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Rijpkema M, Vlot EA, Stehouwer MC, Bruins P. Does heparin rebound lead to postoperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass? Perfusion 2023:2676591231199218. [PMID: 37734336 DOI: 10.1177/02676591231199218] [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: 09/23/2023]
Abstract
BACKGROUND Heparin rebound is a common observed phenomenon after cardiac surgery with CPB and is associated with increased postoperative blood loss. However, the administration of extra protamine may lead to increased blood loss as well. Therefore, we want to investigate the relation between heparin rebound and postoperative blood loss and the necessity to provide extra protamine to reverse heparin rebound. METHODS We searched PubMed, Cochrane, EMBASE, Google Scholar and Web of Science to review the question: "Does heparin rebound lead to postoperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass." Combination of search words were framed within four major categories: heparin rebound, blood loss, cardiac surgery and cardiopulmonary bypass. All studies that met our question were included. Quality assessment was performed using the Cochrane risk of bias (RoB2) tool for randomized controlled trials and the risk of bias in non-randomized studies of intervention (ROBINS-I) for non-randomised trials. RESULTS 4 randomized and 17 non-randomized studies were included. The mean incidence of heparin rebound was 40%. The postoperative heparin levels, due to heparin rebound, were often below or equal to 0.2 IU/mL. We could not demonstrate an association between heparin rebound and postoperative blood loss or transfusion requirements. However the quality of evidence was poor due to a broad variety of definitions of heparin rebound, measured by various coagulation tests and studies with small sample sizes. CONCLUSION The influence of heparin rebound on postoperative bleeding seems to be negligible, but might get significant in conjunction with incomplete heparin reversal or other coagulopathies. For that reason, it might be useful to get a picture of the entire coagulation spectrum after cardiac surgery, as can be done by the use of a viscoelastic test in conjunction with an aggregometry test.
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Affiliation(s)
- Marije Rijpkema
- Department of Anaesthesiology, Intensive Care and Pain Management, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Eline A Vlot
- Department of Anaesthesiology, Intensive Care and Pain Management, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Marco C Stehouwer
- Department of extracorporeal circulation, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Peter Bruins
- Department of Anaesthesiology, Intensive Care and Pain Management, St Antonius Hospital, Nieuwegein, The Netherlands
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2
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Michael S, Sofia MG, Wei W, Patrick G, John A, Dana A. Efficacy of the Hepcon system in reducing hemorrhagic and thrombotic complications in antiphospholipid syndrome patients undergoing cardiac surgery. Perfusion 2023:2676591231197990. [PMID: 37608561 DOI: 10.1177/02676591231197990] [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: 08/24/2023]
Abstract
INTRODUCTION Patients with Antiphospholipid Syndrome (APS) undergoing cardiopulmonary bypass (CPB) surgery are at increased risk for thrombotic and hemorrhagic complications. Anticoagulation during CPB is typically monitored with activated clotting time (ACT) which may be falsely prolonged in patients with APS. The Hepcon Hemostasis Management System quantitatively determines the whole blood heparin concentration through heparin/protamine titration. METHODS This was a retrospective study of APS patients who underwent cardiac surgery requiring CPB at the Cleveland Clinic between April 2013, and July 2020. The primary endpoint was the composite rate of hemorrhagic or thromboembolic complications per surgical case in patients monitored by Hepcon versus patients monitored by ACT. Secondary endpoints were median volume of chest tube output and packed red blood cell (PRBC) transfusion within the first three post-operative days. RESULTS 43 patients were included. 20 (47%) patients were monitored using Hepcon while 23 (53%) were monitored using ACT. For the primary endpoint of rate of thromboembolic or hemorrhagic complications per surgical case, there was no statistically significant difference between the Hepcon and ACT groups (HMS, 6/20 [30%]; ACT, 7/23 [30%]; p = >0.99). For the secondary endpoints, there was no statistically significant difference in median post-operative chest tube output (780 mL vs. 850 mL; p = 0.88) and median post-operative PRBC transfusion (1 unit vs. 0 unit; p = 0.28) between the Hepcon and ACT groups, respectively. CONCLUSION There was no difference in the composite outcome of thrombotic or hemorrhagic complications in patients monitored by Hepcon versus those monitored by ACT.
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Affiliation(s)
- Sheu Michael
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Molina Garcia Sofia
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Wei Wei
- Department of Biostatistics, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Grady Patrick
- Department of Perfusion, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Apostolakis John
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Angelini Dana
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
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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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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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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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7
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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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8
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Wool GD. Benefits and Pitfalls of Point-of-Care Coagulation Testing for Anticoagulation Management: An ACLPS Critical Review. Am J Clin Pathol 2019; 151:1-17. [PMID: 30215666 DOI: 10.1093/ajcp/aqy087] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Objectives Point-of-care (POC) testing is generally less precise and has higher reagent costs per test than laboratory-based assays. However, POC hemostasis testing can offer significant advantages in particular situations: patient-managed warfarin therapy as well as rapid turnaround time heparin management for intraoperative patients. Of note, POC hemostasis testing is generally approved for the purposes of anticoagulation monitoring and is inferior to laboratory coagulation testing for the diagnosis of congenital or acquired coagulopathy. Methods The frequently used POC coagulation instruments for POC international normalized ratio and activated clotting time are reviewed, as well as their typical performance relative to central laboratory testing (where available). Results Several cases are discussed that highlight the benefits, as well as pitfalls, of POC coagulation testing. Conclusions POC coagulation testing for anticoagulation monitoring offers advantages in particular situations. Clear policies and protocols must be developed to guide proper use of POC versus central laboratory hemostasis testing.
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Affiliation(s)
- Geoffrey D Wool
- The Department of Pathology, University of Chicago, Chicago, IL
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9
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Kjellberg G, Holm M, Fux T, Lindvall G, van der Linden J. Calculation Algorithm Reduces Protamine Doses Without Increasing Blood Loss or the Transfusion Rate in Cardiac Surgery: Results of a Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2018; 33:985-992. [PMID: 30206011 DOI: 10.1053/j.jvca.2018.07.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The aim of the study was to investigate whether the HeProCalc algorithm affects heparin and protamine dosage, postoperative blood loss, and transfusion rate. DESIGN Randomized controlled trial. SETTING University hospital. PARTICIPANTS The study comprised 210 cardiac surgery patients undergoing cardiac surgery with cardiopulmonary bypass. Twenty patients were excluded because of re-exploration for localized surgical bleeding (n = 9), violation of protocol (n = 2), aprotinin use (n = 3 and nadir body temperature <32°C (n = 6). INTERVENTIONS Study participants were randomly assigned to either traditional heparin and protamine dosage based on body weight only (control group) or dosage based on the HeProCalc algorithm (intervention group). MEASUREMENTS AND MAIN RESULTS The initial median heparin dose was 32,500 IU (interquartile range [IQR] 30,000-35,000) in the intervention group compared with 35,000 IU (IQR 30,000-37,500) (p = 0.025) in the control group. The total heparin dose in the intervention group was 40,000 IU (IQR 32,500-47,500) compared with 42,500 IU (IQR 35,000-50,000) in the control group (p = 0.685). The total protamine dose was 210 mg (IQR 190-240) in the intervention group compared with 350 mg (IQR 300-380) (p < 0.001) in the control group. The ratio of total protamine to initial dose of heparin in the intervention group was 0.62 compared with 1.0 (p < 0.001). The amount of chest tube bleeding after 12 postoperative hours was 320 mL (IQR 250-460) in the intervention group compared with 350 mL (IQR 250-450) (p = 0.754) in the control group. Neither the transfusion rate nor postoperative blood loss differed significantly between the 2 groups. CONCLUSION Use of the HeProCalc algorithm reduced protamine dosage and the protamine/heparin ratio after cardiopulmonary bypass compared with conventional dosage based on weight without significant effect on postoperative blood loss or the transfusion rate.
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Affiliation(s)
- Gunilla Kjellberg
- Department of Thoracic Surgery and Anesthesia, Academic Hospital, Uppsala, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - Manne Holm
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Division of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
| | - Thomas Fux
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Division of Perioperative Medicine and Intensive Care, Section Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden
| | - Gabriella Lindvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Division of Perioperative Medicine and Intensive Care, Section Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden
| | - Jan van der Linden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Division of Perioperative Medicine and Intensive Care, Section Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden
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10
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Anticoagulant and side-effects of protamine in cardiac surgery: a narrative review. Br J Anaesth 2018; 120:914-927. [DOI: 10.1016/j.bja.2018.01.023] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 01/10/2018] [Accepted: 01/29/2018] [Indexed: 01/10/2023] Open
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Seki T, Shingu Y, Sugiki H, Wakasa S, Katoh H, Ooka T, Tachibana T, Kubota S, Matsui Y. Anticoagulation management during cardiopulmonary bypass in patients with antiphospholipid syndrome. J Artif Organs 2018. [DOI: 10.1007/s10047-018-1032-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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12
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Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk AB, Wahba A, Pagano D. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88-120. [DOI: 10.1053/j.jvca.2017.06.026] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 01/28/2023]
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13
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Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Boer C. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:79-111. [DOI: 10.1093/ejcts/ezx325] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Miles LF, Marchiori P, Falter F. Pilot validation of an individualised pharmacokinetic algorithm for protamine dosing after systemic heparinisation for cardiopulmonary bypass. Perfusion 2017; 32:481-488. [PMID: 28820026 DOI: 10.1177/0267659117695881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION This manuscript represents a pilot study assessing the feasibility of a single-compartment, individualised, pharmacokinetic algorithm for protamine dosing after cardiopulmonary bypass. METHODS A pilot cohort study in a specialist NHS cardiothoracic hospital targeting patients undergoing elective cardiac surgery using cardiopulmonary bypass. Patients received protamine doses according to a pharmacokinetic algorithm (n = 30) or using an empirical, fixed-dose model (n = 30). Categorical differences between the groups were evaluated using the Chi-squared test or Fisher's exact test. Continuous data was analysed using a paired Student's t-test for parametric data and the paired samples Wilcoxon test for non-parametric data. RESULTS Patients who had protamine dosing according to the algorithm demonstrated a lower protamine requirement post-bypass relative to empirical management as measured by absolute dose (243 ± 49mg vs. 305 ± 34.7mg; p<0.001) and the heparin to protamine ratio (0.79 ± 0.12 vs. 1.1 ± 0.15; p<0.001). There was no difference in the pre- to post-bypass activated clotting time (ACT) ratio (1.05 ± 0.12 vs. 1.02 ± 0.15; p=0.9). Patients who received protamine according to the algorithm had no significant difference in transfusion requirement (13.3% vs. 30.0%; p=0.21). CONCLUSIONS This study showed that an individualized pharmacokinetic algorithm for the reversal of heparin after cardiopulmonary bypass is feasible in comparison with a fixed dosing strategy and may reduce the protamine requirement following on-pump cardiac surgery.
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Affiliation(s)
- Lachlan F Miles
- 1 Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | | | - Florian Falter
- 3 Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, UK
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Hoenicka M, Rupp P, Müller-Eising K, Deininger S, Kunert A, Liebold A, Gorki H. Anticoagulation management during multivessel coronary artery bypass grafting: a randomized trial comparing individualized heparin management and conventional hemostasis management. J Thromb Haemost 2015; 13:1196-206. [PMID: 25954849 DOI: 10.1111/jth.12999] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Individualized heparin management (IHM) uses heparin dose-response curves to improve hemostasis management during cardiac surgery as compared with activated clotting time-based methods. OBJECTIVES IHM was compared with conventional hemostasis management (CHM) in a randomized, prospective study (ID DRKS00007580). METHODS One-hundred and twenty patients undergoing multivessel coronary artery bypass grafting (CABG) were enrolled. Heparin and protamine consumption, blood losses, blood transfusions and administration of hemostatic agents were recorded. Time courses of platelet counts and of coagulation parameters were determined. Coagulation was analyzed at intensive care unit (ICU) arrival by thromboelastometry. RESULTS IHM patients received significantly lower initial heparin doses (289.3IU kg(-1) [interquartile range (IQR) 221.5-376.2 IU kg(-1) ] versus 350.5 IU kg(-1) [IQR 346.8-353.7 IU kg(-1) ], P < 0.0001) but similar total heparin doses (418.5 IU kg(-1) [IQR 346.9-590.5 IU kg(-1) ] versus 435.8 IU kg(-1) [IQR 411.7-505.1 IU kg(-1) ]). IHM patients received significantly less protamine, resulting in protamine/total heparin ratios of 0.546 [IQR 0.469-0.597] versus 0.854 [IQR 0.760-0.911] in CHM patients (P < 0.0001). Activated partial thromboplastin time (50.5 s [IQR 40.0-60.0 s] versus 37.0 s [IQR 33.0-40.0 s], P < 0.0001), activated clotting time (136 s [IQR 129.0-150.5 s] versus 126.5 s [IQR 120.3-134.0 s], P = 0.0002) and INTEM clotting times (215 s [IQR 192-237] versus 201 s [IQR 191-216 s], P = 0.0397) were significantly longer in IHM patients than in CHM patients at ICU arrival, with no difference in prothrombin time (P = 0.538). IHM patients lost significantly more blood within 12 h postoperatively (420 mL [IQR 337.5-605.0 mL] versus 345 mL [IQR 230.0-482.5 mL], P = 0.0041), and required significantly more hemostatic agents to control bleeding. Red blood cell transfusion requirements and time courses of platelet counts did not differ between groups. CONCLUSIONS Multivessel CABG patients did not benefit from IHM in comparison with our established protocol based on activated clotting time.
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Affiliation(s)
- M Hoenicka
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - P Rupp
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - K Müller-Eising
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - S Deininger
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - A Kunert
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - A Liebold
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - H Gorki
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
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Sniecinski RM, Levy JH. Anticoagulation management associated with extracorporeal circulation. Best Pract Res Clin Anaesthesiol 2015; 29:189-202. [PMID: 26060030 DOI: 10.1016/j.bpa.2015.03.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 03/20/2015] [Indexed: 11/25/2022]
Abstract
The use of extracorporeal circulation requires anticoagulation to maintain blood fluidity throughout the circuit, and to prevent thrombotic complications. Additionally, adequate suppression of hemostatic activation avoids the unnecessary consumption of coagulation factors caused by the contact of blood with foreign surfaces. Cardiopulmonary bypass represents the greatest challenge in this regard, necessitating profound levels of anticoagulation during its conduct, but also quick, efficient reversal of this state once the surgical procedure is completed. Although extracorporeal circulation has been around for more than half a century, many questions remain regarding how to best achieve anticoagulation for it. Although unfractionated heparin is the predominant agent used for cardiopulmonary bypass, the amount required and how best to monitor its effects are still unresolved. This review discusses the use of heparin, novel anticoagulants, and the monitoring of anticoagulation during the conduct of cardiopulmonary bypass.
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Affiliation(s)
- Roman M Sniecinski
- Emory University School of Medicine, Department of Anesthesiology, 1364 Clifton Rd, NE, Atlanta, GA 30322, USA.
| | - Jerrold H Levy
- Cardiothoracic Anesthesia and Critical Care, Duke University Medical Center, 2301 Erwin Road, 5691H HAFS, Durham, NC 27710, USA.
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Tran MH, Lin DM, Wilcox T, Schiro D, Cannesson M, Milliken J. Effects of a multimodality blood conservation schema toward improvement of intraoperative hemoglobin levels and off-pump transfusions in coronary artery bypass graft surgery. Transfusion 2014; 54:2769-74. [DOI: 10.1111/trf.12745] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/25/2014] [Accepted: 04/28/2014] [Indexed: 01/12/2023]
Affiliation(s)
- Minh-Ha Tran
- Department of Pathology and Laboratory Medicine; UC Irvine School of Medicine; Irvine California
| | - David M. Lin
- Department of Internal Medicine; UC Irvine School of Medicine; Irvine California
| | | | - Dana Schiro
- Perioperative Services; UC Irvine Medical Center; Irvine California
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Services; UC Irvine School of Medicine; Irvine California
| | - Jeffrey Milliken
- Department of Surgery; UC Irvine School of Medicine; Irvine California
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Koster A, Börgermann J, Gummert J, Rudloff M, Zittermann A, Schirmer U. Protamine Overdose and Its Impact on Coagulation, Bleeding, and Transfusions After Cardiopulmonary Bypass. Clin Appl Thromb Hemost 2013; 20:290-5. [DOI: 10.1177/1076029613484085] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: We assessed the effects of protamine overdosing on thrombelastometry, bleeding, and transfusions in patients after cardiopulmonary bypass (CPB). Methods: In group 1 (n = 15), representing the clinical standard, the protamine dose was based on the initial heparin dose, and group 2 (n = 15) received protamine based on the heparin concentration measured after CPB. Primary end points were thromboelastometric parameters. Secondary end points were perioperative blood loss and utilization of blood products. Results: During CPB, heparin concentrations decreased by 40%, resulting in overdosing of protamine in group 1. Thromboelastometry revealed longer clotting time (CT) in group 1 ( P values < .05). Four patients in group 1 but none in group 2 had excessive prolonged CT values (>360 seconds) and concomitant microvascular bleeding, requiring substantial replacement of coagulation factors. Conclusions: Heparin dose-based protamine management leads to protamine overdosing with inhibition of the coagulation process. Protamine management guided by heparin concentration avoids these complications.
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Affiliation(s)
- Andreas Koster
- Institute for Anaesthesiology, Heart and Diabetes Centre North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Jochen Börgermann
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Markus Rudloff
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Armin Zittermann
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Uwe Schirmer
- Institute for Anaesthesiology, Heart and Diabetes Centre North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
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Guo Y, Tang J, Du L, Liu J, Liu RC, Liu X, Guo Y. Protamine Dosage Based on Two Titrations Reduces Blood Loss After Valve Replacement Surgery: A Prospective, Double-Blinded, Randomized Study. Can J Cardiol 2012; 28:547-52. [DOI: 10.1016/j.cjca.2012.03.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 03/20/2012] [Accepted: 03/20/2012] [Indexed: 10/28/2022] Open
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20
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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.
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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
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Sniecinski RM, Chandler WL. Activation of the Hemostatic System During Cardiopulmonary Bypass. Anesth Analg 2011; 113:1319-33. [DOI: 10.1213/ane.0b013e3182354b7e] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Muedra V, Bonanad S, Gómez M, Villalonga V, Sánchez F, Llopis JE. Relationships between antithrombin activity, anticoagulant efficacy of heparin therapy and perioperative variables in patients undergoing cardiac surgery requiring cardiopulmonary bypass. Perfusion 2011; 26:487-95. [PMID: 21665912 DOI: 10.1177/0267659111412999] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION A study on 149 cardiopulmonary bypass (CPB) patients was performed to elucidate possible relationships between antithrombin (AT) activity and a subject's clinical profile or surgery characteristics. METHODS An initial dose (300 IU/kg) of heparin was administered before CPB. Additional boluses (100 IU/kg) were administered if the activated clotting time (ACT)≤460 s. AT activity and hematological parameters were determined preoperatively, during and after CPB, and at 12, 24, 36, and 48 hours post-intervention. RESULTS 29.5% patients required an additional dose of heparin during CPB. Preoperative AT was 96.5 ± 13.9% in all but 4 patients. AT was significantly lower during CPB and upon leaving the operating room (59.7%-80.0%). A small, but significant, inverse correlation was observed between AT at the end of CPB and the patient's age, as well as between basal preoperative AT and total heparin administered. CONCLUSIONS Patient's age could be a moderate indicator of AT activity drop and low preoperative AT activity could be a sign of reduced anticoagulant efficacy of heparin during CPB.
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Affiliation(s)
- V Muedra
- Department of Anesthesia, Critical Care and Pain Therapy, La Ribera University Hospital, Alzira, Valencia, Spain.
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Girolami A, Scarparo P, Candeo N, Lombardi AM. Congenital prekallikrein deficiency. Expert Rev Hematol 2011; 3:685-95. [PMID: 21091145 DOI: 10.1586/ehm.10.69] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The congenital deficiency of prekallikrein (PK) is a rare condition in which there is a peculiar discrepancy between a severe in vitro defect and absence of bleeding. The gene controlling PK synthesis is located on chromosome 4 and consists of 14 exons and 15 introns. Only approximately 80 cases of PK deficiency have been described in the literature. Owing to the lack of bleeding, most cases go undetected or, if detected, go unreported. Occasional bleeding or thrombosis have been reported in a few patients but this was only due to the presence of associated risk factors. It is certain that the defect does not protect from thrombosis. Diagnosis is based on the presence of a great prolongation of partial thromboplastin time and normal prothrombin time and thrombin time. The long partial thromboplastin time is fully corrected by the addition of normal plasma or normal serum and presents the unusual feature of shortening on long incubation times. Platelet and vascular tests are normal. Immunological studies allow differentiation into two types, namely cases of true deficiency, which are approximately 70% of the total, and cases with abnormal forms. PK is a glycoprotein synthesized in the liver as a single-chain peptide of 88000 Da. It mostly circulates (∼75%) as a complex with high-molecular-weight kininogen. It is cleaved by FXIIa into a heavy chain and a light chain (catalytic domain), held together by disulfide bonds. Molecular biology techniques have so far only been applied to eleven families, and these studies do not yet allow definite phenotype/genotype conclusions. The exons involved are 5, 8, 11, 14 and 15. The noncoagulative effects of PK, mainly based on the effect of kallikrein, have been studied less, since they appear to be the result of the involvement of other components of the contact phase. Kallikrein can mainly affect the formation of bradykinin from high-molecular-weight kininogen and the activation of pro-urokinase to urokinase. Bradykinin causes inflammation, vasodilatation and an increase in vessel permeability. The activation of pro-urokinase results in enhanced fibrinolysis. However, fibrinolysis has been reported to be normal or defective in these patients.
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Affiliation(s)
- Antonio Girolami
- Department of Medical and Surgical Sciences, Padua University, Via Ospedale, Padua, Italy.
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Management of regional citrate anticoagulation in pediatric high-flux dialysis: activated coagulation time versus post-filter ionized calcium. Pediatr Nephrol 2010; 25:1305-10. [PMID: 20221775 DOI: 10.1007/s00467-010-1483-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 01/29/2010] [Accepted: 02/01/2010] [Indexed: 10/19/2022]
Abstract
Recent years has seen an increasing use of regional citrate anticoagulation in pediatric dialysis. Several approaches have been described for monitoring anticoagulation in the extracorporeal circuit, such as serum citrate levels, post-filter ionized calcium (iCa), and activated coagulation time (ACT). However, no standard recommendations have yet been established for applying any of these parameters, especially for iCa. The objective of this retrospective analysis was to establish adequate coagulation management using post-filter iCa values. Normal values for ACTester-based ACT were established using a group of 64 children who were divided into two subgroups, with one subgroup comprising children without chronic kidney disease or coagulation disorder (age 1.2-17.5 years, median 9.7 years) and one consisting of 32 uremic patients (age 0.6-17.5 years, median 13.7 years). In a second group of 13 patients (aged 7-17 years), all of whom were undergoing high-flux dialysis (HD) with regional citrate anticoagulation (RCA), we assessed 73 post-filter blood samples for ionized calcium and ACT. A receiver operating characteristic graph was used to identify the iCa threshold needed to achieve adequate anticoagulation. Normal values for ACT were 90 s [2 standard deviations (SD) 72-109] in healthy children and 94 s (2 SD 75-113) in the uremic children. There was no statistically significant difference between the groups. In the children undergoing HD with RCA, the post-filter iCa level correlated with ACT (r = -0.94, p < 0.001). A post-filter iCa level of < or = 0.30 mmol/l reliably predicted an ACT >120 s. Our citrate protocol [citrate 3% rate (ml/h) approximately blood flow rate (ml/min) x 2] meets the established criteria with a high sensitivity. Based on these results, we conclude that the post-filter iCa level can be reliably used for the management of extracorporeal anticoagulation with citrate in pediatric HD. We recommend the application of our citrate prescription protocol in the setting of pediatric intermittent hemodialysis.
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Mauldin FW, Viola F, Hamer TC, Ahmed EM, Crawford SB, Haverstick DM, Lawrence MB, Walker WF. Adaptive force sonorheometry for assessment of whole blood coagulation. Clin Chim Acta 2010; 411:638-44. [PMID: 20096680 DOI: 10.1016/j.cca.2010.01.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Revised: 01/12/2010] [Accepted: 01/14/2010] [Indexed: 12/01/2022]
Abstract
BACKGROUND Viscoelastic diagnostics that monitor the hemostatic function of whole blood (WB), such as thromboelastography, have been developed with demonstrated clinical utility. By measuring the cumulative effects of all components of hemostasis, viscoelastic diagnostics have circumvented many of the challenges associated with more common tests of blood coagulation. METHODS We describe a new technology, called sonorheometry, that adaptively applies acoustic radiation force to assess coagulation function in WB. The repeatability (precision) of coagulation parameters was assessed using citrated WB samples. A reference range of coagulation parameters, along with corresponding measurements from prothrombin time (PT) and partial thromboplastin time (PTT), were obtained from WB samples of 20 healthy volunteers. In another study, sonorheometry monitored anticoagulation with heparin (0-5 IU/ml) and reversal from varied dosages of protamine (0-10 IU/ml) in heparinized WB (2 IU/ml). RESULTS Sonorheometry exhibited low CVs for parameters: clot initiation time (TC1), <7%; clot stabilization time (TC2), <6.5%; and clotting angle (theta), <3.5%. Good correlation was observed between clotting times, TC1 and TC2, and PTT (r=0.65 and 0.74 respectively; n=18). Linearity to heparin dosage was observed with average linearity r>0.98 for all coagulation parameters. We observed maximum reversal of heparin anticoagulation at protamine to heparin ratios of 1.4:1 from TC1 (P=0.6) and 1.2:1 from theta (P=0.55). CONCLUSIONS Sonorheometry is a non-contact method for precise assessment of WB coagulation.
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Affiliation(s)
- F William Mauldin
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
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Basora M, Fita G, Panigua P, Litvan H, Fló A, Reverter JC. [Survey of perioperative hemostasis and transfusion management in cardiac surgery: how do anesthesiologists practice?]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2010; 57:3-10. [PMID: 20196517 DOI: 10.1016/s0034-9356(10)70156-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To determine practices related to control of perioperative hemostasis and transfusion in patients undergoing cardiac surgery in Spain, including the extent to which protocols are being used. METHODS A questionnaire was created to collect information from physicians in anesthesiology and postoperative recovery care between July 1 and September 20, 2007. The physicians were asked about practice in the 12 months prior to the survey. RESULTS Thirty-four hospitals responded. Seventy percent reported that they did not have protocols or guidelines for the control of hemostasis during cardiac surgery. Forty-four percent did not have information on the proportion of patients who received transfusions; 47% gave transfusions to 75% of patients. The standard preoperative tests were platelet counts, activated partial thromboplastin time, and prothrombin time. Acetylsalicylic acid and clopidogrel were suspended before surgery at 15 (44%) and 25 (73%) hospitals, respectively. In cases of resistance to heparin, additional doses of the drug were injected, in combination with plasma or antithrombin in 29% and 12% of the hospitals, respectively. In the intensive postoperative recovery care unit, only 1 hospital used thromboelastography. Only 1 other hospital used a platelet function analyzer. CONCLUSIONS Hemostasis, perioperative coagulation, and criteria for transfusion vary widely among the hospitals surveyed. Few guidelines are available and they are not often being followed. A high percentage of patients receive transfusions, although not all hospitals can cite a figure. New technology has not been widely applied.
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Affiliation(s)
- M Basora
- Servicio de Anestesiología y Reanimación, Hospital Clínic, Barcelona.
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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.
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Affiliation(s)
- Sean Garvin
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA
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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.
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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
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