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Which factors have a great impact on coagulopathy and hemostatic impairment after cardiopulmonary bypass in cardiovascular surgery? An analysis based on rotational thromboelastometry. Gen Thorac Cardiovasc Surg 2021; 70:230-238. [PMID: 34386904 DOI: 10.1007/s11748-021-01688-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study aimed to investigate which factors have a great impact on coagulopathy after cardiopulmonary bypass (CPB) using rotational thromboelastometry (ROTEM). METHODS Ninety-eight patients undergoing cardiovascular surgery using CPB were enrolled. Data of amplitude 10 min after clotting time (A10) of ROTEM measured routinely before and after CPB were retrospectively collected. ROTEM has some assays by which we can evaluate the capacity of extrinsic coagulation (EXTEM), intrinsic coagulation (INTEM), fibrin polymerization (FIBTEM), and the effect of heparin (HEPTEM). The platelet component, defined as PLTEM, can be calculated by subtracting FIBTEM from EXTEM. Age, sex, total plasma volume, pre-CPB A10, lowest body temperature, in-out balance during CPB, intraoperative bleeding amount, and type of pumps were considered as possible factors. Univariate and multivariate analyses were performed for the rate of change of A10. RESULTS The change rate of each A10 had a significant negative correlation with bleeding amount (p < 0.01 for EXTEM, p < 0.01 for INTEM, p = 0.02 for FIBTEM, p < 0.01 for PLTEM). Female sex was a significant contributive predictor for the greater decline of EXTEM (p < 0.01) and INTEM (p < 0.01), positive balance for EXTEM (p < 0.01), FIBTEM (p = 0.01), and PLTEM (p < 0.01), long CPB time for INTEM (p = 0.01), centrifugal pump for FIBTEM (p < 0.01), and large pre-CPB A10 for PLTEM (p < 0.01). CONCLUSION In perioperative hemostatic management using ROTEM, attention should be given to the effects of these multiple factors.
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Abuelkasem E, Mazzeffi MA, Henderson RA, Wipfli C, Monroe A, Strauss ER, Chow JH, Tanaka KA. Clinical Impact of Protamine Titration-Based Heparin Neutralization in Patients Undergoing Coronary Bypass Grafting Surgery. J Cardiothorac Vasc Anesth 2019; 33:2153-2160. [PMID: 30737123 DOI: 10.1053/j.jvca.2019.01.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVES A hemostasis management system (HMS) is a point-of-care method for heparin and protamine titration. The authors hypothesized that protamine dosing over the HMS estimate would be associated with elevated activated clotting time (ACT), increased bleeding, and transfusion owing to protamine's anticoagulant activity. DESIGN A retrospective cohort study. SETTING Single-center university hospital. PARTICIPANTS One hundred eighty-nine patients undergoing elective coronary artery bypass grafting surgery. INTERVENTIONS Patients were stratified into 3 groups per ratio of actual total administered protamine versus the HMS-derived protamine estimate: (1) low-ratio (≤66% of HMS estimate), (2) moderate-ratio (66%-100% of HMS estimate), and (3) high-ratio (>100% of HMS estimate). MEASUREMENTS AND MAIN RESULTS The primary endpoints were post-protamine ACT, and residual heparin levels on HMS among the 3 groups in addition to bleeding and transfusion. There were 54 (28.6%) patients in the low, 95 (50.3%) in the moderate, and 40 (21.2%) in the high-ratio group. The high-ratio patients who were overdosed with protamine relative to the HMS estimate had elevated ACT, international normalized ratio, and activated partial thromboplastin time values, and subsequently received more red blood cell (RBC) and non-RBC transfusions compared to lower-ratio groups. Higher actual/HMS protamine ratios were associated independently with post-protamine ACT elevations after adjustment for sex, body mass index (BMI), and cardiopulmonary bypass (CPB) time. CONCLUSION Most patients received the protamine dose sufficiently close to the HMS estimate, but protamine dosing above the HMS estimate occurred in both obese and nonobese patients, which was associated independently with prolonged ACT after adjusting for sex, BMI, and CPB time.
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Affiliation(s)
- Ezeldeen Abuelkasem
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Reney A Henderson
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Camron Wipfli
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Angie Monroe
- Perioperative Services, University of Maryland Medical Center, Baltimore, MD
| | - Erik R Strauss
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Jonathan H Chow
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
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Chang E, Gatling JW, Bode S, Herrmann PC, Bull BS, Applegate RL. Extreme Plasma Dilution Decreases Heparin and Protamine Cardiopulmonary Bypass Requirements: A Case Report on a Jehovah's Witness Patient. ACTA ACUST UNITED AC 2017; 8:291-293. [PMID: 28328588 DOI: 10.1213/xaa.0000000000000493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The primary focus of cardiopulmonary bypass management in Jehovah's Witness patients is the need to conserve blood. A consequence of these strategies inevitably results in hemodilution that is frequently extreme enough to dilute clotting factors and potentially impair coagulation. The purpose of this case report is to demonstrate that a hemodiluted patient requires less heparin to sustain anticoagulation and less protamine to reverse heparin at cardiopulmonary bypass termination. Patient harm may ensue unless the effects of extreme hemodilution are recognized.
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Affiliation(s)
- Emilie Chang
- From the *Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California; and †Department of Pathology & Human Anatomy, Loma Linda University School of Medicine, Loma Linda, California
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Odonkor P, Srinivas A, Strauss E, Williams B, Mazzeffi M, Tanaka KA. Perioperative Coagulation Management of a Hemophilia A Patient During Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2017; 21:312-320. [DOI: 10.1177/1089253217702747] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Perioperative management of cardiovascular surgical procedures requiring cardiopulmonary bypass (CPB) in patients with hemophilia A poses a clinical challenge in coagulation management. Use of CPB requires the administration of an anticoagulant, usually unfractionated heparin, and also causes dilutional coagulopathy, platelet dysfunction or platelet consumption coagulopathy. Hypothermia and activation of the inflammatory cascade also affect coagulation. The effects of CPB on circulating levels of factor VIII have not been clearly defined. In this review, the effects of CPB and hemodilution on FVIII are shown in a case presentation, and perioperative laboratory testing in patients with hemophilia A having cardiac surgery is discussed along with perioperative and postoperative coagulation management.
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Affiliation(s)
| | | | - Erik Strauss
- University of Maryland Medical System, Baltimore, MD, USA
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Kalaska B, Kaminski K, Sokolowska E, Czaplicki D, Kujdowicz M, Stalinska K, Bereta J, Szczubialka K, Pawlak D, Nowakowska M, Mogielnicki A. Nonclinical evaluation of novel cationically modified polysaccharide antidotes for unfractionated heparin. PLoS One 2015; 10:e0119486. [PMID: 25781030 PMCID: PMC4362941 DOI: 10.1371/journal.pone.0119486] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/13/2015] [Indexed: 01/25/2023] Open
Abstract
Protamine, the only registered antidote of unfractionated heparin (UFH), may produce a number of adverse effects, such as anaphylactic shock or serious hypotension. We aimed to develop an alternative UFH antidote as efficient as protamine, but safer and easier to produce. As a starting material, we have chosen generally non-toxic, biocompatible, widely available, inexpensive, and easy to functionalize polysaccharides. Our approach was to synthesize, purify and characterize cationic derivatives of dextran, hydroxypropylcellulose, pullulan and γ-cyclodextrin, then to screen them for potential heparin-reversal activity using an in vitro assay and finally examine efficacy and safety of the most active polymers in Wistar rat and BALB/c mouse models of experimentally induced arterial and venous thrombosis. Efficacy studies included the measurement of thrombus formation, activated partial thromboplastin time, bleeding time, and anti-factor Xa activity; safety studies included the measurement of hemodynamic, hematologic and immunologic parameters. Linear, high molecular weight dextran substituted with glycidyltrimethylammonium chloride groups at a ratio of 0.65 per glucose unit (Dex40-GTMAC3) is the most potent and the safest UFH inhibitor showing activity comparable to that of protamine while possessing lower immunogenicity. Cationic polysaccharides of various structures neutralize UFH. Dex40-GTMAC3 is a promising and potentially better UFH antidote than protamine.
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Affiliation(s)
- Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Kamil Kaminski
- Faculty of Chemistry, Jagiellonian University, Krakow, Poland
| | - Emilia Sokolowska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Dominik Czaplicki
- Department of Cell Biochemistry, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | | | - Krystyna Stalinska
- Department of Cell Biochemistry, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | - Joanna Bereta
- Department of Cell Biochemistry, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | | | - Dariusz Pawlak
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | | | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
- * E-mail:
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Kamiński K, Kałaska B, Koczurkiewicz P, Michalik M, Szczubiałka K, Mogielnicki A, Buczko W, Nowakowska M. New arginine substituted derivative of poly(allylamine hydrochloride) for heparin reversal. MEDCHEMCOMM 2014. [DOI: 10.1039/c3md00374d] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Brauer SD, Applegate RL, Jameson JJ, Hay KL, Lauer RE, Herrmann PC, Bull BS. Association of Plasma Dilution With Cardiopulmonary Bypass-Associated Bleeding and Morbidity. J Cardiothorac Vasc Anesth 2013; 27:845-52. [DOI: 10.1053/j.jvca.2013.01.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Indexed: 11/11/2022]
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A novel method for the direct determination of heparin concentration during cardiopulmonary bypass surgery. Clin Chem Lab Med 2013; 51:2037-43. [DOI: 10.1515/cclm-2013-0278] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 05/24/2013] [Indexed: 11/15/2022]
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Stéphan F. [Managing of excessive bleeding after cardiac surgery under cardiopulmonary bypass]. Transfus Clin Biol 2012; 19:159-64. [PMID: 23039953 DOI: 10.1016/j.tracli.2012.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 07/21/2012] [Indexed: 11/19/2022]
Abstract
The occurrence of abnormal bleeding in postoperative cardiac surgery performed under cardiopulmonary bypass is relatively common. If the option of reoperation is not retained, the initiation of medical treatment is inevitable. Next to the transfusion of blood products, other therapies were often used empirically and as "off-label". The place of each in a future regimen should be based on well-conducted clinical studies to determine the optimal risk/benefit ratio.
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Affiliation(s)
- F Stéphan
- Réanimation adulte, centre chirurgical Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis Robinson, France.
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Arnékian V, Camous J, Fattal S, Rézaiguia-Delclaux S, Nottin R, Stéphan F. Use of prothrombin complex concentrate for excessive bleeding after cardiac surgery. Interact Cardiovasc Thorac Surg 2012; 15:382-9. [PMID: 22623627 DOI: 10.1093/icvts/ivs224] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Prothrombin complex concentrates (PCCs) are sometimes used as 'off label' for excessive bleeding after cardiopulmonary bypass (CPB). The main objective of this study was to retrospectively evaluate the clinical and biological efficacy of PCC in this setting. METHODS We reviewed the charts of all patients who had undergone cardiac surgery under CPB in our institution for 2 years. Patients treated for active bleeding with haemostatic therapy were identified. Chest tube blood loss was quantified postoperatively in the first 24 h. Coagulation parameters were recorded at intensive care unit admission and in the patient's first 24 h. Thromboembolic complications were also ascertained. RESULTS Seventy-seven patients out of the 677 studied (11.4%) were included: PCC was solely administered in 24 patients (group I), fresh frozen plasma in 26 (group II) and both in 27 (group III). The mean dose of PCC was 10.0 UI/kg ± 3.5 for group I vs 14.1 UI/kg ± 11.2 for group III (P = 0.09). Initial blood loss in the first hour was different between the three groups (P = 0.05): 224 ± 131 ml for group I, 369 ± 296 ml for group II and 434 ± 398 ml for group III. Only group I vs group III presented a significant difference (P = 0.02). Variations of blood loss over time were no different according to the treatment groups (P = 0.12). Reductions in blood loss expressed in percentage showed no difference between the three groups after 2 h: 54.5% (68.6-30.8) for group I; 45.0% (81.6-22.2) for group II; 57.6 (76.0-2.1) for group III; (P = 0.89). Re-exploration for bleeding involved 1 patient in group I (4%), 2 in group II (8%) and 10 in group III (37%) (P = 0.002). Except for fibrinogen, variations of prothrombin time, activated partial thromboplastin time and platelets with time were not different according to the treatment groups. Cerebral infarction occurred in one patient in group II. CONCLUSIONS Administration of low-dose of PCC significantly decreased postoperative bleeding after CPB.
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Affiliation(s)
- Vrigina Arnékian
- Cardiothoracic Intensive Care Unit, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
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Abstract
There have been numerous publications on the coagulopathy of cardiopulmonary bypass (CPB). This review provides an introduction to the history and main components of current CPB circuits and summarizes the current knowledge of pathogenesis, prevention, and treatment of the CPB coagulopathy. It encompasses an overview of intra- and postoperative monitoring of coagulation with special emphasis on the near-patient testing, its main complications, and the transfusion support, while taking into account the major changes in the technology used and supportive care provided since its inception.
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Affiliation(s)
- Martin W Besser
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK
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Maurer J, Haselbach S, Klein O, Baykut D, Vogel V, Mäntele W. Analysis of the Complex Formation of Heparin with Protamine by Light Scattering and Analytical Ultracentrifugation: Implications for Blood Coagulation Management. J Am Chem Soc 2010; 133:1134-40. [DOI: 10.1021/ja109699s] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jürgen Maurer
- Institute of Biophysics, Johann Wolfgang Goethe-University Frankfurt, Max von Laue-Strasse 1, 60438 Frankfurt am Main, Germany
| | - Stephanie Haselbach
- Institute of Biophysics, Johann Wolfgang Goethe-University Frankfurt, Max von Laue-Strasse 1, 60438 Frankfurt am Main, Germany
| | - Oliver Klein
- Institute of Biophysics, Johann Wolfgang Goethe-University Frankfurt, Max von Laue-Strasse 1, 60438 Frankfurt am Main, Germany
| | - Doan Baykut
- Institute of Biophysics, Johann Wolfgang Goethe-University Frankfurt, Max von Laue-Strasse 1, 60438 Frankfurt am Main, Germany
| | - Vitali Vogel
- Institute of Biophysics, Johann Wolfgang Goethe-University Frankfurt, Max von Laue-Strasse 1, 60438 Frankfurt am Main, Germany
| | - Werner Mäntele
- Institute of Biophysics, Johann Wolfgang Goethe-University Frankfurt, Max von Laue-Strasse 1, 60438 Frankfurt am Main, Germany
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Kaspereit F, Hoffmann S, Pragst I, Dickneite G. Prothrombin complex concentrate mitigates diffuse bleeding after cardiopulmonary bypass in a porcine model. Br J Anaesth 2010; 105:576-82. [PMID: 20716565 PMCID: PMC2955534 DOI: 10.1093/bja/aeq216] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Extracorporeal circuit priming and intravascular volume expansion during cardiopulmonary bypass (CPB) may lead to dilutional coagulopathy and excessive diffuse postoperative bleeding. Prothrombin complex concentrate (PCC) containing clotting factors II (FII), VII (FVII), IX (FIX), and X (FX) could be of potential value in correcting dilutional coagulopathy and reducing blood loss. Methods Anaesthetized pigs underwent CPB with hypothermia for 2 h at 25°C followed by 1 h of normothermia. Approximately 1 h after CPB, animals randomly received either isotonic saline 1 ml kg−1 or PCC 30 IU kg−1 in a volume of 1 ml kg−1. Diffuse coagulopathic bleeding was assessed as suture hole blood loss from a Gore-Tex patch placed over a full-thickness incision in the left carotid artery. Results After CPB, levels of FII, FVII, FIX, and FX declined from baseline by 32% to 48%, and PCC fully or partially reversed those deficits. Median suture hole blood loss after administration of saline placebo was 74 ml. PCC reduced suture hole bleeding by a median of 54 ml with a 95% confidence interval of 6–112 ml (P=0.026) compared with saline. PCC, but not saline, normalized skin bleeding time. Peak thrombin generation markedly decreased after CPB, but then returned in PCC-treated animals to a level higher than baseline by 28.7 nM (14.5–41.1 nM; P=0.031). Conclusions PCC was effective in correcting dilutional coagulopathy and reducing diffuse bleeding in an in vivo large-animal CPB model. Further research is warranted on PCC as a haemostatic agent in CPB.
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Affiliation(s)
- F Kaspereit
- Department of Preclinical Research and Development, CSL Behring GmbH, Marburg, Germany
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Herrmann PC, Hay KL, Bull BS. An algorithm for preventing bypass-associated dilutional (BAD) coagulopathy: Theory and example. Blood Cells Mol Dis 2010; 45:98-101. [PMID: 20427210 DOI: 10.1016/j.bcmd.2010.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 03/29/2010] [Accepted: 03/29/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Crystalloid administered during cardiopulmonary bypass may significantly dilute clotting factor concentrations, particularly in low blood volume patients. Should the administered fluid (pump prime plus IVs) drop the clotting factor concentrations below approximately 38%, almost all patients will bleed, heparin levels will be overestimated and excessive neutralizing protamine will be administered. This combination can render blood virtually unclottable. This paper describes algorithms that quantify dilution risk and the maximum fluid that can be safely administered. A confirmatory calculation to prevent excessive protamine administration is also described.
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Affiliation(s)
- Paul C Herrmann
- School of Medicine, Department of Pathology and Human Anatomy, Loma Linda University, Loma Linda, CA 92350, USA
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