conjugated AMPs/APs clearly affected the ability of nanoparticle to permeabilize the outer membrane of Escherichia coli, but none of the conjugated AgNPs acquired the capacity to permeabilize its cytoplasmic membrane, regardless of the membranolytic potency of the bound polypeptide. Low hemolytic activity was also found for all AgNP-AMP/AP conjugates, regardless of the hemolytic activity of the free polypeptides, making conjugation a promising strategy not only to enhance their antimicrobial potential but also to effectively reduce the toxicity of membranolytic AMPs. The observation that metabolic processes and O2 consumption in bacteria were efficiently inhibited by all forms of AgNPs is the most likely explanation for their rapid and bactericidal action. AMP-dependent properties in the activity pattern of various conjugates toward eukaryotic cells suggest that immunomodulatory, wound-healing, and other effects of the polypeptides are at least partially transferred to the nanoparticles, so that functionalization of AgNPs may have effects beyond just modulation of direct antibacterial activity. In addition, some conjugated nanoparticles are selectively toxic to tumor cells. However, caution is required as not all modulatory effects are necessarily beneficial to normal host cells.
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Affiliation(s)
- Maria S. Zharkova
- World-Class Research Center “Center for Personalized Medicine”, FSBSI Institute of Experimental Medicine, Saint Petersburg, Russia
| | - Olga Yu. Golubeva
- Laboratory of the Nanostructures Research, Institute of Silicate Chemistry, Russian Academy of Sciences, Saint Petersburg, Russia
| | - Dmitriy S. Orlov
- World-Class Research Center “Center for Personalized Medicine”, FSBSI Institute of Experimental Medicine, Saint Petersburg, Russia
| | - Elizaveta V. Vladimirova
- World-Class Research Center “Center for Personalized Medicine”, FSBSI Institute of Experimental Medicine, Saint Petersburg, Russia
| | - Alexander V. Dmitriev
- World-Class Research Center “Center for Personalized Medicine”, FSBSI Institute of Experimental Medicine, Saint Petersburg, Russia
| | - Alessandro Tossi
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Olga V. Shamova
- World-Class Research Center “Center for Personalized Medicine”, FSBSI Institute of Experimental Medicine, Saint Petersburg, Russia
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Abstract
Background: Fibrinogen is a substrate for blood clots formation. In cardiac surgery, a number of different mechanisms lead to a decrease in fibrinogen levels and consequent impaired haemostasis. Patients undergoing cardiac surgery are therefore frequently exposed to blood loss and allogeneic blood transfusion, which are risk factors associated with morbidity and mortality. Thus, particular efforts in fibrinogen management should be made to decrease bleeding and the need for blood transfusion. Therefore, fibrinogen remains an active focus of investigations from basic science to clinical practice. This review aims to summarise the latest evidence regarding the role of fibrinogen and current practices in fibrinogen management in adult cardiac surgery. Methods: The PubMed database was systematically searched for literature investigating the role and disorders of fibrinogen in cardiac surgery and diagnostic and therapeutic procedures related to fibrinogen deficiency aimed at reducing blood loss and transfusion requirements. Clinical trials and reviews from the last 10 years were included. Results: In total, 146 articles were analysed. Conclusion: The early diagnosis and treatment of fibrinogen deficiency is crucial in maintaining haemostasis in bleeding patients. Further studies are needed to better understand the association between fibrinogen levels, bleeding, and fibrinogen supplementation and their impacts on patient outcomes in different clinical settings.
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Systemic Anticoagulation and Reversal. Surg Clin North Am 2021; 102:53-63. [PMID: 34800389 DOI: 10.1016/j.suc.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
An increasing number of patients are on anticoagulation for a variety of indications. Patients on anticoagulation who present to the hospital with life-threatening hemorrhage, whether trauma related or not, must be assessed for the reversal of anticoagulation. Identification of the type of anticoagulation, the timing of the most recent usage of anticoagulation, and the efficacy of the anticoagulation all have an impact on whether reversal agents should be used. There are a variety of reversal agents, both nonspecific and specific, that could be used for reversal; however, not all reversal agents work for all anticoagulation medication. As more anticoagulation medications are used and indications expand, providers must be aware of the reversal agents available and the efficacy and indications for these reversal agents.
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Can the Minimum Protamine Dose to Neutralize Heparin at the Completion of Cardiopulmonary Bypass be Significantly Lower than the Conventional Practice? THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:170-176. [PMID: 34658407 DOI: 10.1182/ject-2100023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/31/2021] [Indexed: 11/20/2022]
Abstract
Systemic anticoagulation with heparin during cardiopulmonary bypass (CPB) should be neutralized by protamine administration to restore normal hemostasis. However, protamine has potentially serious side effects and excessive protamine can cause increased postoperative bleeding. Thus, our goal is to appropriately dose protamine at the completion of CPB to neutralize heparin so that neither residual heparin nor excessive protamine is present. We performed a retrospective study of 216 patients who underwent cardiac surgery to search for a safe minimum protamine dose (PD) when measuring heparin concentration (HC). In addition, we developed a formula to determine PD using total heparin dose (THD) and CPB time without measuring HC. When protamine-to-heparin ratio (P-to-H) is set at 1 mg protamine to 100 international unit (IU) heparin in HMS Plus Hemostasis Management System (HMS), we determined that 75% of the calculated total PD is a safe minimum PD to sufficiently neutralize circulating heparin after CPB. On average, this translates into either .37 mg protamine/100 IU heparin of THD or .54 mg/100 IU of the first heparin bolus. The formula we developed to calculate PD without measuring HC can provide a PD that strongly agrees with the safe minimum PD when measuring HC. The safe minimum PD to neutralize circulating heparin after CPB can be significantly lower than conventional dosing practices. Reduction of PD may decrease the risk of postoperative bleeding and protamine-related adverse events. Based on our data, we decreased P-to-H in HMS to examine whether it is possible to reduce PD further than the safe minimum PD determined in this study.
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Reversal Activity and Toxicity of Heparin-Binding Copolymer after Subcutaneous Administration of Enoxaparin in Mice. Int J Mol Sci 2021; 22:ijms222011149. [PMID: 34681808 PMCID: PMC8541278 DOI: 10.3390/ijms222011149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 11/23/2022] Open
Abstract
Uncontrolled bleeding after enoxaparin (ENX) is rare but may be life-threatening. The only registered antidote for ENX, protamine sulfate (PS), has 60% efficacy and can cause severe adverse side effects. We developed a diblock copolymer, heparin-binding copolymer (HBC), that reverses intravenously administered heparins. Here, we focused on the HBC inhibitory activity against subcutaneously administered ENX in healthy mice. BALB/c mice were subcutaneously injected with ENX at the dose of 5 mg/kg. After 110 min, vehicle, HBC (6.25 and 12.5 mg/kg), or PS (5 and 10 mg/kg) were administered into the tail vein. The blood was collected after 3, 10, 60, 120, 360, and 600 min after vehicle, HBC, or PS administration. The activities of antifactors Xa and IIa and biochemical parameters were measured. The main organs were collected for histological analysis. HBC at the lower dose reversed the effect of ENX on antifactor Xa activity for 10 min after antidote administration, whereas at the higher dose, HBC reversed the effect on antifactor Xa activity throughout the course of the experiment. Both doses of HBC completely reversed the effect of ENX on antifactor IIa activity. PS did not reverse antifactor Xa activity and partially reversed antifactor IIa activity. HBC modulated biochemical parameters. Histopathological analysis showed changes in the liver, lungs, and spleen of mice treated with HBC and in the lungs and heart of mice treated with PS. HBC administered in an appropriate dose might be an efficient substitute for PS to reverse significantly increased anticoagulant activity that may be connected with major bleeding in patients receiving ENX subcutaneously.
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Chandiramani AS, Jenkin I, Botezatu B, Harky A. Protamine-Induced Coronary Graft Thrombosis: A Review. J Cardiothorac Vasc Anesth 2021; 36:2679-2684. [PMID: 34774407 DOI: 10.1053/j.jvca.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/07/2021] [Accepted: 10/06/2021] [Indexed: 11/11/2022]
Abstract
Perioperative myocardial infarction is a serious complication affecting a significant portion of patients undergoing coronary artery bypass graft surgery. This may arise due to coronary graft thrombosis, a rare but potentially fatal phenomenon associated with both congenital and acquired risk factors. Multiple case reports implicate the role of protamine in the development of such thromboses. The role of protamine in facilitating the regulation of hemostasis by reversing the anticoagulant effects of heparin in patients undergoing cardiopulmonary bypass is well-recognized. However, discussion of its potential contribution to coronary graft thrombosis and mechanisms by which this may occur is lacking. Furthermore, its narrow therapeutic index and side effect profile are such that its appropriateness as a universal reversal agent to heparin requires reconsideration. This article reviews the current body of evidence regarding the use of protamine in cardiac surgery and the limited case reports pertaining to its potential role in the pathophysiology of coronary graft thrombosis.
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Affiliation(s)
- Ashwini Suresh Chandiramani
- College of Medical, Veterinary and Life Sciences, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Ifan Jenkin
- Department of General Surgery, The Whittington Hospital, London, United Kingdom
| | - Bianca Botezatu
- Department of Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
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Liu G, Wang H, Luo Q, Cao L, Yang L, Yu C, Yan F, Yuan S. Low postoperative blood platelet count may be a risk factor for 3-year mortality in patients with acute type A aortic dissection. J Cardiothorac Surg 2021; 16:274. [PMID: 34579735 PMCID: PMC8477470 DOI: 10.1186/s13019-021-01623-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/14/2021] [Indexed: 11/16/2022] Open
Abstract
Background Mortality and complications remain high after acute type A aortic dissection (ATAAD) open surgery and are associated with coagulation dysfunction. Platelets play an important role in the process of coagulation. This study explored the relationship between postoperative platelet counts and 3-year mortality after operation in patients with ATAAD undergoing open aortic repair surgery. Methods Patients with ATAAD who underwent Total Arch Replacement and Frozen Elephant Trunk in Fuwai Hospital from 2011 to 2015 were selected for this study. The perioperative data were collected and sorted through the electronic clinical case system. Multivariate Logistic regression was used to analyze the risk factors for death within three years after surgery. Results A total of 495 patients were included in the analysis. After correction for confounding factors, decreased postoperative platelet count remained an independent factor that was associated with lower mortality (OR = 0.918, 95% CI 0.853–0.988, P = 0.023). Conclusions The study indicated that decreased postoperative platelet count may lead to increased 3-year mortality, in patients with ATAAD who underwent open aortic repair surgery. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01623-7.
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Affiliation(s)
- Guangyu Liu
- Anesthesia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, 100037, China
| | - Hongbai Wang
- Anesthesia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, 100037, China
| | - Qipeng Luo
- Pain Medicine Center, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Liang Cao
- Anesthesia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, 100037, China
| | - Lijing Yang
- Anesthesia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, 100037, China
| | - Cuntao Yu
- Vascular Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, 100037, China
| | - Fuxia Yan
- Anesthesia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, 100037, China
| | - Su Yuan
- Anesthesia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, 100037, China.
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Ho LTS, McVey MJ, Kuiper GJAJM, Gross PL, Karkouti K. Analysis of the effect of varying protamine-to-heparin ratio on coagulation in vitro. Br J Anaesth 2021; 127:e128-e130. [PMID: 34334192 DOI: 10.1016/j.bja.2021.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/15/2021] [Accepted: 06/20/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Loretta T S Ho
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anaesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada.
| | - Mark J McVey
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Department of Physics, Ryerson University, Toronto, ON, Canada
| | - Gerhardus J A J M Kuiper
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Treatment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Peter L Gross
- The Thrombosis and Atherosclerosis Research Institute, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Keyvan Karkouti
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anaesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada; Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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Li T, Meng Z, Zhu X, Gan H, Gu R, Wu Z, Liu T, Han P, Gao J, Han S, Dou G. In vitro and in vivo safety studies indicate that R15, a synthetic polyarginine peptide, could safely reverse the effects of unfractionated heparin. FEBS Open Bio 2021; 11:2468-2489. [PMID: 34184429 PMCID: PMC8409304 DOI: 10.1002/2211-5463.13240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/03/2021] [Accepted: 06/28/2021] [Indexed: 11/09/2022] Open
Abstract
Unfractionated heparin (UFH) is an anionic glycosaminoglycan that is widely used to prevent blood clotting. However, in certain cases, unwanted side effects can require it to be neutralized. Protamine sulfate (PS), a basic peptide rich in arginine, is the only approved antagonist for UFH neutralization. Many adverse reactions occur with the clinical application of PS, including systemic hypotension, pulmonary hypertension, and anaphylaxis. We previously described R15, a linear peptide composed of 15 arginine molecules, as a potential UFH antagonist. In this study, the in-depth safety of R15 was explored to reveal its merits and associated risks in comparison with PS. In vitro safety studies investigated the interactions of R15 with erythrocytes, fibrin, complement, and rat plasma. In vivo safety studies explored potential toxicity and immunogenicity of R15 and the UFH-R15 complex. Results showed that both PS and R15 can induce erythrocyte aggregation, thicken fibrin fibers, activate complement, and cause anticoagulation in a concentration-dependent manner. However, those influences weakened in whole blood or in live animals and were avoided when R15 was in a complex with UFH. We found dramatically enhanced complement activation when there was excess UFH in analyses involving UFH-PS complexes, and a slight increase in those involving UFH-R15 complexes. Within 2 h, R15 was degraded in rat plasma in vitro, whereas PS was not. Enhanced creatinine was found after a single intravenous injection of PS or R15 (900 U·kg-1 , body weight), suggesting possible abnormal renal function. The UFH-PS complex, but not the UFH-R15 complex, exhibited obvious immunogenicity. In conclusion, R15 is nonimmunogenic and potentially safe at a therapeutic dose to reverse the effects of UFH.
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Affiliation(s)
- Tong Li
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Zhiyun Meng
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Xiaoxia Zhu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Hui Gan
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Ruolan Gu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Zhuona Wu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Taoyun Liu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Peng Han
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Jiarui Gao
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Su Han
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Guifang Dou
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
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69
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Wahba A, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Puis L. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Eur J Cardiothorac Surg 2021; 57:210-251. [PMID: 31576396 DOI: 10.1093/ejcts/ezz267] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav's University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
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Bailly A, Gaillard C, Cadiet J, Fortuit C, Roux F, Morin H, Desanlis E, LE Teurnier Y, Miguet B, Robert D, Silleran J, Rigal JC, LE Thuaut A, Pere M, Roussel JC, Rozec B. Evaluation of the impact of HMS Plus on postoperative blood loss compared with ACT Plus in cardiac surgery. Minerva Anestesiol 2021; 87:1191-1199. [PMID: 34102807 DOI: 10.23736/s0375-9393.21.15482-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The standardized management of anticoagulation during the cardiopulmonary bypass seems inaccurate because of patients and surgeries variability. This study evaluates if an individualized management of heparin and protamine guided by the HMS Plus system during cardiopulmonary bypass could reduce postoperative blood loss. METHODS We conducted a prospective, controlled, unblinded, single-center study. 188 patients operated for cardiac surgery were included. Patients were divided in ACT Plus group (standardized approach) and HMS Plus group (individualized approach). The primary outcome was blood-loss volume during the first 24 postoperative hours. The main secondary outcomes were the need for allogeneic blood transfusions and the final protamine/heparin ratio. RESULTS There was no difference between the two groups for baseline characteristics. Medium bloodloss volume (±DS) in the ACT Plus group was 522 mL ±260 mL vs. 527 mL ±255 mL in the HMS Plus group (P = 0.58). The final protamine/heparin ratio (±DS) in the ACT Plus group was 0.94 ±0.1 vs. 0.58 ± 0.1 in the HMS Plus group (P < 0.0001). The transfusion rate during surgery in the ACT Plus group was 25% vs. 14% in the HMS Plus group (P = 0.09). CONCLUSIONS HMS Plus did not reduce the mean blood-loss volume during the first 24 postoperative hours compared with ACT Plus. Its utility for potential transfusion rate reduction remains to be proven.
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Affiliation(s)
- Arthur Bailly
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France -
| | - Côme Gaillard
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Julien Cadiet
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Camille Fortuit
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - François Roux
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Hélène Morin
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Enguerrand Desanlis
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Yann LE Teurnier
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Bertrand Miguet
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - David Robert
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Jacqueline Silleran
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Jean-Christophe Rigal
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Aurélie LE Thuaut
- Department of Methodology and Biostatistics, University Hospital of Nantes, Nantes, France
| | - Morgane Pere
- Department of Methodology and Biostatistics, University Hospital of Nantes, Nantes, France
| | - Jean-Christian Roussel
- Department of Thoracic and Cardiovascular Surgery, Université de Nantes, CHU Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - Bertrand Rozec
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France.,Université de Nantes, CHU Nantes, Nantes, France
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71
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Ruseska I, Fresacher K, Petschacher C, Zimmer A. Use of Protamine in Nanopharmaceuticals-A Review. NANOMATERIALS (BASEL, SWITZERLAND) 2021; 11:1508. [PMID: 34200384 PMCID: PMC8230241 DOI: 10.3390/nano11061508] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/27/2021] [Accepted: 05/27/2021] [Indexed: 12/18/2022]
Abstract
Macromolecular biomolecules are currently dethroning classical small molecule therapeutics because of their improved targeting and delivery properties. Protamine-a small polycationic peptide-represents a promising candidate. In nature, it binds and protects DNA against degradation during spermatogenesis due to electrostatic interactions between the negatively charged DNA-phosphate backbone and the positively charged protamine. Researchers are mimicking this technique to develop innovative nanopharmaceutical drug delivery systems, incorporating protamine as a carrier for biologically active components such as DNA or RNA. The first part of this review highlights ongoing investigations in the field of protamine-associated nanotechnology, discussing the self-assembling manufacturing process and nanoparticle engineering. Immune-modulating properties of protamine are those that lead to the second key part, which is protamine in novel vaccine technologies. Protamine-based RNA delivery systems in vaccines (some belong to the new class of mRNA-vaccines) against infectious disease and their use in cancer treatment are reviewed, and we provide an update on the current state of latest developments with protamine as pharmaceutical excipient for vaccines.
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Affiliation(s)
| | | | | | - Andreas Zimmer
- Department of Pharmaceutical Technology and Biopharmacy, Institute of Pharmaceutical Sciences, Karl-Franzens-University Graz, Universitätsplatz 1, 8010 Graz, Austria; (I.R.); (K.F.); (C.P.)
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72
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Miles LF, Burt C, Arrowsmith J, McKie MA, Villar SS, Govender P, Shaylor R, Tan Z, De Silva R, Falter F. Optimal protamine dosing after cardiopulmonary bypass: The PRODOSE adaptive randomised controlled trial. PLoS Med 2021; 18:e1003658. [PMID: 34097705 PMCID: PMC8216535 DOI: 10.1371/journal.pmed.1003658] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 06/21/2021] [Accepted: 05/14/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The dose of protamine required following cardiopulmonary bypass (CPB) is often determined by the dose of heparin required pre-CPB, expressed as a fixed ratio. Dosing based on mathematical models of heparin clearance is postulated to improve protamine dosing precision and coagulation. We hypothesised that protamine dosing based on a 2-compartment model would improve thromboelastography (TEG) parameters and reduce the dose of protamine administered, relative to a fixed ratio. METHODS AND FINDINGS We undertook a 2-stage, adaptive randomised controlled trial, allocating 228 participants to receive protamine dosed according to a mathematical model of heparin clearance or a fixed ratio of 1 mg of protamine for every 100 IU of heparin required to establish anticoagulation pre-CPB. A planned, blinded interim analysis was undertaken after the recruitment of 50% of the study cohort. Following this, the randomisation ratio was adapted from 1:1 to 1:1.33 to increase recruitment to the superior arm while maintaining study power. At the conclusion of trial recruitment, we had randomised 121 patients to the intervention arm and 107 patients to the control arm. The primary endpoint was kaolin TEG r-time measured 3 minutes after protamine administration at the end of CPB. Secondary endpoints included ratio of kaolin TEG r-time pre-CPB to the same metric following protamine administration, requirement for allogeneic red cell transfusion, intercostal catheter drainage at 4 hours postoperatively, and the requirement for reoperation due to bleeding. The trial was listed on a clinical trial registry (ClinicalTrials.gov Identifier: NCT03532594). Participants were recruited between April 2018 and August 2019. Those in the intervention/model group had a shorter mean kaolin r-time (6.58 [SD 2.50] vs. 8.08 [SD 3.98] minutes; p = 0.0016) post-CPB. The post-protamine thromboelastogram of the model group was closer to pre-CPB parameters (median pre-CPB to post-protamine kaolin r-time ratio 0.96 [IQR 0.78-1.14] vs. 0.75 [IQR 0.57-0.99]; p < 0.001). We found no evidence of a difference in median mediastinal/pleural drainage at 4 hours postoperatively (140 [IQR 75-245] vs. 135 [IQR 94-222] mL; p = 0.85) or requirement (as a binary outcome) for packed red blood cell transfusion at 24 hours postoperatively (19 [15.8%] vs. 14 [13.1%] p = 0.69). Those in the model group had a lower median protamine dose (180 [IQR 160-210] vs. 280 [IQR 250-300] mg; p < 0.001). Important limitations of this study include an unblinded design and lack of generalisability to certain populations deliberately excluded from the study (specifically children, patients with a total body weight >120 kg, and patients requiring therapeutic hypothermia to <28°C). CONCLUSIONS Using a mathematical model to guide protamine dosing in patients following CPB improved TEG r-time and reduced the dose administered relative to a fixed ratio. No differences were detected in postoperative mediastinal/pleural drainage or red blood cell transfusion requirement in our cohort of low-risk patients. TRIAL REGISTRATION ClinicalTrials.gov Unique identifier NCT03532594.
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Affiliation(s)
- Lachlan F. Miles
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Anaesthesia, Austin Health, Melbourne, Australia
- * E-mail:
| | - Christiana Burt
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Joseph Arrowsmith
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Mikel A. McKie
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Sofia S. Villar
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Pooveshnie Govender
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Ruth Shaylor
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - Zihui Tan
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Ravi De Silva
- Department of Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Florian Falter
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
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Bartoszko J, Karkouti K. Managing the coagulopathy associated with cardiopulmonary bypass. J Thromb Haemost 2021; 19:617-632. [PMID: 33251719 DOI: 10.1111/jth.15195] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/29/2022]
Abstract
Cardiopulmonary bypass (CPB) has allowed for significant surgical advancements, but accompanying risks can be significant and must be expertly managed. One of the foremost risks is coagulopathic bleeding. Increasing levels of bleeding in cardiac surgical patients at the time of separation from CPB are associated with poor outcomes and mortality. CPB-associated coagulopathy is typically multifactorial and rarely due to inadequate reversal of systemic heparin alone. The components of the bypass circuit induce systemic inflammation and multiple disturbances of the coagulation and fibrinolytic systems. Anticipating coagulopathy is the first step in managing it, and specific patient and procedural risk factors have been identified as predictors of excessive bleeding. Medication management pre-procedure is critical, as patients undergoing cardiac surgery are commonly on anticoagulants or antiplatelet agents. Important adjuncts to avoid transfusion include antifibrinolytics, and perfusion practices such as red cell salvage, sequestration, and retrograde autologous priming of the bypass circuit have varying degrees of evidence supporting their use. Understanding the patient's coagulation status helps target product replacement and avoid larger volume transfusion. There is increasing recognition of the role of point-of-care viscoelastic and functional platelet testing. Common pitfalls in the management of post-CPB coagulopathy include overdosing protamine for heparin reversal, imperfect laboratory measures of thrombin generation that result in normal or near-normal laboratory results in the presence of continued bleeding, and delayed recognition of surgical bleeding. While challenging, the effective management of CPB-associated coagulopathy can significantly improve patient outcomes.
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Affiliation(s)
- Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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Murugesh WR, Prasad SS, Ramachandrappa Sujay K, Dinesh Kumar US. Is a fixed low-dose protamine better at reducing postoperative bleeding in off pump coronary artery bypass grafting? Asian Cardiovasc Thorac Ann 2021; 29:922-927. [PMID: 33626877 DOI: 10.1177/0218492321997393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
CONTEXT Protamine is used ubiquitously in all cardiac surgeries for reversal of heparin. Risk of postoperative bleeding is increased with inadequate heparin reversal or due to anticoagulant side effects of protamine; hence, it is important to dose protamine properly. This study compares 80% protamine dose with full dose on postoperative bleeding and transfusion needs in OPCAB. AIMS The aim of our study was to find whether lower dose of protamine could reduce postoperative bleeding and need for blood product transfusions in off pump coronary artery bypass grafting as compared to the regular dose of protamine. SETTINGS AND DESIGN This was a double-blinded randomised controlled trial where patients posted for off pump CABG meeting the inclusion criteria were included in the study. METHODS AND MATERIAL Ninety patients were randomised to two groups, group F receiving full dose of protamine of 1 mg per mg heparin used, and group L received 0.8 mg per mg. Postoperative activated clotting time, bleeding at 1 h, 4 h, 24 h and total drainage till drains removal and blood product transfusion requirements were noted.Statistical analysis used: SPSS software. RESULTS Both groups were matched in demographics, preoperative cessation of heparin and aspirin and platelet counts. Both groups received equal heparin dose, activated clotting time before protamine, activated clotting time post protamine in OT and ICU were equal as were the conduits used. There was no significant difference between the groups in post-operative drainage over time or in the need for blood product transfusions. CONCLUSIONS Eighty per cent of the dose of protamine can adequately reverse the heparin used during off pump cardiac surgery without any increase in incidence of postoperative bleeding or need for blood product transfusions.
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Affiliation(s)
- Wali R Murugesh
- Department of Cardiac Anaesthesia, JSS Medical College and Hospital, Mysuru, India
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Fukushima H, Oguchi T, Sato H, Nakadate Y, Sato T, Omiya K, Kawakami A, Matsuoka T, Matsukawa T. Ulinastatin attenuates protamine-induced cardiotoxicity in rats by inhibiting tumor necrosis factor alpha. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2021; 394:373-381. [PMID: 33029649 DOI: 10.1007/s00210-020-01983-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/29/2020] [Indexed: 11/24/2022]
Abstract
Protamine causes cardiac depression, which may be mediated by tumor necrosis factor alpha (TNF-α). Ulinastatin, a human urinary protease inhibitor, inhibits TNF-α. Here, we aimed to investigate whether ulinastatin prevented protamine-induced myocardial depression by inhibiting TNF-α. Rat hearts were perfused using a Langendorff system, and three protocols were followed. Protocol 1: The hearts were divided into saline, ulinastatin-low, and ulinastatin-high groups. Protamine was administered to each group, and myocardial contractility was the primary outcome. Protocol 2: The hearts were allotted to saline or ulinastatin group. Protamine was administered to each group. TNF-α expression in the coronary effluent and myocardial tissue was measured. Protocol 3: The hearts were allotted to saline and ulinastatin groups. Recombinant rat-TNF-α was administered to each group. Protamine alone reduced the maximum left ventricular pressure derivative (LV dP/dt max) by 45 ± 4%. In contrast, the reduction in LV dP/dt max was 4 ± 3% in the ulinastatin-high group. Compared with that in the saline group, the increase in TNF-α in the coronary effluent was attenuated in the ulinastatin group. Recombinant TNF-α alone reduced LV dP/dt max (- 21 ± 14%). In contrast, when TNF-α was added in the presence of ulinastatin, the decrease in LV dP/dt max was prevented significantly (- 3 ± 8%). We showed, for the first time, that ulinastatin protected against protamine-induced myocardial damage, both by inhibiting TNF-α synthesis and by directly preventing the cardiodepressant action of TNF-α.
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Affiliation(s)
- Hisashi Fukushima
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-City, Yamanashi, 409-3898, Japan
- Department of Anesthesia, National Hospital Organization Mito Medical Center, Sakuranosato 280, Ibaraki-machi, Higashiibaraki-gun, Ibaraki, 311-3193, Japan
| | - Takeshi Oguchi
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-City, Yamanashi, 409-3898, Japan.
| | - Hiroaki Sato
- Department of Anesthesia, Royal Victoria Hospital, McGill University Health Centre, 1001 Decarie Boulevard, Montreal, Quebec, H4A 3J1, Canada
| | - Yosuke Nakadate
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-City, Yamanashi, 409-3898, Japan
| | - Tamaki Sato
- Department of Anesthesia, Royal Victoria Hospital, McGill University Health Centre, 1001 Decarie Boulevard, Montreal, Quebec, H4A 3J1, Canada
| | - Keisuke Omiya
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-City, Yamanashi, 409-3898, Japan
| | - Akiko Kawakami
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-City, Yamanashi, 409-3898, Japan
| | - Toru Matsuoka
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-City, Yamanashi, 409-3898, Japan
| | - Takashi Matsukawa
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-City, Yamanashi, 409-3898, Japan
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76
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De Simone F, Nardelli P, Licheri M, Frau G, Redaelli MB, Monaco F, Zangrillo A, Landoni G. Less is more: We are administering too much protamine in cardiac surgery. Ann Card Anaesth 2021; 24:178-182. [PMID: 33884973 PMCID: PMC8253032 DOI: 10.4103/aca.aca_26_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context Protamine is routinely administered to neutralize the anticlotting effects of heparin, traditionally at a dose of 1 mg for every 100 IU of heparin-a 1:1 ratio protamine sparing effects-but this is based more on experience and practice than literature evidence. The use of Hemostasis Management System (HMS) allows an individualized heparin and protamine titration. This usually results in a decreased protamine dose, thus limiting its side effects, including paradox anticoagulation. Aims This study aims to assess how the use of HMS allows to reduction of protamine administration while restoring the basal activated clotting time (ACT) at the end of cardiac surgery. Settings and Design A retrospective observational study in a tertiary care university hospital. Subjects and Methods We analyzed data from 42 consecutive patients undergoing cardiopulmonary bypass (CPB) for cardiac surgery. For all patients HMS tests were performed before and after CPB, to determine how much heparin was needed to reach target ACT, and how much protamine was needed to reverse it. Results At the end of cardiopulmonary bypass, 2.2 ± 0.5 mg/kg of protamine was sufficient to reverse heparin effects. The protamine-to-heparin ratio was 0.56:1 over heparin total dose (a 44% reduction) and 0.84:1 over heparin initial dose (a 16% reduction). Conclusion A lower dose of protamine was sufficient to revert heparin effects after cardiopulmonary bypass. While larger studies are needed to confirm these findings and detect differences in clinically relevant outcomes, the administration of a lower protamine dose is endorsed by current guidelines and may help to avoid the detrimental effects of protamine overdose, including paradox bleeding.
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Affiliation(s)
- Francesco De Simone
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margherita Licheri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanna Frau
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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77
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Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, Ten Cate-Hoek AJ, Elalamy I, Enzmann FK, Geroulakos G, Gottsäter A, Hunt BJ, Mansilha A, Nicolaides AN, Sandset PM, Stansby G, Esvs Guidelines Committee, de Borst GJ, Bastos Gonçalves F, Chakfé N, Hinchliffe R, Kolh P, Koncar I, Lindholt JS, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, De Maeseneer MG, Comerota AJ, Gloviczki P, Kruip MJHA, Monreal M, Prandoni P, Vega de Ceniga M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg 2020; 61:9-82. [PMID: 33334670 DOI: 10.1016/j.ejvs.2020.09.023] [Citation(s) in RCA: 291] [Impact Index Per Article: 72.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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78
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Görlacher M, Panagiotou E, Himmelreich N, Hüllen A, Beedgen L, Dimitrov B, Geiger V, Zielonka M, Peters V, Strahl S, Vázquez-Jiménez J, Kerst G, Thiel C. Fatal outcome after heart surgery in PMM2-CDG due to a rare homozygous gene variant with double effects. Mol Genet Metab Rep 2020; 25:100673. [PMID: 33209585 PMCID: PMC7658698 DOI: 10.1016/j.ymgmr.2020.100673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/23/2020] [Indexed: 12/19/2022] Open
Abstract
Variants in Phosphomannomutase 2 (PMM2) lead to PMM2-CDG, the most frequent congenital disorder of glycosylation (CDG). We here describe the disease course of a ten-month old patient who presented with the classical PMM2-CDG symptoms as cerebellar hypoplasia, retinitis pigmentosa, seizures, short stature, hepato- and splenomegaly, anaemia, recurrent vomiting and inverted mamillae. A severe form of tetralogy of Fallot was diagnosed and corrective surgery was performed at the age of 10 months. At the end of the cardiopulmonary bypass, a sudden oedematous reaction of the myocardium accompanied by biventricular pump failure was observed immediately after heparin antagonization with protamine sulfate. The patient died seven days after surgery, since myocardial function did not recover on ECMO support. We here describe the first patient carrying the homozygous variant g.18313A > T in the PMM2 gene (NG_009209.1) that either can lead to c.394A > T (p.I132F) or even loss of 100 bp due to exon 5 skipping (c.348_447del; p.G117Rfs*4) which is comparable to a null allele. Proliferation and doubling time of the patient's fibroblasts were affected. In addition, we show that the induction of cellular stress by elevating the cell culture temperature to 40 °C led to a decrease of the patients' PMM2 transcript as well as PMM2 protein levels and subsequently to a significant loss of residual activity. We assume that metabolic stressful processes occurring after cardiac surgery led to the drop of the patient's PMM activity below a life-sustaining niveau which paved the way for the fatal outcome.
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Affiliation(s)
- Marlen Görlacher
- Centre for Child and Adolescent Medicine, Department I, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Nastassja Himmelreich
- Centre for Child and Adolescent Medicine, Department I, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Hüllen
- Centre for Child and Adolescent Medicine, Department I, University Hospital Heidelberg, Heidelberg, Germany
| | - Lars Beedgen
- Centre for Child and Adolescent Medicine, Department I, University Hospital Heidelberg, Heidelberg, Germany
| | - Bianca Dimitrov
- Centre for Child and Adolescent Medicine, Department I, University Hospital Heidelberg, Heidelberg, Germany
| | - Virginia Geiger
- Centre for Child and Adolescent Medicine, Department I, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Zielonka
- Centre for Child and Adolescent Medicine, Department I, University Hospital Heidelberg, Heidelberg, Germany
| | - Verena Peters
- Centre for Child and Adolescent Medicine, Department I, University Hospital Heidelberg, Heidelberg, Germany
| | - Sabine Strahl
- Centre for Organismal Studies (COS), Glycobiology, Heidelberg University, Heidelberg, Germany
| | | | - Gunter Kerst
- Department of Pediatric Cardiology, University Hospital RWTH, Aachen, Germany
| | - Christian Thiel
- Centre for Child and Adolescent Medicine, Department I, University Hospital Heidelberg, Heidelberg, Germany
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79
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Goedhart ALM, Gerritse BM, Rettig TCD, van Geldorp MWA, Bramer S, van der Meer NJM, Boonman-de Winter LJ, Scohy TV. A 0.6-protamine/heparin ratio in cardiac surgery is associated with decreased transfusion of blood products. Interact Cardiovasc Thorac Surg 2020; 31:391-397. [PMID: 32620960 DOI: 10.1093/icvts/ivaa109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/09/2020] [Accepted: 05/23/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES In cardiac surgery, adequate heparinization is necessary to prevent thrombus formation in the cardiopulmonary bypass (CPB). To counteract the heparin effect after weaning from CPB, protamine is administered. The optimal protamine/heparin ratio is still unknown. METHODS In this before-after study, we evaluated the effect of a 0.6/1-protamine/heparin ratio implementation as of May 2017 versus a 0.8/1-protamine/heparin ratio on the 12-h postoperative blood loss and the amount of blood and blood component transfusions (fresh frozen plasma, packed red blood cells, fibrinogen concentrate, platelet concentrate and prothrombin complex concentrate) after cardiac surgery. A total of 2051 patients who underwent cardiac surgery requiring CPB between May 2016 and May 2018 were included. RESULTS In the 0.6/1-protamine/heparin ratio group, only 28.8% of the patients received blood component transfusion, compared to 37.9% of the patients in the 0.8/1-ratio group (P < 0.001). The median 12-h postoperative blood loss was 230 ml (interquartile range 140-320) in the 0.6/1-ratio group versus 260 ml (interquartile range 155-365) in the 0.8/1-ratio group (P < 0.001). CONCLUSIONS A 0.6/1-protamine/heparin ratio after weaning from CPB is associated with a significantly reduced 12-h postoperative blood loss and blood components transfusion.
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Affiliation(s)
- Anne L M Goedhart
- Department of Anaesthesiology and Intensive Care, Amphia Hospital, Breda, Netherlands
| | - Bastiaan M Gerritse
- Department of Anaesthesiology and Intensive Care, Amphia Hospital, Breda, Netherlands
| | - Thijs C D Rettig
- Department of Anaesthesiology and Intensive Care, Amphia Hospital, Breda, Netherlands
| | | | - Sander Bramer
- Department of Cardiothoracic Surgery, Amphia Hospital, Breda, Netherlands
| | | | | | - Thierry V Scohy
- Department of Anaesthesiology and Intensive Care, Amphia Hospital, Breda, Netherlands
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80
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Al Hussein H, Al Hussein H, Sircuta C, Cotoi OS, Movileanu I, Nistor D, Cordos B, Deac R, Suciu H, Brinzaniuc K, Simionescu DT, Harpa MM. Challenges in Perioperative Animal Care for Orthotopic Implantation of Tissue-Engineered Pulmonary Valves in the Ovine Model. Tissue Eng Regen Med 2020; 17:847-862. [PMID: 32860183 DOI: 10.1007/s13770-020-00285-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Development of valvular substitutes meeting the performance criteria for surgical correction of congenital heart malformations is a major research challenge. The sheep is probably the most widely used animal model in heart valves regenerative medicine. Although the standard cardiopulmonary bypass (CPB) technique and various anesthetic and surgical protocols are reported to be feasible and safe, they are associated with significant morbidity and mortality rates. The premise of this paper is that the surgical technique itself, especially the perioperative animal care and management protocol, is essential for successful outcomes and survival. METHODS Ten juvenile and adult female sheep aged 7.8-37.5 months and weighing 32.0-58.0 kg underwent orthotopic implantation of tissue-engineered pulmonary valve conduits on beating heart under normothermic CPB. The animals were followed-up for 6 months before scheduled euthanasia. RESULTS Based on our observations, we established a guide for perioperative care, follow-up, and treatment containing information regarding the appropriate clinical, biological, and ultrasound examinations and recommendations for feasible and safe anesthetic, surgical, and euthanasia protocols. Specific recommendations were also included for perioperative care of juvenile versus adult sheep. CONCLUSION The described surgical technique was feasible, with a low mortality rate and minimal surgical complications. The proposed anesthetic protocol was safe and effective, ensuring both adequate sedation and analgesia as well as rapid recovery from anesthesia without significant complications. The established guide for postoperative care, follow-up and treatment in sheep after open-heart surgery may help other research teams working in the field of heart valves tissue regeneration.
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Affiliation(s)
- Hussam Al Hussein
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.,The Emergency Institute for Cardiac Diseases and Transplantation of Tirgu Mures, 50 Gh. Marinescu Street, 540136, Tirgu Mures, Romania
| | - Hamida Al Hussein
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.
| | - Carmen Sircuta
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania
| | - Ovidiu S Cotoi
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania
| | - Ionela Movileanu
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.,The Emergency Institute for Cardiac Diseases and Transplantation of Tirgu Mures, 50 Gh. Marinescu Street, 540136, Tirgu Mures, Romania
| | - Dan Nistor
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.,The Emergency Institute for Cardiac Diseases and Transplantation of Tirgu Mures, 50 Gh. Marinescu Street, 540136, Tirgu Mures, Romania
| | - Bogdan Cordos
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania
| | - Radu Deac
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania
| | - Horatiu Suciu
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.,The Emergency Institute for Cardiac Diseases and Transplantation of Tirgu Mures, 50 Gh. Marinescu Street, 540136, Tirgu Mures, Romania
| | - Klara Brinzaniuc
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania
| | - Dan T Simionescu
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.,Clemson University, 306 Rhodes Annex, Clemson, SC, 29634, USA
| | - Marius M Harpa
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.,The Emergency Institute for Cardiac Diseases and Transplantation of Tirgu Mures, 50 Gh. Marinescu Street, 540136, Tirgu Mures, Romania
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81
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Huang Q, Zhao H, Shui M, Guo DS, Wang R. Heparin reversal by an oligoethylene glycol functionalized guanidinocalixarene. Chem Sci 2020; 11:9623-9629. [PMID: 34094229 PMCID: PMC8162181 DOI: 10.1039/d0sc03922e] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 08/10/2020] [Indexed: 02/02/2023] Open
Abstract
Unfractionated heparin (UFH), a naturally occurring anionic polysaccharide, is widely used as an anticoagulant agent in clinical practice. When overdosed or used in sensitive patients, UFH may cause various risks and a UFH neutralizer needs to be administered immediately to reverse heparinization. However, the most common UFH neutralizer, protamine sulfate, often causes various adverse effects, some of which are life-threatening. Herein, we designed a highly biocompatible, oligoethylene glycol functionalized guanidinocalixarene (GC4AOEG) as an antidote against UFH. GC4AOEG and UFH exhibited a strong binding affinity, ensuring specific recognition and neutralization of UFH by GC4AOEG in vitro and in vivo. As a consequence, UFH-induced excessive bleeding was significantly alleviated by GC4AOEG in different mouse bleeding models. Additionally, no adverse effects were observed during these treatments in vivo. Taken together, GC4AOEG, as a strategically designed, biocompatible artificial receptor with strong recognition affinity towards UFH, may have significant clinical potential as an alternative UFH reversal agent.
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Affiliation(s)
- Qiaoxian Huang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau Macau SAR China
| | - Hong Zhao
- College of Chemistry, Key Laboratory of Functional Polymer Materials (Ministry of Education), State Key Laboratory of Elemento-Organic Chemistry, Nankai University Tianjin China
| | - Mingju Shui
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau Macau SAR China
| | - Dong-Sheng Guo
- College of Chemistry, Key Laboratory of Functional Polymer Materials (Ministry of Education), State Key Laboratory of Elemento-Organic Chemistry, Nankai University Tianjin China
| | - Ruibing Wang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau Macau SAR China
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82
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Bolliger D, Maurer M, Tanaka KA. Toward Optimal Anticoagulation Monitoring During Cardiopulmonary Bypass: It Is Still A Tough "ACT". J Cardiothorac Vasc Anesth 2020; 34:2928-2930. [PMID: 32741612 DOI: 10.1053/j.jvca.2020.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 07/06/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Daniel Bolliger
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Markus Maurer
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland Medical Center, Baltimore, Maryland
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83
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Bouchez S, De Somer F. The evolving role of the modern perfusionist: insights from transesophageal echocardiography. Perfusion 2020; 36:222-232. [PMID: 32729372 DOI: 10.1177/0267659120944094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transesophageal echocardiography is a relatively non-invasive, mobile, safe imaging technique that is ideal for providing real-time information on cardiac anatomy and function during heart surgery. The technology has evolved from two-dimensional to real-time three-dimensional imaging during cardiac procedures, which has significantly benefited preoperative planning, intraoperative guidance, evaluation, and postoperative follow-up. Transesophageal echocardiography may serve the clinical perfusionist by providing imaging guidance for identifying potential problems before cardiopulmonary bypass, guiding the proper placement of cannulas, monitoring cardiac performance on cardiopulmonary bypass, and providing useful feedback during weaning from cardiopulmonary bypass. Although the perfusionist should be able to understand all echocardiographic images and measurements in depth, perfusion-related echocardiographic information can or should be used to optimize the clinical practice of the modern perfusionist. Vice versa, whenever the perfusionist suspects a problem, the surgical team including the sonographer should verify this "clinical treat" by echocardiography whenever possible.
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Affiliation(s)
- Stefaan Bouchez
- Department of Anesthesiology, Ghent University Hospital, Ghent, Belgium
| | - Filip De Somer
- Department of Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
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84
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Auci E, Vetrugno L, Riccardi I, Brussa A, Orso D, Baroselli A, Gigante A, Cecotti R, Bassi F, Livi U, Bove T. Multiple Electrode Aggregometry After Cardiopulmonary Bypass to Assess Platelet (Dys)-Function and Transfusion Threshold: A Concordance Study. J Cardiothorac Vasc Anesth 2020; 34:3306-3313. [PMID: 32684430 DOI: 10.1053/j.jvca.2020.06.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/31/2020] [Accepted: 06/17/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Cardiac surgery patients have a high risk of postoperative bleeding. Historically, the platelet count has been one of the main parameters used to establish the need for platelet transfusions, and the recent introduction of point-of-care tests for platelet function has allowed clinicians to rationalize platelet transfusion needs by assessing the platelet (dys-)function of the patient. For the present study, the authors evaluated how the introduction of one of these systems-the adenosine diphosphate (ADP) test, performed using a Multiplate electrode analyzer (Roche Diagnostics, Basel, Switzerland)-into their clinical practice had modified their platelet transfusion practice. The relationship between the platelet count and the functional evaluation of platelet aggregation (via the ADP test) also was examined. DESIGN This was a retrospective, single-center, observational study. SETTING Cardiac surgery department of a tertiary care center in North-east Italy. PARTICIPANTS Cardiac surgery patients requiring cardiac bypass in 2017 and 2019. INTERVENTIONS The primary outcome was to compare platelet transfusion practice before and after the implementation of a platelet function test (the ADP test) into the institution's transfusion algorithm, which replaced the platelet count as the trigger. Secondary outcomes were assessing whether the incorporation of the ADP test into their transfusion algorithm brought about a reduction in the frequency of platelet transfusions compared with previous rates (when only platelets counts were used); assessing patient blood loss in the first 12 postoperative hours; and ascertaining the percentage of patients requiring surgical reexplorations. MEASUREMENTS AND MAIN RESULTS The study comprised 110 patients undergoing cardiac surgery from the platelet count period (2017) and 110 patients from the ADP test period (2019). Agreement between platelet counts versus ADP tests in determining the need for platelet transfusion was moderate (κ = 0.483; 95% confidence interval [CI] 0.239-0.728), and the general linear regression relationship between platelet counts and the ADP test (Akaike information criterion = 2536; p < 0.001) was determined. Since the introduction of ADP testing, a highly significant reduction in platelet transfusions has occurred: 41.82% (platelet count period) versus 13.64% (ADP test period) (p < 0.001); average blood loss in the 12 hours postsurgery also was less in the ADP test period (p < 0.001) at 300 mL (95% CI 150-730) compared with 440 mL in the platelet count period (95% CI 135-900). Furthermore, a decreasing trend was observed in the number of patients requiring reexploration to optimize hemostasis in the first 12 hours postsurgery (6.36% v 2.73%); however, this trend did not achieve statistical significance (p = 0.195). CONCLUSION The application of new Multiplate analyzer technologies, like the ADP test, have the potential to reduce platelet transfusion rates in cardiac surgery patients compared with the use of platelet counts alone; this point-of-care test may constitute an important strategy to help spare the use of allogeneic blood products. Additional studies are needed to confirm this trend and establish the best cutoff values to apply.
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Affiliation(s)
- Elisabetta Auci
- Department of Anesthesia and Intensive Care Medicine, ASUFC "Santa Maria della Misericordia" University Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Anesthesia and Intensive Care Clinic, ASUFC "Santa Maria della Misericordia" University Hospital of Udine, Udine, Italy; Department of Medicine, University of Udine, Udine, Italy.
| | - Ilaria Riccardi
- Department of Anesthesia and Intensive Care Clinic, ASUFC "Santa Maria della Misericordia" University Hospital of Udine, Udine, Italy
| | - Alessandro Brussa
- Department of Anesthesia and Intensive Care Clinic, ASUFC "Santa Maria della Misericordia" University Hospital of Udine, Udine, Italy
| | - Daniele Orso
- Department of Medicine, University of Udine, Udine, Italy
| | - Antonio Baroselli
- Department of Anesthesia and Intensive Care Medicine, ASUFC "Santa Maria della Misericordia" University Hospital of Udine, Udine, Italy
| | - Andrea Gigante
- Department of Anesthesia and Intensive Care Medicine, ASUFC "Santa Maria della Misericordia" University Hospital of Udine, Udine, Italy
| | - Roberta Cecotti
- Department of Anesthesia and Intensive Care Medicine, ASUFC "Santa Maria della Misericordia" University Hospital of Udine, Udine, Italy
| | - Flavio Bassi
- Department of Anesthesia and Intensive Care Medicine, ASUFC "Santa Maria della Misericordia" University Hospital of Udine, Udine, Italy
| | - Ugolino Livi
- Department of Cardiothoracic Surgery, ASUFC "Santa Maria della Misericordia" University Hospital of Udine, Udine, Italy; Department of Medicine, University of Udine, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care Clinic, ASUFC "Santa Maria della Misericordia" University Hospital of Udine, Udine, Italy; Department of Medicine, University of Udine, Udine, Italy
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85
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Mujer MT, Al-Abcha A, Flores J, Saleh Y, Robinson P. A comparison of figure-of-8-suture versus manual compression for venous access closure after cardiac procedures: An updated meta-analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:856-865. [PMID: 32638389 DOI: 10.1111/pace.14008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/09/2020] [Accepted: 07/05/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Manual compression (MC) is the current standard to achieve postprocedural hemostasis in patients who need venous vascular access closure after cardiovascular procedures. Figure-of-8 (F8) suture for venous access closure has been reported to be a safe and efficacious alternative to MC. METHODS A systematic search was done using PubMed, Google Scholar, EMBASE, SCOPUS, and ClinicalTrials.gov without language restriction up until April 15, 2020 for studies comparing F8 suture versus MC. Risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI) were calculated using a random effects model. RESULTS Time to achieve hemostasis was significantly reduced in the F8 arm [MD -21.04 min (95% CI: -35.66 to -6.42; P = .005)]. Access site bleeding was significantly lower in the F8 group [RR 0.35 (95% CI: 0.18 to 0.66; P = .001)] along with a lower incidence of hematoma formation [RR 0.42 (95% CI: 0.26 to 0.67; P = .0003)]. There was no significant difference in rates of fistula or pseudoaneurysm formation between the two groups. Overall access site complications were lower in the F8 arm [RR 0.38 (95% CI: 0.26 to 0.55; P < .00001)] and the effect was more pronounced for sheaths ≥10 Fr [RR 0.33 (95% CI: 0.18 to 0.60; P = .0003)]. There was lower postprocedural protamine use in the F8 group [RR 0.07 (95% CI: 0.01 to 0.36; P = .001)]. CONCLUSION For large-bore venous access closure, the F8 suture results in a shortened time to achieve hemostasis along with a lower overall risk of access site complications and postprocedural protamine use.
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Affiliation(s)
- Mark Terence Mujer
- Department of Medicine, Michigan State University, East Lansing, Michigan
| | - Abdullah Al-Abcha
- Department of Medicine, Michigan State University, East Lansing, Michigan
| | - Jairus Flores
- University of the Philippines College of Medicine, Manila, Philippines
| | - Yehia Saleh
- Department of Medicine, Michigan State University, East Lansing, Michigan
| | - Peter Robinson
- Pat and Jim Calhoun Cardiology Center, University of Connecticut, Farmington, Connecticut
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86
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Neuroprotective Cationic Arginine-Rich Peptides (CARPs): An Assessment of Their Clinical Safety. Drug Saf 2020; 43:957-969. [DOI: 10.1007/s40264-020-00962-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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87
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Honda M, Matsumoto M, Aizawa M. Potential Application of Protamine for Antimicrobial Biomaterials in Bone Tissue Engineering. Int J Mol Sci 2020; 21:E4368. [PMID: 32575446 PMCID: PMC7352774 DOI: 10.3390/ijms21124368] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 12/15/2022] Open
Abstract
Bacterial infection of biomaterials is a serious problem in the field of medical devices. It is urgently necessary to develop new biomaterials with bactericidal activity. Antimicrobial peptides and proteins (AMPs), alternative antibacterial agents, are expected to overcome the bacterial resistance. The aim of this study was to develop a new intelligent material in bone tissue engineering based on protamine-loaded hydroxyapatite (protamine/HAp) that uses AMPs rather than antibiotics. It was found that the adsorption of protamine to HAp followed the Langmuir adsorption model and was due to electrostatic and/or hydrophobic interactions. In vitro bacterial adhesion and growth on protamine/HAp was inhibited in a protamine dose-dependent manner. Adherent bacteria exhibited an aberrant morphology for high dosages of protamine/HAp, resulting in the formation of large aggregates and disintegration of the membrane. The released protamine from protamine/HAp also prevented the growth of planktonic bacteria in vitro. However, a high dosage of protamine from powders at loading concentrations over 1000 μg·mL-1 induced a cytotoxic effect in vitro, although those exhibited no apparent cytotoxicity in vivo. These data revealed that protamine/HAp (less than 1000 μg·mL-1) had both antimicrobial activity and biocompatibility and can be applied for bone substitutes in orthopedic fields.
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Affiliation(s)
- Michiyo Honda
- Department of Applied Chemistry, School of Science and Technology, Meiji University, Kanagawa 214-8571, Japan;
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo 160-8582, Japan;
| | - Mamoru Aizawa
- Department of Applied Chemistry, School of Science and Technology, Meiji University, Kanagawa 214-8571, Japan;
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88
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Veerhoek D, van Barneveld LJ, Haumann RG, Kamminga SK, Vonk AB, Boer C, Symersky P. Anticoagulation management during pulmonary endarterectomy with cardiopulmonary bypass and deep hypothermic circulatory arrest. Perfusion 2020; 36:87-96. [PMID: 32522088 DOI: 10.1177/0267659120928682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Pulmonary endarterectomy requires cardiopulmonary bypass and deep hypothermic circulatory arrest, which may prolong the activated clotting time. We investigated whether activated clotting time-guided anticoagulation under these circumstances suppresses hemostatic activation. METHODS Individual heparin sensitivity was determined by the heparin dose-response test, and anticoagulation was monitored by the activated clotting time and heparin concentration. Perioperative hemostasis was evaluated by thromboelastometry, platelet aggregation, and several plasma coagulation markers. RESULTS Eighteen patients were included in this study. During cooling, tube-based activated clotting time increased from 719 (95% confidence interval = 566-872 seconds) to 1,273 (95% confidence interval = 1,136-1,410 seconds; p < 0.01) and the cartridge-based activated clotting time increased from 693 (95% confidence interval = 590-796 seconds) to 883 (95% confidence interval = 806-960 seconds; p < 0.01), while thrombin-antithrombin showed an eightfold increase. The heparin concentration showed a slightly declining trend during cardiopulmonary bypass. After protamine administration (protamine-to-heparin bolus ratio of 0.82 (0.71-0.90)), more than half of the patients showed an intrinsically activated coagulation test and intrinsically activated coagulation test without heparin effect clotting time >240 seconds. Platelet aggregation through activation of the P2Y12 (adenosine diphosphate test) and thrombin receptor (thrombin receptor activating peptide-6 test) decreased (both -33%) and PF4 levels almost doubled (from 48 (95% confidence interval = 42-53 ng/mL) to 77 (95% confidence interval = 71-82 ng/mL); p < 0.01) between weaning from cardiopulmonary bypass and 3 minutes after protamine administration. CONCLUSION This study shows a wide variation in individual heparin sensitivity in patients undergoing pulmonary endarterectomy with deep hypothermic circulatory arrest. Although activated clotting time-guided anticoagulation management may underestimate the level of anticoagulation and consequently result in a less profound inhibition of hemostatic activation, this study lacked power to detect adverse outcomes.
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Affiliation(s)
- Dennis Veerhoek
- Department of Cardio-Thoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Laurentius Jm van Barneveld
- Department of Cardio-Thoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Renard G Haumann
- Department of Cardio-Thoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Suzanne K Kamminga
- Department of Anesthesiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Alexander Ba Vonk
- Department of Cardio-Thoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Christa Boer
- Department of Anesthesiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Petr Symersky
- Department of Cardio-Thoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands
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89
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Chan M, Wong A. Management and monitoring of large enoxaparin overdose treated with protamine. Emerg Med Australas 2020; 32:712-713. [PMID: 32524713 DOI: 10.1111/1742-6723.13551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 05/02/2020] [Accepted: 05/10/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Michael Chan
- General Medicine Department, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anselm Wong
- Victorian Poisons Information Centre and Emergency Department, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Department of Medicine and Radiology, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
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90
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Braatz E, Sesartic V, Liska J. Will high-dose heparin affect blood loss and inflammatory response in patients undergoing cardiopulmonary bypass? Perfusion 2020; 36:63-69. [PMID: 32493115 DOI: 10.1177/0267659120924917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION We performed a randomized study to investigate if a high versus a standard dose of heparin dose during cardiopulmonary bypass could affect intra- and post-operative bleeding and reduce the inflammatory response. METHODS A total of 30 patients undergoing elective coronary artery bypass grafting were randomized into high or standard dose of heparin during cardiopulmonary bypass. Blood loss was documented peri- and post-operatively, and interleukin-6, tumor necrosis factor-α, and C3 were measured in conjunction with cardiopulmonary bypass. RESULTS Data from 29 patients were analyzed after exclusion of one patient. The mean initial bolus and total heparin doses were 43,000 ± 5,800 IU versus 35,000 ± 4,100 IU, (p < 0.001), and 58,000 ± 9,500 IU versus 45,000 ± 7,900 IU, (p < 0.001) in the intervention and the control group, respectively. The median intra-operative bleeding was 150 mL (interquartile range 100-325) in the control versus 225 mL (IQR 200-350) in the intervention group, p = 0.15. The median chest tube blood loss 12 hour post-operatively was 300 mL (interquartile range 250-385) in the control versus 450 mL (IQR 315-505) in the intervention group, p = 0.029. There was no significant difference between the control group and the intervention group during cardiopulmonary bypass for the measured inflammatory markers interleukin-6 (p = 0.98), tumor necrosis factor-α (p = 0.72), or C3 (p = 0.13). CONCLUSION This small study showed a small increase of post-operative bleeding associated with higher heparin dosage in conjunction with cardiopulmonary bypass but did not demonstrate an effect of heparin on the inflammatory response to cardiopulmonary bypass.
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Affiliation(s)
- Erik Braatz
- Department of Perioperative Medicine & Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Vanja Sesartic
- Department of Perioperative Medicine & Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Liska
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
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91
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Pieterse J, Valchanov K, Abu-Omar Y, Falter F. Thrombotic risk in central venoarterial extracorporeal membrane oxygenation post cardiac surgery. Perfusion 2020; 36:50-56. [DOI: 10.1177/0267659120922016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Post-cardiotomy cardiogenic shock is an accepted indication for venoarterial extracorporeal membrane oxygenation. The true incidence and risk factors for the development of thrombosis in this setting remain unclear. Methods: Patients supported with central venoarterial extracorporeal membrane oxygenation due to ventricular dysfunction precluding weaning from cardiopulmonary bypass were retrospectively identified. Electronic records from a single institution spanning a 4-year period from January 2015 to December 2018 were interrogated to assess the incidence of thrombosis. The relationship to exposures including intracardiac stasis and procoagulant usage was explored. Results: Twenty-four patients met the inclusion criteria and six suffered major intracardiac thrombosis. All cases of thrombosis occurred early, and none survived to hospital discharge. The lack of left ventricular ejection conferred a 46% risk of developing thrombosis compared to 0% if ejection was maintained (p = 0.0093). Aprotinin use was also associated with thrombus formation (p = 0.035). There were no significant differences between numbers of patients receiving other procoagulants when grouped by thrombosis versus no thrombosis. Conclusion: Stasis is the predominant risk factor for intracardiac thrombosis. This occurs rapidly and the outcome is poor. As a result, we suggest early left ventricular decompression. Conventional management of post-bypass coagulopathy seems safe if the aortic valve is opening.
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Affiliation(s)
- John Pieterse
- Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Kamen Valchanov
- Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Yasir Abu-Omar
- Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Florian Falter
- Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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92
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Are We Able to Dose Protamine Accurately Yet? A Review of the Protamine Conundrum. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:63-70. [PMID: 32280146 DOI: 10.1182/ject-1900038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/11/2020] [Indexed: 01/01/2023]
Abstract
Without anticoagulation, cardiopulmonary bypass would not have developed over the last nearly 60 years into one of the most influential innovations in medicine; without the ability to reverse anticoagulation, cardiac surgery might not have become the common intervention, which is now practiced globally. Despite the recent breathtaking developments in extracorporeal technology, heparin and protamine remain the pillars of anticoagulation and its reversal until this day. However, there is still much controversy in particular about protamine dosing regimens. A number of recent publications investigating various approaches to dosing protamine have rekindled this debate. This review is seeking to capture the current thinking about protamine dosing after cessation of cardiopulmonary bypass.
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93
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Krizek T, Molnarova K, Pavlu V, Filounova B, Martinkova E. Interaction of heparin and tetraarginine in capillary electrophoresis: Implication for analytical applications. Electrophoresis 2020; 41:1826-1831. [DOI: 10.1002/elps.202000011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/20/2020] [Accepted: 03/23/2020] [Indexed: 01/28/2023]
Affiliation(s)
- Tomas Krizek
- Department of Analytical Chemistry Faculty of Science Charles University Prague Czech Republic
| | - Katarina Molnarova
- Department of Analytical Chemistry Faculty of Science Charles University Prague Czech Republic
| | - Vera Pavlu
- Department of Analytical Chemistry Faculty of Science Charles University Prague Czech Republic
| | - Barbora Filounova
- Department of Analytical Chemistry Faculty of Science Charles University Prague Czech Republic
| | - Eva Martinkova
- Department of Analytical Chemistry Faculty of Science Charles University Prague Czech Republic
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94
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Thrombin generation and bleeding in cardiac surgery: a clinical narrative review. Can J Anaesth 2020; 67:746-753. [PMID: 32133581 DOI: 10.1007/s12630-020-01609-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 12/27/2022] Open
Abstract
This narrative review discusses the role of thrombin generation in coagulation and bleeding in cardiac surgery, the laboratory methods for clinical detection of impaired thrombin generation, and the available hemostatic interventions that can be used to improve thrombin generation. Coagulopathy after cardiopulmonary bypass (CPB) is associated with excessive blood loss and adverse patient outcomes. Thrombin plays a crucial role in primary hemostasis, and impaired thrombin generation can be an important cause of post-CPB coagulopathy. Existing coagulation assays have significant limitations in assessing thrombin generation, but whole-blood assays designed to measure thrombin generation at the bed-side are under development. Until then, clinicians may need to institute therapy empirically for non-surgical bleeding in the setting of normal coagulation measures. Available therapies for impaired thrombin generation include administration of plasma, prothrombin complex concentrate, and bypassing agents (recombinant activated factor VII and factor eight inhibitor bypassing activity). In vitro experiments have explored the relative potency of these therapies, but clinical studies are lacking. The potential incorporation of thrombin generation assays into clinical practice and treatment algorithms for impaired thrombin generation must await further clinical development.
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95
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Boorman S, Douglas H, Driessen B, Gillespie MJ, Schaer TP. Fatal Ovarian Hemorrhage Associated With Anticoagulation Therapy in a Yucatan Mini-Pig Following Venous Stent Implantation. Front Vet Sci 2020; 7:18. [PMID: 32083102 PMCID: PMC7002391 DOI: 10.3389/fvets.2020.00018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 01/10/2020] [Indexed: 01/10/2023] Open
Abstract
Swine models are commonly utilized in endovascular research for development of intravascular interventions and medical device development. As part of a pilot study for a venous vascular stent device, a 5-year-old female Yucatan mini-pig underwent bilateral external iliac vein stent placement under general anesthesia. To reduce thrombotic complications by reduction of thrombus formation on wires, sheaths, and catheters, the pig was heparinized with a total of 300 IU/kg of heparin, establishing an activated clotting time (ACT) of 436 s. The ACT had returned to below 200 s by the end of the procedure. To prevent postoperative thrombosis, the pig received an anticoagulation therapy protocol consisting of enoxaparin, clopidogrel, and aspirin. There were no complications during the immediate postoperative period. However, the pig died 4 days after surgery. Necropsy established the cause of death as abdominal exsanguination due to severe, acute, intra-ovarian hemorrhage, most likely related to ovulation. Life-threatening ovarian hemorrhage is occasionally seen in women with congenital or acquired bleeding disorders; to our knowledge this is the first report of fatal ovarian hemorrhage in an animal enrolled in a pre-clinical research trial.
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Affiliation(s)
- Sophie Boorman
- Department of Clinical Sciences, College of Veterinary Medicine, JT Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, United States
| | - Hope Douglas
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Bernd Driessen
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Matthew J Gillespie
- Department of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Thomas P Schaer
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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96
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Puis L, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Wahba A. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Interact Cardiovasc Thorac Surg 2020; 30:161-202. [PMID: 31576402 PMCID: PMC10634377 DOI: 10.1093/icvts/ivz251] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav s University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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97
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Törnudd M, Ramström S, Kvitting JPE, Alfredsson J, Pihl R, Berg S. Protamine stimulates platelet aggregation in vitro with activation of the fibrinogen receptor and alpha-granule release, but impairs secondary activation via ADP and thrombin receptors. Platelets 2020; 32:90-96. [PMID: 31992110 DOI: 10.1080/09537104.2020.1719992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Heparin and protamine are fundamental in the management of anticoagulation during cardiac surgery. Excess protamine has been associated with increased bleeding. Interaction between protamine and platelet function has been demonstrated but the mechanism remains unclear. We examined the effect of protamine on platelet function in vitro using impedance aggregometry, flow cytometry, and thrombin generation. Platelets were exposed to protamine at final concentrations of 0, 20, 40, and 80 µg/mL, alone or together with adenosine diphosphate (ADP) or thrombin PAR1 receptor-activating peptide (TRAP). We found that in the absence of other activators, protamine (80 µg/mL) increased the proportion of platelets with active fibrinogen receptor (binding of PAC-1) from 3.6% to 97.0% (p < .001) measured with flow cytometry. Impedance aggregometry also increased slightly after exposure to protamine alone. When activated with ADP or TRAP protamine at 80 µg/mL reduced aggregation, from 73.8 ± 29.4 U to 46.9 ± 21.1 U (p < .001) with ADP and from 126.4 ± 16.1 U to 94.9 ± 23.7 U (p < .01) with TRAP. P-selectin exposure (a marker of alpha-granule release) measured by median fluorescence intensity (MFI) increased dose dependently with protamine alone, from 0.76 ± 0.20 (0 µg/mL) to 10.2 ± 3.1 (80 µg/mL), p < .001. Protamine 80 µg/mL by itself resulted in higher MFI (10.16 ± 3.09) than activation with ADP (2.2 ± 0.7, p < .001) or TRAP (5.7 ± 2.6, p < .01) without protamine. When protamine was combined with ADP or TRAP, there was a concentration-dependent increase in the alpha-granule release. In conclusion, protamine interacts with platelets in vitro having both a direct activating effect and impairment of secondary activation of aggregation by other agonists.
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Affiliation(s)
- Mattias Törnudd
- Department of Cardiothoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden
| | - Sofia Ramström
- Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University , Linköping, Sweden.,Cardiovascular Research Centre, School of Medical Sciences, Örebro University , Örebro, Sweden
| | | | - Joakim Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden
| | - Richard Pihl
- Department of Cardiothoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden.,Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University , Linköping, Sweden
| | - Sören Berg
- Department of Cardiothoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden
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98
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Kunst G, Milojevic M, Boer C, De Somer FM, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Puis L, Wahba A, Alston P, Fitzgerald D, Nikolic A, Onorati F, Rasmussen BS, Svenmarker S. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Br J Anaesth 2019; 123:713-757. [DOI: 10.1016/j.bja.2019.09.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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99
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Meesters MI, von Heymann C. Optimizing Perioperative Blood and Coagulation Management During Cardiac Surgery. Anesthesiol Clin 2019; 37:713-728. [PMID: 31677687 DOI: 10.1016/j.anclin.2019.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Bleeding and transfusion are common in cardiac surgery and associated with poorer outcome. Bleeding is frequently due to coagulopathy caused by the complex interaction between cardiopulmonary bypass, major surgical trauma, anticoagulation management, and perioperative factors. Patient blood management has emerged to improve outcome by the prediction, prevention, monitoring, and treatment of bleeding and transfusion. Each part of this chain has several individual modalities and when combined leads to result in a better outcome. This article reviews the hemostasis disturbances in cardiac surgery with cardiopulmonary bypass and gives an overview of the most important patient blood management strategies.
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Affiliation(s)
- Michael Isaäc Meesters
- Department of Anesthesiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584 CX, the Netherlands.
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, Berlin 10249, Germany
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100
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Gan Y, Yang Z, Mei W, Zhu C. Identifying optimal heparin management during cardiopulmonary bypass in Chinese people: a retrospective observational comparative study. J Thromb Thrombolysis 2019; 49:480-486. [PMID: 31701359 DOI: 10.1007/s11239-019-01987-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Traditionally heparin is adapted according to total body weight (TBW) to providing anticoagulation during cardiopulmonary bypass (CPB), but it may be inaccurate in some patients. The medical records of 100 adult patients who received CPB in Tongji Hospital of Tongji Medical College Huazhong University of Science and Technology over a 10-month period in 2017 were included in the retrospective study. An unfractionated heparin (UFH) bolus of 300 IU/kg TBW was injected before initiation of CPB followed by additional doses (50 to 100 IU/kg) to maintain a target activated coagulation time (ACT) of at least 480 s. We used TBW, ideal body weight (IBW), lean body weight (LBW), or body mass index (BMI) to establish and evaluate a linear model of ACT and the amount of heparin respectively. The linear fit effect of the model based on BMI on the original data is better than the others. As the instruments to measure heparin concentration is unavailable in most medical institutions in China. The new linear model based on BMI is helpful to estimate a more individualized heparin dosage in the heparinized phase and to provide useful reference to the amount of remaining heparin in the neutralization phase.
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Affiliation(s)
- Yongbo Gan
- School of Mathematics and Statistics, Wuhan University, Wuhan, 430072, Hubei, China
| | - Zhijian Yang
- School of Mathematics and Statistics, Wuhan University, Wuhan, 430072, Hubei, China
| | - Wei Mei
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Chang Zhu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
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