51
|
Noui N, Zogheib E, Walczak K, Werbrouck A, Amar AB, Dupont H, Caus T, Remadi JP. Anticoagulation monitoring during extracorporeal circulation with the Hepcon/HMS device. Perfusion 2012; 27:214-20. [DOI: 10.1177/0267659112436632] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective: The objective of our study was to compare the standard protocol of anticoagulation to the Hepcon/HMS. Method: This study included forty-four patients who underwent coronary bypass grafting surgery (CABG), or biological aortic valve replacement (AVR). Unfractionated heparin (UH) was used for patients who underwent operations in the control group (n = 22) (300U/Kg of UH with a goal of an ACT of 400s). The heparin was antagonized dose/dose by protamine. For the patients who underwent operations in the HMS group (n = 22), the heparin and protamine doses were assessed by the Hepcon/HMS device. Results: The sex ratio amounted to 1.93 (29 men and 15 women) and the mean age was 70 ± 11 years. The patients in the HMS group had a chest closure time that was significantly shorter than patients in the control group. The times were, respectively, 42 ± 15 minutes and 68 ± 27 minutes (p = 0.001). The protamine/heparin ratio was significantly lower in the HMS group (0.62 ± 0.13 vs. 1 ± 0.11) (p = 0.0001). The postoperative bleeding amounted to 804 ± 729 ml in the HMS group versus 1416 ± 1103 in the control group (p = 0.016). In multivariate linear regression analysis, only two independent factors were significantly associated with bleeding: the Hepcon/HMS (OR = 0.1-p = 0.03) and the preoperative hemoglobin rate (OR = 1.4 - p = 0.05). Postoperatively, within 72 hours, the red blood cell transfusion was 1.04 ± 1.5 units for the HMS group and 2.1 ± 1.87 units for the control group (p = 0.05). Conclusion: During cardiac surgery under CPB, heparin and protamine titration with the Hepcon/HMS device could predict a lower protamine dose and lower postoperative bleeding without higher thromboembolic events, and lower perioperative red blood cell transfusion with a shorter chest closure time.
Collapse
Affiliation(s)
- N Noui
- Anesthesiology Unit, South Hospital, Amiens, France
| | - E Zogheib
- Anesthesiology Unit, South Hospital, Amiens, France
| | - K Walczak
- Anesthesiology Unit, South Hospital, Amiens, France
| | - A Werbrouck
- Anesthesiology Unit, South Hospital, Amiens, France
| | - A Ben Amar
- Cardio-vascular Surgery Unit, University Hospital, CHU Amiens, France
| | - H Dupont
- Anesthesiology Unit, South Hospital, Amiens, France
| | - T Caus
- Cardio-vascular Surgery Unit, University Hospital, CHU Amiens, France
| | - JP Remadi
- Cardio-vascular Surgery Unit, University Hospital, CHU Amiens, France
| |
Collapse
|
52
|
Xu B, Wu X, Li H, Tong H, Wang L. Fluorescent detection of heparin by a cationic conjugated polyfluorene probe containing aggregation-induced emission units. POLYMER 2012. [DOI: 10.1016/j.polymer.2011.11.058] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
53
|
Pu K, Zhan R, Liang J, Liu B. Conjugated polyelectrolytes for label-free visual detection of heparin. Sci China Chem 2011. [DOI: 10.1007/s11426-011-4241-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
54
|
Cao R, Li B. A simple and sensitive method for visual detection of heparin using positively-charged gold nanoparticles as colorimetric probes. Chem Commun (Camb) 2011; 47:2865-7. [DOI: 10.1039/c0cc05094f] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
55
|
Gruenwald CE, Manlhiot C, Chan AK, Crawford-Lean L, Foreman C, Holtby HM, Van Arsdell GS, Richards R, Moriarty H, McCrindle BW. Randomized, Controlled Trial of Individualized Heparin and Protamine Management in Infants Undergoing Cardiac Surgery With Cardiopulmonary Bypass. J Am Coll Cardiol 2010; 56:1794-802. [DOI: 10.1016/j.jacc.2010.06.046] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 05/05/2010] [Accepted: 06/06/2010] [Indexed: 11/29/2022]
|
56
|
Lund PE, Wassbäck G, Thomas O, Carlsson T, Schött U. Comparison of two infusion rates of antithrombin concentrate in cardiopulmonary bypass surgery. Perfusion 2010; 25:305-12. [DOI: 10.1177/0267659110377677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Antithrombin concentrate (AT) is used to treat heparin resistance (HR) in cardiac surgery. It is usually given slowly due to the fear of anaphylaxis. This may delay cardiac catheterisation and the start of cardiopulmonary bypass (CPB). HR is often defined as the failure to reach or maintain a target activated clotting time (ACT) despite a standard dose of heparin. It is not generally possible to predict which patients will display HR, although there are known risk factors. Routine early administration of AT before heparinisation is probably not cost-effective. Infusing AT relatively quickly after demonstrating HR may be more cost-effective, while not delaying surgery. The aim of this study is to investigate the safety and side effects of a faster infusion of AT. Methods: Forty patients undergoing elective heart surgery were included and randomised to two groups in a double-blind fashion. Each group received 1000 IU of AT intravenously (IV). One group received a slow infusion (100 IU/min) before full-dose heparinisation. The other group received a fast infusion (250 IU/min). Haemodynamic and respiratory data were recorded. Any adverse effects were noted. Thrombin-antithrombin, anti-Xa and antithrombin levels in plasma were measured. Results: No anaphylaxis occurred in either group. No differences were found regarding haemodynamics, respiration or laboratory results. Two patients experienced major haemorrhage and recovered; there were two deaths, thought to be unrelated to the study drugs. Conclusion: AT can be infused at a rate of 250 IU/min. This is faster than the current recommendation of 100 IU/min. This rate of infusion allows restricting AT infusion to those patients who display HR, without delaying surgery. Optimal anticoagulant therapy for CPB probably includes point-of-care measurement of ACT and plasma AT and small, but rapid, infusions of AT in heparin-resistant patients.
Collapse
Affiliation(s)
- Philip E. Lund
- Örebro University Hospital, Department of Cardiothoracic Anaesthesiology and Intensive Care, Örebro, Sweden
| | | | | | - Tony Carlsson
- Örebro University Hospital, Department of Cardiothoracic Anaesthesiology and Intensive Care, Örebro, Sweden
| | - Ulf Schött
- Lund University Skane University Hospital, Department of Anaesthesiology and Intensive Care, Lund, Sweden,
| |
Collapse
|
57
|
Guzzetta NA, Monitz HG, Fernandez JD, Fazlollah TM, Knezevic A, Miller BE. Correlations Between Activated Clotting Time Values and Heparin Concentration Measurements in Young Infants Undergoing Cardiopulmonary Bypass. Anesth Analg 2010; 111:173-9. [DOI: 10.1213/ane.0b013e3181e13470] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
58
|
Cartwright BL, Bean M, Cooper JO. Lupus Anticoagulant, Antiphospholipid Syndrome and Cardiac Surgery. Anaesth Intensive Care 2010; 38:364-9. [PMID: 20369774 DOI: 10.1177/0310057x1003800220] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The presence of lupus anticoagulant and the related condition antiphospholipid syndrome present a challenge in cardiac surgery where measured anticoagulation may not reflect the in vivo patient status of hypercoagulation. We report the successful management of a patient with lupus anticoagulant presenting for aortic valve replacement and coronary revascularisation. We used heparin for anticoagulation, specialised additional tests of anticoagulation and a reduced protamine dose. We also used tranexamic acid. The clinical problems with anticoagulation in patients with lupus anticoagulant include anticoagulant choice, measurement of adequate anticoagulation, antifibrinolytic usage, protamine dosing and blood product transfusion.
Collapse
Affiliation(s)
- B. L. Cartwright
- Green Lane Department of Cardiothoracic Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - M. Bean
- Green Lane Department of Cardiothoracic Anaesthesia, Auckland City Hospital, Auckland, New Zealand
- Clinical Perfusionist, Department of Clinical Perfusion, Green Lane Cardiovascular Services
| | - J. O. Cooper
- Green Lane Department of Cardiothoracic Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
59
|
Garvin S, FitzGerald DC, Despotis G, Shekar P, Body SC. Heparin concentration-based anticoagulation for cardiac surgery fails to reliably predict heparin bolus dose requirements. Anesth Analg 2009; 111:849-55. [PMID: 19861367 DOI: 10.1213/ane.0b013e3181b79d09] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hemostasis management has evolved to include sophisticated point-of-care systems that provide individualized dosing through heparin concentration-based anticoagulation. The Hepcon HMS Plus system (Medtronic, Minneapolis, MN) estimates heparin dose, activated clotting time (ACT), and heparin dose response (HDR). However, the accuracy of this test has not been systematically evaluated in large cohorts. METHODS We examined institutional databases for all patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) at our institution from February 2005 to July 2008. During this period, the Hepcon HMS Plus was used exclusively for assessment of heparin dosing and coagulation monitoring. Detailed demographic, surgical, laboratory, and heparin dosing data were recorded. ACT, calculated and measured HDR, and heparin concentrations were recorded. Performance of the Hepcon HMS Plus was assessed by comparison of actual and target ACT values and calculated and measured HDR. RESULTS In 3880 patients undergoing cardiac surgery, heparin bolus dosing to a target ACT resulted in wide variation in the postheparin ACT (r(2) = 0.03). The postheparin ACT did not reach the target ACT threshold in 7.4%(i.e., when target ACT was 300 s) and 16.9% (i.e., when target ACT was 350 s) of patients. Similarly, the target heparin level calculated from the HDR did not correlate with the postbolus heparin level, with 18.5% of samples differing by more than 2 levels of the assay. Calculated and measured HDR were not linearly related at any heparin level. CONCLUSIONS The Hepcon HMS Plus system poorly estimates heparin bolus requirements in the pre-CPB period. Further prospective studies are needed to elucidate what constitutes adequate anticoagulation for CPB and how clinicians can reliably and practically assess anticoagulation in the operating room.
Collapse
Affiliation(s)
- Sean Garvin
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA
| | | | | | | | | |
Collapse
|
60
|
Heparin resistance and its incidence in patients undergoing on-pump surgery. COR ET VASA 2009. [DOI: 10.33678/cor.2009.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
61
|
Management of a Patient with Lupus Anticoagulant and Antiphospholipid Syndrome for Off-Pump Coronary Artery Bypass Grafting Using the Hepcon® System. Anesth Analg 2009; 108:1116-9. [PMID: 19299773 DOI: 10.1213/ane.0b013e3181994f88] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
62
|
Dickinson KJ, Troxler M, Homer-Vanniasinkam S. The surgical application of point-of-care haemostasis and platelet function testing. Br J Surg 2008; 95:1317-30. [DOI: 10.1002/bjs.6359] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AbstractBackgroundDisordered coagulation complicates many diseases and their treatments, often predisposing to haemorrhage. Conversely, patients with cardiovascular disease who demonstrate antiplatelet resistance may be at increased thromboembolic risk. Prompt identification of these patients facilitates optimization of haemostatic dysfunction. Point-of-care (POC) tests are performed ‘near patient’ to provide a rapid assessment of haemostasis and platelet function.MethodsThis article reviews situations in which POC tests may guide surgical practice. Their limitations and potential developments are discussed. The paper is based on a Medline and PubMed search for English language articles on POC haemostasis and platelet function testing in surgical practice.ResultsPOC tests identifying perioperative bleeding tendency are already widely used in cardiovascular and hepatic surgery. They are associated with reduced blood loss and transfusion requirements. POC tests to identify thrombotic predisposition are able to determine antiplatelet resistance, predicting thromboembolic risk. So far, however, these tests remain research tools.ConclusionPOC haemostasis testing is a growing field in surgical practice. Such testing can be correlated with improved clinical outcome.
Collapse
Affiliation(s)
- K J Dickinson
- Leeds Vascular Institute, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - M Troxler
- Leeds Vascular Institute, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - S Homer-Vanniasinkam
- Leeds Vascular Institute, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| |
Collapse
|
63
|
Pu KY, Liu B. A Multicolor Cationic Conjugated Polymer for Naked-Eye Detection and Quantification of Heparin. Macromolecules 2008. [DOI: 10.1021/ma801269n] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kan-Yi Pu
- Department of Chemical and Biomolecular Engineering, 4 Engineering Drive 4, National University of Singapore, Singapore 117567, Singapore
| | - Bin Liu
- Department of Chemical and Biomolecular Engineering, 4 Engineering Drive 4, National University of Singapore, Singapore 117567, Singapore
| |
Collapse
|
64
|
Dunning J, Versteegh M, Fabbri A, Pavie A, Kolh P, Lockowandt U, Nashef SAM. Guideline on antiplatelet and anticoagulation management in cardiac surgery. Eur J Cardiothorac Surg 2008; 34:73-92. [PMID: 18375137 DOI: 10.1016/j.ejcts.2008.02.024] [Citation(s) in RCA: 246] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 02/15/2008] [Accepted: 02/19/2008] [Indexed: 01/17/2023] Open
Abstract
This document presents a professional view of evidence-based recommendations around the issues of antiplatelet and anticoagulation management in cardiac surgery. It was prepared by the Audit and Guidelines Committee of the European Association for Cardio-Thoracic Surgery (EACTS). We review the following topics: evidence for aspirin, clopidogrel and warfarin cessation prior to cardiac surgery; perioperative interventions to reduce bleeding including the use of aprotinin and tranexamic acid; the use of thromboelastography to guide blood product usage; protamine reversal of heparin; the use of factor VIIa to control severe bleeding; anticoagulation after mechanical, tissue valve replacement and mitral valve repair; the use of antiplatelets and clopidogrel after cardiac surgery to improve graft patency and reduce thromboembolic complications and thromboprophylaxis in the postoperative period. This guideline is subject to continuous informal review, and when new evidence becomes available. The formal review date will be at 5 years from publication (September 2013).
Collapse
Affiliation(s)
- Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | | | | | | | | | | | | |
Collapse
|
65
|
Comparing the Activated Clotting Times Obtained From 2 Point-of-Care Devices in Patients Receiving Unfractionated Heparin During Percutaneous Coronary Intervention. POINT OF CARE 2008. [DOI: 10.1097/poc.0b013e3181635db0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
66
|
Tůma P, Samcová E, Opekar F, Štulík K. Determination of Intact Heparin by Capillary Electrophoresis with Contactless Conductivity Detection in Background Electrolytes Containing Hydrophilic Polymers. ACTA ACUST UNITED AC 2008. [DOI: 10.1135/cccc20080187] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Intact heparin was characterized and determined in model samples, in infusion solutions and in blood plasma by capillary electrophoresis (CE) with contactless conductivity detection. The CE separation of polydisperse heparin took place in open silica capillaries, in electrolytes containing a polymer (hydroxyethyl)cellulose, poly(ethylene glycol) or dextran. The best separation of heparin from excess inorganic ions present in real samples was attained in a background electrolyte consisting of 0.8 M acetic acid and 1% (w/v) dextran (100 kDa). The limit of detection (LOD) was 1.3 μmol l-1. This electrolyte was used in determination of heparin in blood plasma and in infusion solutions.
Collapse
|
67
|
Milović NM, Behr JR, Godin M, Hou CSJ, Payer KR, Chandrasekaran A, Russo PR, Sasisekharan R, Manalis SR. Monitoring of heparin and its low-molecular-weight analogs by silicon field effect. Proc Natl Acad Sci U S A 2006; 103:13374-9. [PMID: 16938875 PMCID: PMC1569171 DOI: 10.1073/pnas.0604471103] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Indexed: 11/18/2022] Open
Abstract
Heparin is a highly sulfated glycosaminoglycan that is used as an important clinical anticoagulant. Monitoring and control of the heparin level in a patient's blood during and after surgery is essential, but current clinical methods are limited to indirect and off-line assays. We have developed a silicon field-effect sensor for direct detection of heparin by its intrinsic negative charge. The sensor consists of a simple microfabricated electrolyte-insulator-silicon structure encapsulated within microfluidic channels. As heparin-specific surface probes the clinical heparin antagonist protamine or the physiological partner antithrombin III were used. The dose-response curves in 10% PBS revealed a detection limit of 0.001 units/ml, which is orders of magnitude lower than clinically relevant concentrations. We also detected heparin-based drugs such as the low-molecular-weight heparin enoxaparin (Lovenox) and the synthetic pentasaccharide heparin analog fondaparinux (Arixtra), which cannot be monitored by the existing near-patient clinical methods. We demonstrated the specificity of the antithrombin III functionalized sensor for the physiologically active pentasaccharide sequence. As a validation, we showed correlation of our measurements to those from a colorimetric assay for heparin-mediated anti-Xa activity. These results demonstrate that silicon field-effect sensors could be used in the clinic for routine monitoring and maintenance of therapeutic levels of heparin and heparin-based drugs and in the laboratory for quantitation of total amount and specific epitopes of heparin and other glycosaminoglycans.
Collapse
Affiliation(s)
| | | | - Michel Godin
- *Biological Engineering Division, Departments of
| | | | - Kristofor R. Payer
- Microsystems Technology Laboratories, Massachusetts Institute of Technology, Cambridge, MA 02139
| | | | | | | | - Scott R. Manalis
- *Biological Engineering Division, Departments of
- Electrical Engineering and Computer Science and
| |
Collapse
|
68
|
|