1
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Vappala S, Smith SA, Kizhakkedathu JN, Morrissey JH. Inhibitors of Polyphosphate and Neutrophil Extracellular Traps. Semin Thromb Hemost 2024; 50:970-977. [PMID: 37192652 PMCID: PMC10651799 DOI: 10.1055/s-0043-1768936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
The contact pathway of blood clotting has received intense interest in recent years as studies have linked it to thrombosis, inflammation, and innate immunity. Because the contact pathway plays little to no role in normal hemostasis, it has emerged as a potential target for safer thromboprotection, relative to currently approved antithrombotic drugs which all target the final common pathway of blood clotting. Research since the mid-2000s has identified polyphosphate, DNA, and RNA as important triggers of the contact pathway with roles in thrombosis, although these molecules also modulate blood clotting and inflammation via mechanisms other than the contact pathway of the clotting cascade. The most significant source of extracellular DNA in many disease settings is in the form of neutrophil extracellular traps (NETs), which have been shown to contribute to incidence and severity of thrombosis. This review summarizes known roles of extracellular polyphosphate and nucleic acids in thrombosis, with an emphasis on novel agents under current development that target the prothrombotic activities of polyphosphate and NETs.
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Affiliation(s)
- Sreeparna Vappala
- Department of Pathology and Laboratory Medicine; and Centre for Blood Research, Life Science Institute; University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie A. Smith
- Department of Biological Chemistry, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jayachandran N. Kizhakkedathu
- Department of Pathology and Laboratory Medicine; and Centre for Blood Research, Life Science Institute; University of British Columbia, Vancouver, British Columbia, Canada
- Department of Chemistry; and School of Biomedical Engineering; University of British Columbia, Vancouver, British Columbia, Canada
| | - James H. Morrissey
- Department of Biological Chemistry, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Crivellari M, Landoni G, Ursoleo JD, Ferrante L, Oriani A. Protamine and Heparin Interactions: A Narrative Review. Ann Card Anaesth 2024; 27:202-212. [PMID: 38963354 PMCID: PMC11315261 DOI: 10.4103/aca.aca_117_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 11/18/2023] [Accepted: 12/08/2023] [Indexed: 07/05/2024] Open
Abstract
ABSTRACT Protamine, first isolated from salmon fish sperm and now produced through recombinant biotechnology, is an antidote that neutralizes the anticoagulant properties of heparin. Protamine function is based on the capacity to dissociate the heparin-antithrombin III (AT III) complex (an important link that promotes blood fluidification by inhibiting coagulation), forming the inactive heparin-protamine complex. Protamine has itself dose-dependent anticoagulant properties: It interferes with coagulation factors and platelet function; it stimulates fibrinolysis; it can lead to thrombocytopenia and reduction in thrombin-related platelet aggregation; it decreases platelet response to thrombin receptor agonist in a dose-dependent manner. In this review, we will focus on protamine and its interaction with heparin. Notably, protamine is able to antagonize not only unfractionated heparin (UFH) but also low molecular weight heparins to various degrees. Protamine-allergic and anaphylactoid systemic reactions may affect up to 1 in 10 people and should be prevented and treated early.
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Affiliation(s)
- Martina Crivellari
- IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Via Olgettina, 58, 20132, Milan, Italy
| | | | - Luca Ferrante
- Vita-Salute San Raffaele University, Via Olgettina, 58, 20132, Milan, Italy
| | - Alessandro Oriani
- IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
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Mondal S, Abuelkasem E, Vesselinov R, Henderson R, Choi S, Mousa A, Zaza KJ, Tanaka KA. Protamine dosing and its impact in cardiac surgery transfusion practice-A retrospective bi-institutional analysis. Transfusion 2024; 64:467-474. [PMID: 38264767 DOI: 10.1111/trf.17730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/29/2023] [Accepted: 12/29/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Bleeding after cardiac surgery is common and continues to require 10-20% of the national blood supply. Transfusion of allogeneic blood is associated with increased morbidity and mortality. Excessive protamine in the absence of circulating heparin after weaning off CPB can cause anticoagulation and precipitate bleeding. Hence, adequate dose calculation of protamine is crucial yet under evaluated. STUDY DESIGN Retrospective cohort study. METHODS We conducted a retrospective bi-institutional analysis of cardiac surgical patients who underwent cardiopulmonary bypass (CPB)-assisted cardiac surgery to assess the impact of protamine dosing in transfusion practice. Total 762 patients were identified from two institutions using electronic medical records and the Society of Thoracic Surgery (STS) database who underwent cardiac surgery using CPB. Patients were similar in demographics and other baseline characteristics. We divided patients into two groups based on mg of protamine administered to neutralize each 100 U of unfractionated heparin (UFH)-low-ratio group (Protamine: UFH ≤ 0.8) and high-ratio group (Protamine: UFH > 0.8). RESULTS We observed a higher rate of blood transfusion required in high-ratio group (ratio >0.8) compared with low-ratio group (ratio ≤0.8) (p < .001). The increased requirement was consistently demonstrated for intraoperative transfusions of red blood cells, plasma, platelets, and cryoprecipitate. CONCLUSION High protamine to heparin ratio may cause increased bleeding and transfusion in cardiac surgical patients. Protamine to heparin ratio of 0.8 or lower is sufficient to neutralize circulating heparin after weaning off cardiopulmonary bypass.
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Affiliation(s)
- Samhati Mondal
- Department of Anesthesiology, Cardiothoracic Division, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ezeldeen Abuelkasem
- Department of Anesthesiology, Cardiothoracic Division, University of Pittsburgh School of Medicine and UPMC, Pennsylvania, USA
| | - Roumen Vesselinov
- Department of Epidemiology and Public Health, Biostatistics Division; Department of Anesthesiology, National Study Center, University of Maryland, Baltimore, Maryland, USA
| | - Reney Henderson
- Department of Anesthesiology, Cardiothoracic Division, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Seung Choi
- Department of Anesthesiology, WakeMed Health System, Raleigh, North Carolina, USA
| | - Ahmad Mousa
- Department of Anesthesiology, Cardiothoracic Division, University of Pittsburgh School of Medicine and UPMC, Pennsylvania, USA
| | - Khaled J Zaza
- Department of Anesthesiology, Cardiothoracic Division, University of Pittsburgh School of Medicine and UPMC, Pennsylvania, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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4
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Hussein HR, Chang CY, Zheng Y, Yang CY, Li LH, Lee YT, Chen JY, Liang YC, Lin CJ, Chang YC, Geo HN, Noor SM, Kiew LV, Chen FR, Chang CC. Immune-stealth VP28-conjugated heparin nanoparticles for enhanced and reversible anticoagulation. NANOTECHNOLOGY 2024; 35:175102. [PMID: 38262054 DOI: 10.1088/1361-6528/ad21a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/23/2024] [Indexed: 01/25/2024]
Abstract
Heparins are a family of sulfated linear negatively charged polysaccharides that have been widely used for their anticoagulant, antithrombotic, antitumor, anti-inflammatory, and antiviral properties. Additionally, it has been used for acute cerebral infarction relief as well as other pharmacological actions. However, heparin's self-aggregated macrocomplex may reduce blood circulation time and induce life-threatening thrombocytopenia (HIT) complicating the use of heparins. Nonetheless, the conjugation of heparin to immuno-stealth biomolecules may overcome these obstacles. An immunostealth recombinant viral capsid protein (VP28) was expressed and conjugated with heparin to form a novel nanoparticle (VP28-heparin). VP28-heparin was characterized and tested to determine its immunogenicity, anticoagulation properties, effects on total platelet count, and risk of inducing HIT in animal models. The synthesized VP28-heparin trimeric nanoparticle was non-immunogenic, possessed an average hydrodynamic size (8.81 ± 0.58 nm) optimal for the evasion renal filtration and reticuloendothelial system uptake (hence prolonging circulating half-life). Additionally, VP28-heparin did not induce mouse death or reduce blood platelet count when administered at a high dosein vivo(hence reducing HIT risks). The VP28-heparin nanoparticle also exhibited superior anticoagulation properties (2.2× higher prothrombin time) and comparable activated partial thromboplastin time, but longer anticoagulation period when compared to unfractionated heparin. The anticoagulative effects of the VP28-heparin can also be reversed using protamine sulfate. Thus, VP28-heparin may be an effective and safe heparin derivative for therapeutic use.
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Affiliation(s)
- Hussein Reda Hussein
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, 30068 Hsinchu, Taiwan
- Department of Botany and Microbiology, Faculty of Science, Al-Azhar University, Assiut branch 71524, Egypt
| | - Chia-Yu Chang
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, 30068 Hsinchu, Taiwan
| | - Yini Zheng
- Department of Materials Science and Engineering, City University of Hong Kong, Hong Kong
| | - Chih-Yu Yang
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Li-Hua Li
- Department of Pathology and laboratory medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Yi-Tzu Lee
- Department of Emergency, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Jun-Yi Chen
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Yu-Chaun Liang
- Agricultural Biotechnology Research Center, Academia Sinica, Taipei 11529, Taiwan
| | - Chuan-Ju Lin
- Agricultural Biotechnology Research Center, Academia Sinica, Taipei 11529, Taiwan
| | - Yu-Chia Chang
- Agricultural Biotechnology Research Center, Academia Sinica, Taipei 11529, Taiwan
| | - Hui Nee Geo
- Department of Pharmacology, Faculty of Medicine, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Suzita Mohd Noor
- Department of Biomedical Science, Faculty of Medicine, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Lik Voon Kiew
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, 30068 Hsinchu, Taiwan
- Department of Pharmacology, Faculty of Medicine, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Fu-Rong Chen
- Department of Materials Science and Engineering, City University of Hong Kong, Hong Kong
| | - Chia-Ching Chang
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, 30068 Hsinchu, Taiwan
- Department of Electrophysics, National Yang Ming Chiao Tung University, Hsinchu 30010, Taiwan
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), National Yang Ming Chiao Tung University, Hsinchu 30068, Taiwan
- International College of Semiconductor Technology, National Yang Ming Chiao Tung University, 30010 Hsinchu, Taiwan
- Institute of Physics, Academia Sinica, Taipei 10529, Taiwan
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Lwin TN, Mudannayake R, MacDonald S, Arrowsmith JE, Burt C, Besser M, Falter F. Assessing the impact of different heparin dosing regimens for cardiopulmonary bypass on anticoagulation: the HepDOSE pilot study. Can J Anaesth 2024; 71:234-243. [PMID: 37985627 DOI: 10.1007/s12630-023-02645-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 07/11/2023] [Accepted: 07/23/2023] [Indexed: 11/22/2023] Open
Abstract
PURPOSE It has been suggested that a larger heparin dose during cardiopulmonary bypass (CPB) is associated with reduced perioperative coagulopathy and thromboembolic complications. We investigated the effect of different heparin doses during routine elective cardiac surgery. Our primary outcomes include blood loss and transfusion and secondary outcomes investigate the effects on coagulation biomarkers. METHODS In this prospective pilot trial, we allocated 60 patients undergoing cardiac surgery on CPB in a single tertiary cardiac centre into three groups to receive an initial dose of 300, 400, or 500 units (U) per kilogram of intravenous heparin prior to the commencement of CPB. Blood was sampled after induction of anesthesia, at 30 and 60 min of CPB, and three minutes after heparin reversal with protamine. Samples were analyzed for fibrinopeptide A (FPA), fibrinopeptide B (FPB), D-dimer, and thrombin-antithrombin (TAT) complexes. Postoperative blood loss and transfusion was measured for the first 24-hr period after surgery. RESULTS The total mean (95% CI) administered heparin dose in the 300 U·kg-1, 400 U·kg-1, and 500 U·kg-1 groups were 39,975 (36,528 to 43,421) U, 43,195 (36,940 to 49,449) U and 47,900 (44,807 to 50,992) U, respectively. There were no statistically significant differences in FPA, FPB or D-dimer levels at the measured time intervals. There was a trend towards lower TAT levels while on CPB with greater heparin dosing, which was statistically significant after the administration of protamine. The clinical significance appears to be negligible, as there is no difference in overall blood loss and amount of packed red blood cell transfusion or other blood product transfusion. CONCLUSION This pilot study indicates that, while larger heparin dosing for routine cardiac surgery results in subtle biochemical changes in coagulation, there is no demonstrable benefit in postoperative blood loss or transfusion requirements.
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Affiliation(s)
- Thar Nyan Lwin
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Rahul Mudannayake
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Stephen MacDonald
- Division of Clinical Haematology and Blood Transfusion, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Joseph E Arrowsmith
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Christiana Burt
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Martin Besser
- Division of Clinical Haematology and Blood Transfusion, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Florian Falter
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.
- Department of Anaesthetics and Critical Care, The Royal Papworth Hospital NHS Foundation Trust, Papworth Road, Cambridge Biomedical Campus, Cambridge, CB2 0AY, UK.
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Wargowsky R, Zvara J, Qaddumi N, Gonzalez-Almada A, Lin D, Fernandez X, Tanaka K, Mazzeffi M. In vitro comparison of spatiotemporal fibrin clot formation dynamics in plasma treated with different protamine-heparin ratios. Perfusion 2023; 38:1631-1636. [PMID: 36036659 DOI: 10.1177/02676591221122365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Our study aim was to explore how different protamine-heparin ratios impacted enzymatic coagulation and acellular fibrin clot growth in plasma using an in vitro model. We hypothesized that a low protamine-heparin ratio would be associated with superior fibrin clot growth dynamics. METHODS We performed an in vitro study using 15 plasma samples from a commercial supplier. Different protamine-heparin ratios were added to each donor plasma sample: low ratio (0.7-1), traditional ratio (1-1), and high ratio (1.3-1) and clot formation dynamics were evaluated using a Thrombodynamics analyzer. Study outcomes were initial clot growth velocity and clot size at 30 min. RESULTS Plasma samples treated with a one-to-one protamine-heparin ratio had significantly lower mean initial clot growth velocity compared to samples treated with a low protamine-heparin ratio; mean difference -2.3 μm/min (95% CI = -4.0 to -0.7, p = .004). Plasma samples treated with a one-to-one protamine-heparin ratio also had significantly smaller mean clot size at 30 min compared to samples treated with a low protamine-heparin ratio; mean difference -54.0 μm (95% CI = -107.6 to -0.4, p = .048). There were no significant differences in mean initial clot growth velocity or clot size at 30 min between plasma samples treated with a high protamine-heparin ratio and those treated with a one-to-one or low protamine-heparin ratio (all p > .05). CONCLUSIONS Plasma samples treated with a low protamine-heparin ratio had superior clot growth velocity and larger clot size at 30 min compared to a one-to-one ratio, supporting the notion that a low protamine-heparin ratio may optimize enzymatic coagulation after cardiopulmonary bypass.
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Affiliation(s)
- Richard Wargowsky
- Department of Anesthesiology, George Washington University School of Medicine, Washington, DC, USA
| | - Jessica Zvara
- Department of Anesthesiology, George Washington University School of Medicine, Washington, DC, USA
| | - Nidal Qaddumi
- Department of Anesthesiology, George Washington University School of Medicine, Washington, DC, USA
| | - Alberto Gonzalez-Almada
- Department of Anesthesiology, George Washington University School of Medicine, Washington, DC, USA
| | - Dora Lin
- Department of Anesthesiology, George Washington University School of Medicine, Washington, DC, USA
| | - Xiomara Fernandez
- Department of Pathology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Kenichi Tanaka
- Department of Anesthesiology, Oklahoma University College of Medicine, Oklahoma City, OK, USA
| | - Michael Mazzeffi
- Department of Anesthesiology, George Washington University School of Medicine, Washington, DC, USA
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7
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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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8
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Levy JH, Ghadimi K, Kizhakkedathu JN, Iba T. What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives. J Thromb Haemost 2023; 21:1714-1723. [PMID: 37062523 DOI: 10.1016/j.jtha.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023]
Abstract
Protamine, a highly basic protein isolated from salmon sperm, is the only clinically available agent to reverse the anticoagulation of unfractionated heparin. Following intravenous administration, protamine binds to heparin in a nonspecific electrostatic interaction to reverse its anticoagulant effects. In clinical use, protamine is routinely administered to reverse high-dose heparin anticoagulation in cardiovascular procedures, including cardiac surgery with cardiopulmonary bypass. Despite the lack of supportive evidence regarding protamine's effectiveness to reverse low-molecular-weight heparin, it is recommended in guidelines with low-quality evidence. Different dosing strategies have been reported for reversing heparin in cardiac surgical patients based on empiric dosing, pharmacokinetics, or point-of-care measurements of heparin levels. Protamine administration is associated with a spectrum of adverse reactions that range from vasodilation to life-threatening cardiopulmonary dysfunction and shock. The life-threatening responses appear to be hypersensitivity reactions due to immunoglobulin E and/or immunoglobulin G antibodies. However, protamine and heparin-protamine complexes can activate complement inflammatory pathways and inhibit other coagulation factors. Although alternative agents for reversing heparin are not currently available for clinical use, additional research continues evaluating novel therapeutic approaches.
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Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina, USA.
| | - Kamrouz Ghadimi
- Departments of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jayachandran N Kizhakkedathu
- Centre for Blood Research, Department of Pathology and Laboratory Medicine, The School of Biomedical Engineering, The University of British Columbia, Vancouver, British Colombia, Canada
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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9
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La CC, Smith SA, Vappala S, Adili R, Luke CE, Abbina S, Luo HD, Chafeeva I, Drayton M, Creagh LA, de Guadalupe Jaraquemada-Peláez M, Rhoads N, Kalathottukaren MT, Henke PK, Straus SK, Du C, Conway EM, Holinstat M, Haynes CA, Morrissey JH, Kizhakkedathu JN. Smart thrombosis inhibitors without bleeding side effects via charge tunable ligand design. Nat Commun 2023; 14:2177. [PMID: 37100783 PMCID: PMC10133246 DOI: 10.1038/s41467-023-37709-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 03/28/2023] [Indexed: 04/28/2023] Open
Abstract
Current treatments to prevent thrombosis, namely anticoagulants and platelets antagonists, remain complicated by the persistent risk of bleeding. Improved therapeutic strategies that diminish this risk would have a huge clinical impact. Antithrombotic agents that neutralize and inhibit polyphosphate (polyP) can be a powerful approach towards such a goal. Here, we report a design concept towards polyP inhibition, termed macromolecular polyanion inhibitors (MPI), with high binding affinity and specificity. Lead antithrombotic candidates are identified through a library screening of molecules which possess low charge density at physiological pH but which increase their charge upon binding to polyP, providing a smart way to enhance their activity and selectivity. The lead MPI candidates demonstrates antithrombotic activity in mouse models of thrombosis, does not give rise to bleeding, and is well tolerated in mice even at very high doses. The developed inhibitor is anticipated to open avenues in thrombosis prevention without bleeding risk, a challenge not addressed by current therapies.
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Affiliation(s)
- Chanel C La
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Chemistry, University of British Columbia, Vancouver, BC, Canada
| | - Stephanie A Smith
- Department of Biological Chemistry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sreeparna Vappala
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Reheman Adili
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI, USA
- Bloodworks Research Institute, 1551 Eastlake Avenue E.; Ste. 100, Seattle, WA, 98102, USA
| | - Catherine E Luke
- Department of Surgery, Section of Vascular Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Srinivas Abbina
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Haiming D Luo
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Chemistry, University of British Columbia, Vancouver, BC, Canada
| | - Irina Chafeeva
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Matthew Drayton
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Louise A Creagh
- Department of Chemical and Biological Engineering, University of British Columbia, Vancouver, BC, Canada
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada
| | | | - Nicole Rhoads
- Bloodworks Research Institute, 1551 Eastlake Avenue E.; Ste.100, Seattle, WA, 98102, USA
| | - Manu Thomas Kalathottukaren
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Peter K Henke
- Department of Surgery, Section of Vascular Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Suzana K Straus
- Department of Chemistry, University of British Columbia, Vancouver, BC, Canada
| | - Caigan Du
- Department of Urological Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Edward M Conway
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- The School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Michael Holinstat
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Charles A Haynes
- Department of Chemical and Biological Engineering, University of British Columbia, Vancouver, BC, Canada
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada
| | - James H Morrissey
- Department of Biological Chemistry, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Jayachandran N Kizhakkedathu
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada.
- Department of Chemistry, University of British Columbia, Vancouver, BC, Canada.
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.
- The School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada.
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10
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Stone ME, Vespe MW. Heparin Rebound: An In-Depth Review. J Cardiothorac Vasc Anesth 2023; 37:601-612. [PMID: 36641308 DOI: 10.1053/j.jvca.2022.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/17/2022] [Accepted: 12/19/2022] [Indexed: 12/26/2022]
Abstract
The common conception of "heparin rebound" invokes heparin returning to circulation in the postoperative period after apparently adequate intraoperative reversal with protamine. This is believed to portend increased postoperative bleeding and provides the rationale for administering additional empiric doses of protamine in response to prolonged coagulation tests and/or bleeding. However, the relevant literature of the last 60+ years provides only a weak level of evidence that "rebounded" heparin itself is a significant etiology of postoperative bleeding after cardiac surgery with cardiopulmonary bypass. Notably, many of the most frequently cited heparin rebound investigators ultimately concluded that although exceedingly low levels of heparin activity could be detected by anti-Xa assay in some (but not all) patients postoperatively, there was no correlation with actual bleeding. An understanding of the literature requires a careful reading of the details because the investigators lacked standardized definitions for "heparin rebound" and "adequate reversal" while studying the phenomenon with significantly different experimental methodologies and laboratory tests. This review was undertaken to provide a modern understanding of the "heparin rebound" phenomenon to encourage an evidence-based approach to postoperative bleeding. Literature searches were conducted via PubMed using the following MeSH terms: heparin rebound, heparin reversal, protamine, platelet factor 4, and polybrene. Relevant English language articles were reviewed, with subsequent references obtained from the internal citations. Perspective is provided for both those who use HepCon-guided management and those who do not, as are practical recommendations for the modern era based on the published data and conclusions of the various investigators.
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Affiliation(s)
- Marc E Stone
- Icahn School of Medicine at Mount Sinai, New York, NY
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11
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Taneja R, Szoke DJ, Hynes Z, Jones PM. Minimum protamine dose required to neutralize heparin in cardiac surgery: a single-centre, prospective, observational cohort study. Can J Anaesth 2023; 70:219-227. [PMID: 36471142 DOI: 10.1007/s12630-022-02364-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Excess protamine contributes to coagulopathy following cardiopulmonary bypass (CPB) and may increase blood loss and transfusion requirements. The primary aim of this study was to find the least amount of protamine necessary to neutralize residual heparin following CPB using the gold standard assays of anti-IIa and anti-Xa activity. Secondary objectives were to evaluate whether the post-CPB activated clotting time could be used as a surrogate marker for quantifying heparin neutralization. METHODS Twenty-eight consecutive patients undergoing elective cardiac surgery were enrolled. Protamine administration was standardized through an infusion pump at 25 mg·min-1. Blood samples were withdrawn prior to and following administration of 150, 200, 250, and 300 mg protamine and analyzed for activated clotting time and anti-IIa and -Xa activity. RESULTS Following a mean (standard deviation) cumulative heparin dose of 67,700 (19,400) units and a CPB duration of 113 (71) min, protamine requirements varied widely. Eight out of 25 (32%) patients showed complete neutralization of anti-IIa and -Xa activity at the first sampling point (150 mg protamine; protamine:heparin ratio, 0.3 [0.1]). A protamine:heparin ratio of 0.5 (0.2) was sufficient for heparin neutralization in > 90% of patients. After CPB, a low to mid-range activated clotting time correlated well with anti-IIa and -Xa activity. CONCLUSIONS The protamine:heparin ratio required to neutralize residual unfractionated heparin (UFH) following CPB is variable. A protamine:heparin ratio of 0.3 was sufficient to neutralize UFH in some patients, while a ratio of 0.5 is sufficient to neutralize both residual anti-IIa and -Xa activity in most patients. Larger studies are necessary to confirm these findings and evaluate their clinical implications. STUDY REGISTRATION ClinicalTrials.gov (NCT03787641); registered 26 December 2018.
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Affiliation(s)
- Ravi Taneja
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada.
- Division of Critical Care, Department of Medicine, London Health Sciences Centre, University Hospital, B2-223, 339 Windermere Road, London, ON, N6A 5A5, Canada.
| | - Daniel J Szoke
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
| | - Zachary Hynes
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
| | - Philip M Jones
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
- Department of Epidemiology & Biostatistics, University of Western Ontario, London, ON, Canada
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12
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Ultraporous Polyquaternium-Carboxylated Chitosan Composite Hydrogel Spheres with Anticoagulant, Antibacterial, and Rapid Endotoxin Removal Profiles for Sepsis Treatment. Biomacromolecules 2022; 23:3728-3742. [PMID: 35926229 DOI: 10.1021/acs.biomac.2c00583] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hemoperfusion is an important method to remove endotoxins and save the lives of patients with sepsis. However, the current adsorbents for hemoperfusion have disadvantages of insufficient endotoxin adsorption capacity, poor blood compatibility, and so on. Herein, we proposed a novel emulsion templating (ET) method to prepare ultraporous and double-network carboxylated chitosan (CCS)-poly(diallyl dimethylammonium chloride) (PDDA) hydrogel spheres (ET-CCSPD), bearing both negative and positive charges. CCS was introduced to balance the strong positive charges of PDDA to improve hemocompatibility, and emulsion templates endowed the adsorbent with an ultraporous structure for enhanced adsorption efficacy. The ET-CCSPDs neither damaged blood cells nor activated complement responses. In addition, the activated partial thromboplastin time (APTT) was prolonged to 8.5 times, which was beneficial for reducing the injection of anticoagulant in patients. The ET-CCSPDs had excellent scavenging performance against bacteria and endotoxin, with removal ratios of 96.7% for E. coli and 99.8% for S. aureus, respectively, and the static removal ratio of endotoxin in plasma was as high as 99.1% (C0 = 5.50 EU/mL, critical illness level). An adsorption cartridge filled with the ET-CCSPDs could remove 84.7% of endotoxin within 1 h (C0 = 100 EU/mL in PBS). Interestingly, the ET-CCSPDs had a good inhibitory effect on the cytokines produced by endotoxin-mediated septic blood. By developing the ET method to prepare ultraporous and double-network adsorbents, the problems of low adsorption efficiency and poor blood compatibility of traditional endotoxin adsorbents have been solved, thus opening a new route to fabricate absorbents for blood purification.
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13
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Paul R, Banik H, Alzaid M, Bhattacharjee D, Hussain SA. Interaction of a Phospholipid and a Coagulating Protein: Potential Candidate for Bioelectronic Applications. ACS OMEGA 2022; 7:17583-17592. [PMID: 35664573 PMCID: PMC9161252 DOI: 10.1021/acsomega.1c07395] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 04/15/2022] [Indexed: 05/31/2023]
Abstract
In the present communication, we have investigated the interaction between a biomembrane component 1,2-dioleoyl-sn-glycero-3-phosphocholine (DOPC) and a coagulating protein protamine sulfate (PS) using the Langmuir-Blodgett (LB) technique. The π-A isotherm, π-t characteristics, and analysis of isotherm curves suggested that PS strongly interacted with DOPC, affecting the fluidity of the DOPC layer. Electrical characterization indicates that PS as well as the PS-DOPC film showed resistive switching behavior suitable for Write Once Read Many (WORM) memory application. Trap-controlled space charge-limited conduction (SCLC) was the key mechanism behind such observed switching. The presence of DOPC affected the SCLC process, leading to lowering of threshold voltage (V Th), which is advantageous in terms of lower power consumption.
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Affiliation(s)
- Ripa Paul
- Thin
Film and Nanoscience Laboratory, Department of Physics, Tripura University, Suryamaninagar 799022, Tripura, India
| | - Hritinava Banik
- Thin
Film and Nanoscience Laboratory, Department of Physics, Tripura University, Suryamaninagar 799022, Tripura, India
| | - Meshal Alzaid
- Physics
Department, College of Science, Jouf University, P.O. Box 2014, Sakaka, Al-Jouf 75471, Saudi Arabia
| | - Debajyoti Bhattacharjee
- Thin
Film and Nanoscience Laboratory, Department of Physics, Tripura University, Suryamaninagar 799022, Tripura, India
| | - Syed Arshad Hussain
- Thin
Film and Nanoscience Laboratory, Department of Physics, Tripura University, Suryamaninagar 799022, Tripura, India
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14
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Yeh HH, Yu K, Vappala S, Kalathottukaren MT, Abbina S, Luo HD, Grecov D, Kizhakkedathu JN. Rheological and clot microstructure evaluation of heparin neutralization by UHRA and protamine. J Mech Behav Biomed Mater 2021; 124:104851. [PMID: 34600430 DOI: 10.1016/j.jmbbm.2021.104851] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 06/16/2021] [Accepted: 09/19/2021] [Indexed: 11/27/2022]
Abstract
The current study reports the use of small amplitude oscillatory rheometry to investigate the dynamics of blood clot formation upon heparin neutralization under three different oscillatory frequencies, two of which were mimicking physiological heart rates. We utilized two different heparin antidotes, namely protamine and newly developed universal heparin reversal agent (UHRA-7), at different concentrations to determine the quality of blood clot formed upon heparin neutralization by analyzing several key rheological parameters. Scanning electron microscopy (SEM) was used to determine the morphology and microstructure of the blood clot after heparin neutralization to support the rheological observations. The current study revealed that the structure of blood clots formed had significant differences when an oscillatory frequency that mimicked the physiological heart rate was used in comparison to a lower frequency commonly used in current clinical measurements. The limited working dose range for protamine and its intrinsic anticoagulation behaviour was observed. The neutralization profile of UHRA-7 showed a large window of activity. The global assessment of rheological parameters and microstructure of the clot together revealed additional details describing anticoagulant reversal and blood coagulation dynamics by relating the blood clot's fiber thickness and the oscillatory measurements, including storage modulus and blood clot's contractile force. Additionally, a mechanical characterization was conducted to provide a further assessment of blood coagulation using the rheological data.
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Affiliation(s)
- Han Hung Yeh
- School of Biomedical Engineering, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada; Department of Mechanical Engineering, University of British Columbia, Vancouver, British Columbia, V6T 1Z4, Canada
| | - Kai Yu
- Centre for Blood Research and Life Science Institute, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada; Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Sreeparna Vappala
- Centre for Blood Research and Life Science Institute, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada; Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Manu Thomas Kalathottukaren
- Centre for Blood Research and Life Science Institute, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada; Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Srinivas Abbina
- Centre for Blood Research and Life Science Institute, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada; Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Haiming D Luo
- Centre for Blood Research and Life Science Institute, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada; Department of Chemistry, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Dana Grecov
- School of Biomedical Engineering, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada; Department of Mechanical Engineering, University of British Columbia, Vancouver, British Columbia, V6T 1Z4, Canada.
| | - Jayachandran N Kizhakkedathu
- School of Biomedical Engineering, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada; Centre for Blood Research and Life Science Institute, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada; Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada; Department of Chemistry, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada.
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15
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Song X, Ji H, Li Y, Xiong Y, Qiu L, Zhong R, Tian M, Kizhakkedathu JN, Su B, Wei Q, Zhao W, Zhao C. Transient blood thinning during extracorporeal blood purification via the inactivation of coagulation factors by hydrogel microspheres. Nat Biomed Eng 2021; 5:1143-1156. [PMID: 33495638 DOI: 10.1038/s41551-020-00673-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 12/09/2020] [Indexed: 02/07/2023]
Abstract
During extracorporeal blood purification, anticoagulants are administered to prevent thrombogenesis. However, haemorrhagic complications owing to near-complete inactivation of blood coagulation and delayed recovery of haemostasis pose serious risks to patients. Here, we show in vitro and in beagle dogs that hydrogel microspheres that adsorb the coagulation factors VIII, IX and XI provide transient blood thinning when placed in the extracorporeal circuit before blood purification. The microspheres inhibited the activities of the coagulation factors by levels (~8-30%) similar to those occurring in mild haemophilia. On its reintroduction into the animal, the purified pseudo-haemophilic blood favoured faster recovery of haemostasis. The transient blood-thinning strategy may increase the safety of clinical blood-purification procedures.
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Affiliation(s)
- Xin Song
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China
| | - Haifeng Ji
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China
| | - Yupei Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China.,Sichuan University-the Hong Kong Polytechnic University Institute for Disaster Management and Reconstruction, Chengdu, China
| | - Yuqin Xiong
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Li Qiu
- Department of Ultrasound, West China School of Medicine/West China Hospital, Sichuan University, Chengdu, China
| | - Rui Zhong
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences, Peking Union Medical College, Chengdu, China
| | - Meng Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jayachandran N Kizhakkedathu
- Department of Pathology and Laboratory Medicine, Center for Blood Research and Life Science Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Baihai Su
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China.,Sichuan University-the Hong Kong Polytechnic University Institute for Disaster Management and Reconstruction, Chengdu, China
| | - Qiang Wei
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China.,Department of Cellular Biophysics, Max Planck Institute for Medical Research, Heidelberg, Heidelberg, Germany.,Department of Biophysical Chemistry, University of Heidelberg, Heidelberg, Germany
| | - Weifeng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China.
| | - Changsheng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China.
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16
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Hardy M, Douxfils J, Morimont L, Didembourg M, Carlo A, de Maistre E, Lecompte T, Mullier F. Study of in vitro thrombin generation after neutralization of heparin. Int J Lab Hematol 2021; 44:168-176. [PMID: 34582127 DOI: 10.1111/ijlh.13703] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Thrombin generation (TG) documents hypercoagulability. TG in platelet-poor plasma is exquisitely sensitive to heparins, which thus must be neutralized before testing. Heparinase and hexadimethrine bromide (polybrene) have been used for that purpose, but their effects per se on TG have been poorly studied so far. METHODS (i) TG was studied in commercial normal pooled plasma (NPP; CryoCheck® , Cryopep) in absence or presence of neutralizing agents. (ii) NPP was spiked with increasing concentrations of unfractionated heparin (UFH; up to 1.0 IU/mL) or low-molecular-weight heparin (LMWH; enoxaparin up to 1.2 IU/mL) and TG studied after incubation of heparinase (Hepzyme® ; 15 minutes) or polybrene (0.025 mg/mL; 10 minutes). RESULTS (i) With ThromboScreen reagent to initiate TG, addition of heparinase was associated with increased peak, whereas polybrene caused lengthening of lag time and time to peak, compared with nonsupplemented NPP. (ii) With polybrene, TG was completely restored over the whole range of UFH and LMWH studied. By contrast, heparinase failed to fully restore TG in presence of UFH concentrations ≥0.8 IU/mL or LMWH concentrations ≥1.0 IU/mL. Those effects were matched with detectable tiny residual amounts of non-neutralized heparin (as assessed with an anti-Xa assay) and were less pronounced with a higher picomolar concentration of tissue factor (DrugScreen reagent). CONCLUSION Polybrene fully restored TG of heparinized plasma at the expense of an alteration of TG, pointing to the need to use adapted reference ranges. Heparinase failed to do so in presence of high concentrations of both heparins.
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Affiliation(s)
- Michael Hardy
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Hematology Laboratory, Yvoir, Belgium.,Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Anesthesiology Department, Yvoir, Belgium
| | - Jonathan Douxfils
- Pharmacy Department, Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium.,Qualiblood s.a., Namur, Belgium
| | - Laure Morimont
- Pharmacy Department, Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium.,Qualiblood s.a., Namur, Belgium
| | - Marie Didembourg
- Pharmacy Department, Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | | | | | - Thomas Lecompte
- Division of Angiology and Hemostasis - Geneva Platelet Group, Departements of Medecine, Université de Genève et Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Hematology Laboratory, Yvoir, Belgium
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17
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Ho LTS, McVey MJ, Kuiper GJAJM, Gross PL, Karkouti K. Analysis of the effect of varying protamine-to-heparin ratio on coagulation in vitro. Br J Anaesth 2021; 127:e128-e130. [PMID: 34334192 DOI: 10.1016/j.bja.2021.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/15/2021] [Accepted: 06/20/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Loretta T S Ho
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anaesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada.
| | - Mark J McVey
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Department of Physics, Ryerson University, Toronto, ON, Canada
| | - Gerhardus J A J M Kuiper
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Treatment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Peter L Gross
- The Thrombosis and Atherosclerosis Research Institute, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Keyvan Karkouti
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anaesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada; Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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18
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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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19
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Miles LF, Burt C, Arrowsmith J, McKie MA, Villar SS, Govender P, Shaylor R, Tan Z, De Silva R, Falter F. Optimal protamine dosing after cardiopulmonary bypass: The PRODOSE adaptive randomised controlled trial. PLoS Med 2021; 18:e1003658. [PMID: 34097705 PMCID: PMC8216535 DOI: 10.1371/journal.pmed.1003658] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 06/21/2021] [Accepted: 05/14/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The dose of protamine required following cardiopulmonary bypass (CPB) is often determined by the dose of heparin required pre-CPB, expressed as a fixed ratio. Dosing based on mathematical models of heparin clearance is postulated to improve protamine dosing precision and coagulation. We hypothesised that protamine dosing based on a 2-compartment model would improve thromboelastography (TEG) parameters and reduce the dose of protamine administered, relative to a fixed ratio. METHODS AND FINDINGS We undertook a 2-stage, adaptive randomised controlled trial, allocating 228 participants to receive protamine dosed according to a mathematical model of heparin clearance or a fixed ratio of 1 mg of protamine for every 100 IU of heparin required to establish anticoagulation pre-CPB. A planned, blinded interim analysis was undertaken after the recruitment of 50% of the study cohort. Following this, the randomisation ratio was adapted from 1:1 to 1:1.33 to increase recruitment to the superior arm while maintaining study power. At the conclusion of trial recruitment, we had randomised 121 patients to the intervention arm and 107 patients to the control arm. The primary endpoint was kaolin TEG r-time measured 3 minutes after protamine administration at the end of CPB. Secondary endpoints included ratio of kaolin TEG r-time pre-CPB to the same metric following protamine administration, requirement for allogeneic red cell transfusion, intercostal catheter drainage at 4 hours postoperatively, and the requirement for reoperation due to bleeding. The trial was listed on a clinical trial registry (ClinicalTrials.gov Identifier: NCT03532594). Participants were recruited between April 2018 and August 2019. Those in the intervention/model group had a shorter mean kaolin r-time (6.58 [SD 2.50] vs. 8.08 [SD 3.98] minutes; p = 0.0016) post-CPB. The post-protamine thromboelastogram of the model group was closer to pre-CPB parameters (median pre-CPB to post-protamine kaolin r-time ratio 0.96 [IQR 0.78-1.14] vs. 0.75 [IQR 0.57-0.99]; p < 0.001). We found no evidence of a difference in median mediastinal/pleural drainage at 4 hours postoperatively (140 [IQR 75-245] vs. 135 [IQR 94-222] mL; p = 0.85) or requirement (as a binary outcome) for packed red blood cell transfusion at 24 hours postoperatively (19 [15.8%] vs. 14 [13.1%] p = 0.69). Those in the model group had a lower median protamine dose (180 [IQR 160-210] vs. 280 [IQR 250-300] mg; p < 0.001). Important limitations of this study include an unblinded design and lack of generalisability to certain populations deliberately excluded from the study (specifically children, patients with a total body weight >120 kg, and patients requiring therapeutic hypothermia to <28°C). CONCLUSIONS Using a mathematical model to guide protamine dosing in patients following CPB improved TEG r-time and reduced the dose administered relative to a fixed ratio. No differences were detected in postoperative mediastinal/pleural drainage or red blood cell transfusion requirement in our cohort of low-risk patients. TRIAL REGISTRATION ClinicalTrials.gov Unique identifier NCT03532594.
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Affiliation(s)
- Lachlan F. Miles
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Anaesthesia, Austin Health, Melbourne, Australia
- * E-mail:
| | - Christiana Burt
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Joseph Arrowsmith
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Mikel A. McKie
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Sofia S. Villar
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Pooveshnie Govender
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Ruth Shaylor
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - Zihui Tan
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Ravi De Silva
- Department of Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Florian Falter
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
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20
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Mourikis P, Dannenberg L, Zako S, Helten C, M'Pembele R, Richter H, Hohlfeld T, Jung C, Zeus T, Kelm M, Veulemans V, Polzin A. Impact of Transcatheter Aortic Valve Implantation on Thrombin Generation and Platelet Function. Thromb Haemost 2021; 121:1310-1316. [PMID: 33759144 DOI: 10.1055/s-0041-1725190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) is an evolving treatment of severe aortic valve stenosis. However, thromboembolic events such as stroke are common, predominantly early after TAVI. Optimal periprocedural antithrombotic regime is unknown. Especially, as antithrombotic medication enhances bleeding risk, thrombin generation and platelet function are crucial in the pathogenesis of ischemic events. However, the impact of the TAVI procedure on thrombin formation and platelet reactivity is not known by now. METHODS We evaluated thrombin levels using thrombin-antithrombin (TAT) complexes and prothrombin fragments (PTFs) using enzyme-linked immunosorbent assay. Furthermore, platelet reactivity was measured via light transmission aggregometry before and 2 hours after TAVI in 198 patients. RESULTS TAT complexes and PTF F1 + 2 substantially increased during TAVI. Postprocedurally, TAT complexes and PTF were significantly higher after TAVI compared with percutaneous coronary intervention due to acute myocardial infarction, while preprocedural TAT complexes and PTF F1 + 2 did not differ. In contrast, platelet reactivity was not altered early after TAVI. Only adenosine diphosphate-induced aggregation was reduced, reflecting preprocedural loading with clopidogrel. CONCLUSION In this pilot study, we were able to demonstrate that thrombin generation is significantly increased early after TAVI, while platelet function is not affected. Increased thrombin concentrations may contribute to the high risk of postprocedural thromboembolic events. This leads to the hypothesis that extended peri-interventional anticoagulation early after TAVI may be an approach to reduce thromboembolic events.
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Affiliation(s)
- Philipp Mourikis
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Lisa Dannenberg
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Saif Zako
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Carolin Helten
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - René M'Pembele
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Hannah Richter
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Thomas Hohlfeld
- Institute for Pharmacology and Clinical Pharmacology, Heinrich Heine University, Dusseldorf, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Tobias Zeus
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Verena Veulemans
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Amin Polzin
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
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21
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Groene P, da Silva Gaspar Jung S, Acevedo AC, Lenhart B, Schäfer ST. A new strategy for an improved detection of residual heparin and excess protamine - A first in-vitro approach. Thromb Res 2021; 199:75-78. [PMID: 33453614 DOI: 10.1016/j.thromres.2020.12.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 12/03/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Philipp Groene
- Department of Anaesthesiology, University Hospital, LMU Munich, Germany.
| | | | | | - Barbara Lenhart
- Department of Anaesthesiology, University Hospital, LMU Munich, Germany
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22
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Ranger A, Gaspar M, Elkhatteb A, Jackson T, Fox S, Aw TC, Vipond L, Cotterill J, Ghori A, Laffan M, Arachchillage DRJ. The heparin-von Willebrand factor interaction and conventional tests of haemostasis - the challenges in predicting bleeding in cardiopulmonary bypass. Br J Haematol 2020; 192:1073-1081. [PMID: 33278841 DOI: 10.1111/bjh.17263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/13/2020] [Indexed: 01/04/2023]
Abstract
Bleeding is a significant complication of cardiopulmonary bypass (CPB), despite routine anticoagulation monitoring. This is likely to be multifactorial. In this prospective, single-centre cohort study of 30 patients undergoing CPB surgery, our aim was to characterise the changes in von Willebrand factor (VWF) function, platelet interaction and the global coagulation changes during and after CPB surgery and to determine whether bleeding can be predicted. Samples were taken at six time points before, during and after CPB surgery. We observed a significant rise in VWF antigen (VWF:Ag) throughout surgery, which continued postoperatively. The absolute VWF collagen-binding assays (VWF:CB) and VWF ristocetin cofactor (VWF:RCo) rose significantly but the VWF:CB/VWF:Ag and VWF:Ag/VWF:RCo fell significantly (P = 0·0015 and P = 0·0143), suggesting loss of large multimers. We detected a non-significant trend to loss of VWF:RCo after heparinisation and a significant recovery after protamine reversal which could reflect a direct heparin effect. There was a significant increase in the R and K times with a fall in alpha angle and maximum amplitude after heparin administration, using heparinase-thromboelastography (TEG). The parameters both significantly improved following protamine (P = 0·007 and P = 0·0054). The activated clotting time (ACT) and heparin anti-Xa level correlated poorly; neither predicted clinically significant bleeding. None of these parameters had a relationship with intraoperative blood loss or requirement for blood product replacement.
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Affiliation(s)
- Amita Ranger
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Mihaela Gaspar
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Amira Elkhatteb
- Department of Anaesthesia, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Tim Jackson
- Department of Perfusion, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Steve Fox
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - T C Aw
- Department of Anaesthesia, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Lisa Vipond
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Judy Cotterill
- Department of Anaesthesia, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Arshad Ghori
- Department of Anaesthesia, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Mike Laffan
- Department of Immunology and Inflammation, Imperial College London, London, UK.,Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Deepa R J Arachchillage
- Department of Immunology and Inflammation, Imperial College London, London, UK.,Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK.,Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
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23
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Han AR, Han JW, Lee SK. Inherited thrombophilia and anticoagulant therapy for women with reproductive failure. Am J Reprod Immunol 2020; 85:e13378. [DOI: 10.1111/aji.13378] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/09/2020] [Accepted: 10/28/2020] [Indexed: 01/08/2023] Open
Affiliation(s)
- Ae Ra Han
- Department of Obstetrics and Gynecology Myuonggok Medical Research Center Konyang University College of Medicine Daejeon Korea
| | - Jae Won Han
- Department of Obstetrics and Gynecology Myuonggok Medical Research Center Konyang University College of Medicine Daejeon Korea
| | - Sung Ki Lee
- Department of Obstetrics and Gynecology Myuonggok Medical Research Center Konyang University College of Medicine Daejeon Korea
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24
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A Standardized Bolus of 5 000 IU of Heparin Does not Lead to Adequate Heparinization during Non-cardiac Arterial Procedures. Ann Vasc Surg 2020; 71:280-287. [PMID: 32768536 DOI: 10.1016/j.avsg.2020.07.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/04/2020] [Accepted: 07/10/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND In non-cardiac arterial procedures (NCAP), heparin is administered to prevent arterial thromboembolic complications (ATEC). Heparin has a nonpredictable effect in the individual patient, also known as variation in heparin sensitivity. Various dosing protocols are in use, but the optimal dose is currently still unknown. A standardized bolus of 5 000 IU heparin is most frequently used by vascular surgeons and interventional radiologists. The activated clotting time (ACT) is an established method to measure the level of anticoagulation, but has, until now, not gained widespread use in NCAP. The purpose of this study was to evaluate the anticoagulant effect during NCAP of a standardized bolus of 5 000 IU heparin by measuring the ACT. METHODS In this prospective study, 190 patients undergoing NCAP were enrolled between December 2016 and September 2018. The ACT was measured during open and endovascular/hybrid procedures. All patients received a standardized bolus of 5 000 IU heparin. The ACT was measured by the Hemostasis Management System Plus (HMS Plus, Medtronic®), before, 5 minutes after administration of heparin, and every 30 minutes thereafter. The primary outcome was periprocedural ACT values measured. Secondary outcomes were ATEC and hemorrhagic complications. RESULTS A large individual patient variability in the response to heparin was found. The mean baseline ACT in all patients was 129 ± 18 s., and the mean ACT 5 minutes after the initial bolus of heparin was 191 ± 36 s. After the initial dose of 5 000 IU heparin 60 (33%) and 10 (6%) patients reached an ACT of 200 and 250 s., respectively. Despite the use of heparin, ATEC occurred in 17 patients (9%). The lowest number of ATEC occurred in the group of patients with an ACT between 200 and 250 s. CONCLUSIONS A standardized bolus of 5 000 IU heparin does not lead to adequate and safe heparinization in non-cardiac arterial procedures. Patient response to heparin shows a large individual variability. Therefore, routine ACT measurements are necessary to ascertain adequate anticoagulation. Further research is needed to investigate if heparin dosing based on the ACT could result in less arterial thromboembolic complications, without increasing hemorrhagic complications.
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25
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Ashikhmina E, Johnson PM, Aganga DO, Nuttall GA, Lahr BD, Schaff HV, Dearani JA. Thrombin Generation and Antithrombin Activity in Infants Undergoing Cardiopulmonary Bypass—An Exploratory Study. J Cardiothorac Vasc Anesth 2020; 34:2083-2090. [DOI: 10.1053/j.jvca.2019.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/05/2019] [Accepted: 12/07/2019] [Indexed: 11/11/2022]
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26
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Neuroprotective Cationic Arginine-Rich Peptides (CARPs): An Assessment of Their Clinical Safety. Drug Saf 2020; 43:957-969. [DOI: 10.1007/s40264-020-00962-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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27
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Confounding effect of therapeutic protamine and heparin levels on routine and special coagulation testing. Blood Coagul Fibrinolysis 2020; 31:60-64. [PMID: 31904611 DOI: 10.1097/mbc.0000000000000882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: The management of a patient with hemophilia undergoing cardiovascular surgery relies on accurate coagulation test results. Both unfractionated heparin (UFH) and protamine sulfate used during cardiac surgery can interfere with factor and inhibitor assays. Here we describe the effects of UFH and protamine sulfate on routine coagulation, factor activity, and inhibitor assays. Pooled normal plasma (PNP) with UFH, PNP with protamine sulfate, PNP with both protamine sulfate and UFH were tested for the activated partial thromboplastin time (aPTT), prothrombin time (PT), thrombin time (TT), UFH anti-Xa, one-stage factor VIII (FVIII) activity, one-stage factor IX (FIX) activity, and Bethesda inhibitor assays for FVIII and FIX. UFH had a dose-dependent effect with TT, aPTT, and PT. On Bethesda inhibitor testing, FIX inhibition was detected at 1 U/ml UFH and 3 U/ml UFH for FVIII. Increasing protamine sulfate concentration in PNP prolonged the PT and aPTT in a dose-dependent manner, decreased FVIII and FIX activity and did not affect TT or UFH anti-Xa. At protamine sulfate doses of at least 200 μg/ml there was weak FVIII and FIX inhibition detected. At lower ratios of protamine sulfate to UFH (0.6 : 1-0.8 : 1), the aPTT decreased, suggesting reversal of UFH. However, at protamine sulfate to UFH ratios of 1.0 : 1 and higher, aPTT prolongation was observed. Inhibition of FVIII and FIX was detected at low ratios of protamine sulfate to UFH (below 0.4 : 1) and disappeared at higher ratios. UFH and protamine sulfate, alone or in combination, impact factor activity and inhibitor testing for both FVIII and FIX. Hence, factor activity and inhibitor assay results should be interpreted with caution when UFH or protamine sulfate are present.
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28
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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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29
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de Oliveira Barddal HP, Faria FAM, Nogueira AV, Iacomini M, Cipriani TR. Anticoagulant and antithrombotic effects of chemically sulfated guar gum. Int J Biol Macromol 2020; 145:604-610. [PMID: 31883892 DOI: 10.1016/j.ijbiomac.2019.12.210] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 12/18/2019] [Accepted: 12/23/2019] [Indexed: 12/17/2022]
Abstract
Heparin is an extremely important and recognized anticoagulant and antithrombotic agent. Obtained from animal sources and being highly potent, risks of contamination by pathogens and bleeding are some concerns related to heparin use. In the search for alternatives to heparin, several researches have been performed with chemically sulfated polysaccharides obtained from non-animal sources. In this work, studies with guar gum led to a partially hydrolyzed and chemically sulfated derivative (hGGSL) with Mw of 15.6 kDa, DS of 1.91 and promising anticoagulant and antithrombotic properties. In vitro, hGGSL was only 4.5× less potent than unfractionated heparin, acting mainly by inhibiting thrombin via antithrombin, and had its anticoagulant activity inhibited by protamine. In vivo, hGGSL showed potential for subcutaneous use and was effective in reducing venous thrombosis. Collectively, the results provide a basis for the development of a new anticoagulant and antithrombotic agent.
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Affiliation(s)
- Helyn Priscila de Oliveira Barddal
- Department of Biochemistry and Molecular Biology, Sector of Biological Sciences, Federal University of Paraná, CP 19.046, CEP 81.531-980 Curitiba, PR, Brazil
| | - Franciê Assis Melo Faria
- Department of Biochemistry and Molecular Biology, Sector of Biological Sciences, Federal University of Paraná, CP 19.046, CEP 81.531-980 Curitiba, PR, Brazil
| | - Alexsandro Vinícius Nogueira
- Department of Biochemistry and Molecular Biology, Sector of Biological Sciences, Federal University of Paraná, CP 19.046, CEP 81.531-980 Curitiba, PR, Brazil
| | - Marcello Iacomini
- Department of Biochemistry and Molecular Biology, Sector of Biological Sciences, Federal University of Paraná, CP 19.046, CEP 81.531-980 Curitiba, PR, Brazil
| | - Thales Ricardo Cipriani
- Department of Biochemistry and Molecular Biology, Sector of Biological Sciences, Federal University of Paraná, CP 19.046, CEP 81.531-980 Curitiba, PR, Brazil.
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30
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Törnudd M, Ramström S, Kvitting JPE, Alfredsson J, Pihl R, Berg S. Protamine stimulates platelet aggregation in vitro with activation of the fibrinogen receptor and alpha-granule release, but impairs secondary activation via ADP and thrombin receptors. Platelets 2020; 32:90-96. [PMID: 31992110 DOI: 10.1080/09537104.2020.1719992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Heparin and protamine are fundamental in the management of anticoagulation during cardiac surgery. Excess protamine has been associated with increased bleeding. Interaction between protamine and platelet function has been demonstrated but the mechanism remains unclear. We examined the effect of protamine on platelet function in vitro using impedance aggregometry, flow cytometry, and thrombin generation. Platelets were exposed to protamine at final concentrations of 0, 20, 40, and 80 µg/mL, alone or together with adenosine diphosphate (ADP) or thrombin PAR1 receptor-activating peptide (TRAP). We found that in the absence of other activators, protamine (80 µg/mL) increased the proportion of platelets with active fibrinogen receptor (binding of PAC-1) from 3.6% to 97.0% (p < .001) measured with flow cytometry. Impedance aggregometry also increased slightly after exposure to protamine alone. When activated with ADP or TRAP protamine at 80 µg/mL reduced aggregation, from 73.8 ± 29.4 U to 46.9 ± 21.1 U (p < .001) with ADP and from 126.4 ± 16.1 U to 94.9 ± 23.7 U (p < .01) with TRAP. P-selectin exposure (a marker of alpha-granule release) measured by median fluorescence intensity (MFI) increased dose dependently with protamine alone, from 0.76 ± 0.20 (0 µg/mL) to 10.2 ± 3.1 (80 µg/mL), p < .001. Protamine 80 µg/mL by itself resulted in higher MFI (10.16 ± 3.09) than activation with ADP (2.2 ± 0.7, p < .001) or TRAP (5.7 ± 2.6, p < .01) without protamine. When protamine was combined with ADP or TRAP, there was a concentration-dependent increase in the alpha-granule release. In conclusion, protamine interacts with platelets in vitro having both a direct activating effect and impairment of secondary activation of aggregation by other agonists.
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Affiliation(s)
- Mattias Törnudd
- Department of Cardiothoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden
| | - Sofia Ramström
- Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University , Linköping, Sweden.,Cardiovascular Research Centre, School of Medical Sciences, Örebro University , Örebro, Sweden
| | | | - Joakim Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden
| | - Richard Pihl
- Department of Cardiothoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden.,Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University , Linköping, Sweden
| | - Sören Berg
- Department of Cardiothoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden
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31
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McCool IE, Muir JM, Knollmann-Ritschel BEC. Educational Case: The Bleeding Patient. Acad Pathol 2019; 6:2374289519886042. [PMID: 31799382 PMCID: PMC6864031 DOI: 10.1177/2374289519886042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/19/2019] [Indexed: 11/29/2022] Open
Abstract
The following fictional case is intended as a learning tool within the Pathology
Competencies for Medical Education (PCME), a set of national standards for teaching
pathology. These are divided into three basic competencies: Disease Mechanisms and
Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology.
For additional information, and a full list of learning objectives for all three
competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.1
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Affiliation(s)
- Isaac E McCool
- Department of Pathology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jeannie M Muir
- Department of Pathology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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32
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Miklosz J, Kalaska B, Kaminski K, Rusak M, Szczubialka K, Nowakowska M, Pawlak D, Mogielnicki A. The Inhibitory Effect of Protamine on Platelets is Attenuated by Heparin without Inducing Thrombocytopenia in Rodents. Mar Drugs 2019; 17:E539. [PMID: 31533230 PMCID: PMC6780366 DOI: 10.3390/md17090539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/11/2019] [Accepted: 09/13/2019] [Indexed: 01/09/2023] Open
Abstract
Protamine sulfate (PS) is a polycationic protein drug obtained from the sperm of fish, and is used to reverse the anticoagulant effect of unfractionated heparin (UFH). However, the interactions between PS, UFH, and platelets are still not clear. We measured the platelet numbers and collagen-induced aggregation, P-selectin, platelet factor 4, β-thromboglobulin, prostacyclin metabolite, D-dimers, activated partial thromboplastin time, prothrombin time, anti-factor Xa, fibrinogen, thrombus weight and megakaryocytopoiesis in blood collected from mice and rats in different time points.. All of the groups were treated intravenously with vehicle, UFH, PS, or UFH with PS. We found a short-term antiplatelet activity of PS in mice and rats, and long-term platelet-independent antithrombotic activity in rats with electrically-induced thrombosis. The antiplatelet and antithrombotic potential of PS may contribute to bleeding risk in PS-overdosed patients. The inhibitory effect of PS on the platelets was attenuated by UFH without inducing thrombocytopenia. Treatment with UFH and PS did not affect the formation, number, or activation of platelets, or the thrombosis development in rodents.
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Affiliation(s)
- Joanna Miklosz
- Department of Pharmacodynamics, Medical University of Bialystok, 15-222 Bialystok, Poland
| | - Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, 15-222 Bialystok, Poland
| | - Kamil Kaminski
- Department of Physical Chemistry, Faculty of Chemistry, Jagiellonian University, 30-387 Krakow, Poland
| | - Malgorzata Rusak
- Department of Haematological Diagnostics, Medical University of Bialystok, 15-269 Bialystok, Poland
| | - Krzysztof Szczubialka
- Department of Physical Chemistry, Faculty of Chemistry, Jagiellonian University, 30-387 Krakow, Poland
| | - Maria Nowakowska
- Department of Physical Chemistry, Faculty of Chemistry, Jagiellonian University, 30-387 Krakow, Poland
| | - Dariusz Pawlak
- Department of Pharmacodynamics, Medical University of Bialystok, 15-222 Bialystok, Poland
| | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, 15-222 Bialystok, Poland.
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Yang Q, Liu S, Liu X, Liu Z, Xue W, Zhang Y. Role of charge-reversal in the hemo/immuno-compatibility of polycationic gene delivery systems. Acta Biomater 2019; 96:436-455. [PMID: 31254682 DOI: 10.1016/j.actbio.2019.06.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/13/2019] [Accepted: 06/24/2019] [Indexed: 01/08/2023]
Abstract
As an effective and well-recognized strategy used in many delivery systems, such as polycation gene vectors, charge reversal refers to the alternation of vector surface charge from negative (in blood circulation) to positive (in the targeted tissue) in response to specific stimuli to simultaneously satisfy the requirements of biocompatibility and targeting. Although charge reversal vectors are intended to avoid interactions with blood in their application, no overall or systematic investigation has been carried out to verify the role of charge reversal in the blood compatibility. Herein, we comprehensively mapped the effects of a typical charge-reversible polycation gene vector based on pH-responsive 2,3-dimethylmaleic anhydride (DMMA)-modified polyethylenimine (PEI)/pDNA complex in terms of blood components, coagulation function, and immune response as compared to conventional PEGylated modification. The in vitro and in vivo results displayed that charge-reversal modification significantly improves the PEI/pDNA-induced abnormal effect on vascular endothelial cells, platelet activation, clotting factor activity, fibrinogen polymerization, blood coagulation process, and pro-inflammatory cytokine expression. Unexpectedly, (PEI/pDNA)-DMMA induced the cytoskeleton impairment-mediated erythrocyte morphological alternation and complement activation even more than PEI/pDNA. Further, transcriptome sequencing demonstrated that the overexpression of pro-inflammatory cytokines was correlated with vector-induced differentially expressed gene number and mediated by inflammation-related signaling pathways (MAPK, NF-κB, Toll-like receptor, and JAK-STAT) activation. By comparison, charge-reversal modification improved the hemocompatibility to a greater extent than dose PEGylation except for erythrocyte rupture. Nevertheless, it is inferior to mPEG modification in terms of immunocompatibility. These findings provide comprehensive insights to understand the molecular mechanisms of the effects of charge reversal on blood components and their function and to provide valuable information for its potential applications from laboratory to clinic. STATEMENT OF SIGNIFICANCE: The seemingly revolutionary charge reversal strategy has been believed to possess stealth character with negative charge eluding interaction with blood components during circulation. However to date, no overall or systematic investigation has been carried out to verify the role of charge-reversal on the blood/immune compatibility, which impede their development from laboratory to bedside. Therefore, we comprehensively mapped the effects of a typical charge-reversible polycationic gene vector on blood components (vascular endothelial cell, platelet, clotting factors, fibrinogen, RBCs and coagulation function) and immune response (complement and pro-inflammatory cytokines) at cellular and molecular level in comparison to PEGylation modification. These findings help to elucidate the molecular mechanisms for the effects of charge-reversal on blood components and functions, and provide valuable information for the possible application in clinical settings.
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Affiliation(s)
- Qi Yang
- Guangdong Provincial Engineering and Technological Research Center for Drug Carrier Development, Department of Biomedical Engineering, Jinan University, Guangzhou 510632, China
| | - Shuo Liu
- Guangdong Provincial Engineering and Technological Research Center for Drug Carrier Development, Department of Biomedical Engineering, Jinan University, Guangzhou 510632, China
| | - Xin Liu
- Guangdong Provincial Engineering and Technological Research Center for Drug Carrier Development, Department of Biomedical Engineering, Jinan University, Guangzhou 510632, China
| | - Zonghua Liu
- Guangdong Provincial Engineering and Technological Research Center for Drug Carrier Development, Department of Biomedical Engineering, Jinan University, Guangzhou 510632, China; Guangdong Provincial Key Laboratory of Construction and Detection in Tissue Engineering, Southern Medical University, Guangzhou 510515, China
| | - Wei Xue
- Guangdong Provincial Engineering and Technological Research Center for Drug Carrier Development, Department of Biomedical Engineering, Jinan University, Guangzhou 510632, China.
| | - Yi Zhang
- Guangdong Provincial Engineering and Technological Research Center for Drug Carrier Development, Department of Biomedical Engineering, Jinan University, Guangzhou 510632, China; School of Life Science, South China Normal University, Guangzhou 510631, China.
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Olsson A, Alfredsson J, Thelander M, Svedjeholm R, Berglund JS, Berg S. Activated platelet aggregation is transiently impaired also by a reduced dose of protamine. SCAND CARDIOVASC J 2019; 53:355-360. [PMID: 31476919 DOI: 10.1080/14017431.2019.1659396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: Protamine reduces platelet aggregation after cardiopulmonary bypass (CPB). We studied the inhibitory effect of a reduced protamine dose, the duration of impaired platelet function and the possible correlation to postoperative bleeding. Design: Platelet function was assessed by impedance aggregometry in 30 patients undergoing cardiac surgery with CPB at baseline, before protamine administration, after 70% and 100% of the calculated protamine dose, after 20 minutes and at arrival to the intensive care unit. Adenosine diphosphate (ADP), thrombin receptor activating peptide-6 (TRAP), arachidonic acid (AA) and collagen (COL) were used as activators. Blood loss was measured during operation and three hours after surgery. Results are presented as median (25th-75th percentile). Results: Platelet aggregation decreased markedly after the initial dose of protamine (70%) with all activators; ADP 89 (71-110) to 54 (35-78), TRAP 143 (116-167) to 109 (77-136), both p < .01; AA 25 (16-49) to 17 (12-24) and COL 92 (47-103) to 60 (38-81) U, both p < .05. No further decrease was seen after 100% protamine. The effect was transient and after twenty minutes platelet aggregation had started to recover; ADP 76 (54-106), TRAP 138 (95-158), AA 20 (10-35), COL 70 (51-93) U. Blood loss during operation correlated to aggregometry measured at baseline and after protaminization. Conclusions: Protamine after CPB induces a marked decrease in platelet aggregation already at a protamine-heparin ratio of 0.7:1. The impairment seems to be transient and recovery had started after 20 minutes.
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Affiliation(s)
- A Olsson
- Department of Health Science, Blekinge Institute of Technology, Karlskrona, Sweden.,Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,Department of Cardio-Thoracic Surgery, Blekinge Hospital, Karlskrona, Sweden
| | - J Alfredsson
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,Department of Cardiology, Linköping University, Linköping, Sweden
| | - M Thelander
- Department of Cardio-Thoracic Surgery, Blekinge Hospital, Karlskrona, Sweden
| | - R Svedjeholm
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,Department of Cardio-Thoracic and Vascular Surgery, Linköping University, Linköping, Sweden
| | - J Sanmartin Berglund
- Department of Health Science, Blekinge Institute of Technology, Karlskrona, Sweden
| | - S Berg
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,Department of Cardiovascular Anesthesia and Intensive Care, Linköping University, Linköping, Sweden
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Görlinger K, Pérez-Ferrer A, Dirkmann D, Saner F, Maegele M, Calatayud ÁAP, Kim TY. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol 2019; 72:297-322. [PMID: 31096732 PMCID: PMC6676023 DOI: 10.4097/kja.19169] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/08/2019] [Indexed: 02/07/2023] Open
Abstract
Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.
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Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Tem Innovations, Munich, Germany
| | - Antonio Pérez-Ferrer
- Department of Anesthesiology, Infanta Sofia University Hospital, San Sebastián de los Reyes, Madrid, Spain
| | - Daniel Dirkmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Fuat Saner
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Marc Maegele
- Department for Trauma and Orthopedic Surgery, CologneMerheim Medical Center (CMMC), Cologne, Germany.,Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke (UW/H), Campus Cologne-Merheim, Cologne, Germany
| | - Ángel Augusto Pérez Calatayud
- Terapia Intensiva Adultos, Hospital de Especialidades del Niño y la Mujer, Coordinador Grupo Mexicano para el Estudio de la Medicina Intensiva, Colegio Mexicano de Especialistas en Obstetrica Critica (COMEOC), Queretarco, Mexico
| | - Tae-Yop Kim
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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Phillips HR, Tolstyka ZP, Hall BC, Hexum JK, Hackett PB, Reineke TM. Glycopolycation–DNA Polyplex Formulation N/P Ratio Affects Stability, Hemocompatibility, and in Vivo Biodistribution. Biomacromolecules 2019; 20:1530-1544. [DOI: 10.1021/acs.biomac.8b01704] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Haley R. Phillips
- Center for Genome Engineering and Department of Chemistry, University of Minnesota, 207 Pleasant Street SE, Minneapolis, Minnesota 55455, United States
| | - Zachary P. Tolstyka
- Center for Genome Engineering and Department of Chemistry, University of Minnesota, 207 Pleasant Street SE, Minneapolis, Minnesota 55455, United States
| | - Bryan C. Hall
- Center for Genome Engineering and Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Joseph K. Hexum
- Center for Genome Engineering and Department of Chemistry, University of Minnesota, 207 Pleasant Street SE, Minneapolis, Minnesota 55455, United States
| | - Perry B. Hackett
- Center for Genome Engineering and Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Theresa M. Reineke
- Center for Genome Engineering and Department of Chemistry, University of Minnesota, 207 Pleasant Street SE, Minneapolis, Minnesota 55455, United States
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Mchaourab A, Evans GYHR, Austin R. Spontaneous spinal subdural haematoma in a patient on apixaban. BMJ Case Rep 2019; 12:12/1/e227311. [PMID: 30674492 PMCID: PMC6347922 DOI: 10.1136/bcr-2018-227311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
A 68-year-old man on apixaban presented to the emergency department with back pain following a long-haul flight. Investigations for pulmonary embolus and aortic dissection were negative and he was discharged with analgesia for mechanical back pain. He presented three more times with worsening back pain, third time with urinary retention and the fourth time with lower limb weakness and loss of coordination. He was found to have a spinal subdural haematoma on MRI and transferred to a tertiary centre, where he was managed conservatively and discharged for rehabilitation with good neurological recovery.
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Affiliation(s)
- Ahmad Mchaourab
- Accident and Emergency department, Bedford Hospital NHS Trust, Bedford, UK
| | | | - Richard Austin
- Accident and Emergency, Bedford Hospital NHS Trust, Bedford, UK
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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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Approaches to prevent bleeding associated with anticoagulants: current status and recent developments. Drug Deliv Transl Res 2018; 8:928-944. [PMID: 28741113 DOI: 10.1007/s13346-017-0413-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Anticoagulants are widely used for the prophylaxis and treatment of cardiovascular disorders and to prevent blood clotting during surgeries. However, the major limitation associated with anticoagulant therapy is bleeding; all the current anticoagulants do have a bleeding risk. The propensity to bleed is much higher among the elderly population and patients with renal insufficiency. Therefore, there is an utmost and urgent clinical need for a highly efficient, nontoxic antidote with excellent anticoagulant reversal activity. This will significantly improve the safety of anticoagulation therapy. This review summarizes the current options and approaches to reverse anticoagulation activity of clinically used anticoagulants. We start with an introduction to thrombosis and then summarize the details of current clinically available anticoagulants and their mechanisms of action and limitations. This is followed by current practices in anticoagulant neutralization including the details of the only clinically approved unfractionated heparin antidote, protamine; recent advances in the development of antidotes against heparin-based drugs; and direct oral anticoagulants (DOACs).
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Peterson JA, Maroney SA, Zwifelhofer W, Wood JP, Yan K, Bercovitz RS, Woods RK, Mast AE. Heparin-protamine balance after neonatal cardiopulmonary bypass surgery. J Thromb Haemost 2018; 16:1973-1983. [PMID: 30016577 PMCID: PMC6173634 DOI: 10.1111/jth.14245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Indexed: 12/18/2022]
Abstract
Essentials Heparin-protamine balance (HPB) modulates bleeding after neonatal cardiopulmonary bypass (CPB). HPB was examined in 44 neonates undergoing CPB. Post-operative bleeding occurred in 36% and heparin rebound in 73%. Thrombin-initiated fibrin clot kinetic assay and partial thromboplastin time best assessed HPB. SUMMARY Background Neonates undergoing cardiopulmonary bypass (CPB) are at risk of excessive bleeding. Blood is anticoagulated with heparin during CPB. Heparin activity is reversed with protamine at the end of CPB. Paradoxically, protamine also inhibits blood coagulation when it is dosed in excess of heparin. Objectives To evaluate heparin-protamine balance in neonates undergoing CPB by using research and clinical assays, and to determine its association with postoperative bleeding. Patients/Methods Neonates undergoing CPB in the first 30 days of life were studied. Blood samples were obtained during and after surgery. Heparin-protamine balance was assessed with calibrated automated thrombography, thrombin-initiated fibrin clot kinetic assay (TFCK), activated partial thromboplastin time (APTT), anti-FXa activity, and thromboelastometry. Excessive postoperative bleeding was determined by measurement of chest tube output or the development of cardiac tamponade. Results and Conclusions Of 44 neonates enrolled, 16 (36%) had excessive postoperative bleeding. The TFCK value was increased. By heparin in neonatal blood samples, but was only minimally altered by excess protamine. Therefore, it reliably measured heparin in samples containing a wide range of heparin and protamine concentrations. The APTT most closely correlated with TFCK results, whereas anti-FXa and thromboelastometry assays were less correlative. The TFCK and APTT assay also consistently detected postoperative heparin rebound, providing an important continued role for these long-established coagulation tests in the management of postoperative bleeding in neonates requiring cardiac surgical repair. None of the coagulation tests predicted the neonates who experienced postoperative bleeding, reflecting the multifactorial causes of bleeding in this population.
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Affiliation(s)
- J A Peterson
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
| | - S A Maroney
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
| | - W Zwifelhofer
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
| | - J P Wood
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
| | - K Yan
- Departments of Pathology and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - R S Bercovitz
- Departments of Pathology and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - R K Woods
- HermaHeart Center, Division of Pediatric Cardiothoracic Surgery, Children's Hospital of Wisconsin, Milwaukee, WI, USA
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - A E Mast
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
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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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Ghadimi K, Levy JH, Welsby IJ. Perioperative management of the bleeding patient. Br J Anaesth 2018; 117:iii18-iii30. [PMID: 27940453 DOI: 10.1093/bja/aew358] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Perioperative bleeding remains a major complication during and after surgery, resulting in increased morbidity and mortality. The principal causes of non-vascular sources of haemostatic perioperative bleeding are a preexisting undetected bleeding disorder, the nature of the operation itself, or acquired coagulation abnormalities secondary to haemorrhage, haemodilution, or haemostatic factor consumption. In the bleeding patient, standard therapeutic approaches include allogeneic blood product administration, concomitant pharmacologic agents, and increasing application of purified and recombinant haemostatic factors. Multiple haemostatic changes occur perioperatively after trauma and complex surgical procedures including cardiac surgery and liver transplantation. Novel strategies for both prophylaxis and therapy of perioperative bleeding include tranexamic acid, desmopressin, fibrinogen and prothrombin complex concentrates. Point-of-care patient testing using thromboelastography, rotational thromboelastometry, and platelet function assays has allowed for more detailed assessment of specific targeted therapy for haemostasis. Strategic multimodal management is needed to improve management, reduce allogeneic blood product administration, and minimize associated risks related to transfusion.
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Affiliation(s)
- K Ghadimi
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - J H Levy
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - I J Welsby
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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Yu J, Su H, Wei S, Chen F, Liu C. Calcium content mediated hemostasis of calcium-modified oxidized microporous starch. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2018; 29:1716-1728. [PMID: 29813002 DOI: 10.1080/09205063.2018.1481585] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Blood coagulates are closely related to calcium ions (coagulation factor IV), and calcium-doped biomaterials have been reported to be effective in hemostasis. However, the effects exerted by calcium on hemostatic agents have not been previously investigated. The aims of this work were to develop calcium-modified oxidized microporous starch (CaOMS) with controllable calcium contents and to explore the relationship between calcium content and hemostatic effects. The results showed that low calcium content promoted coagulation, while high calcium content inhibited coagulation. CaOMS3 with 2.2 mg/g calcium content was optimal because of its excellent water absorption performance that enhanced physical coagulation, the rapid initiation of coagulation cascade reactions, and the enhanced chemical coagulation by RBC aggregation and platelet activation. The synergistic effects of chemical activation and physical absorption endowed CaOMS with the potential to control internal organ bleeding. These results suggested that CaOMS may be a promising hemostatic agent with wide spread applications.
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Affiliation(s)
- Junxia Yu
- a Key Laboratory for Ultrafine Materials of Ministry of Education, School of Materials Science and Engineering , East China University of Science and Technology , Shanghai , P. R. China.,b Engineering Research Centre for Biomedical Materials of Ministry of Education , East China University of Science and Technology , Shanghai , P. R. China
| | - Huantong Su
- b Engineering Research Centre for Biomedical Materials of Ministry of Education , East China University of Science and Technology , Shanghai , P. R. China
| | - Shuda Wei
- a Key Laboratory for Ultrafine Materials of Ministry of Education, School of Materials Science and Engineering , East China University of Science and Technology , Shanghai , P. R. China.,b Engineering Research Centre for Biomedical Materials of Ministry of Education , East China University of Science and Technology , Shanghai , P. R. China
| | - Fangping Chen
- b Engineering Research Centre for Biomedical Materials of Ministry of Education , East China University of Science and Technology , Shanghai , P. R. China.,c The State Key Laboratory of Bioreactor Engineering, East China University of Science and Technology , Shanghai , P. R. China
| | - Changsheng Liu
- a Key Laboratory for Ultrafine Materials of Ministry of Education, School of Materials Science and Engineering , East China University of Science and Technology , Shanghai , P. R. China.,b Engineering Research Centre for Biomedical Materials of Ministry of Education , East China University of Science and Technology , Shanghai , P. R. China.,c The State Key Laboratory of Bioreactor Engineering, East China University of Science and Technology , Shanghai , P. R. China
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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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Kunz SA, Miles LF, Ianno DJ, Mirowska-Allen KL, Matalanis G, Bellomo R, Seevanayagam S. The effect of protamine dosing variation on bleeding and transfusion after heparinisation for cardiopulmonary bypass. Perfusion 2018; 33:445-452. [PMID: 29544405 DOI: 10.1177/0267659118763043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Accurate dosing of protamine reversal following on-pump cardiac surgical procedures is challenging, with both excessive and inadequate administration recognised to increase bleeding risk. We aimed to examine the relationship between three ratios for heparin reversal and markers of haemostasis. METHODS A retrospective analysis of a prospectively collected database was undertaken at a single tertiary cardiac unit, reviewing all cases of on-pump coronary artery bypass grafts and single valve replacements from 01/01/2011 to 31/12/2015. The ratio between total intra-operative heparin and protamine was stratified to three groups (low: ≤0.6 mg per 100 IU of heparin, moderate: 0.6-1.0 and high: >1.0) and related to the primary outcome of red blood cell (RBC) transfusion, with secondary outcomes being the number of units transfused, the haemoglobin differential and mediastinal drain output at 4 hours. RESULTS Of the 803 patients identified, 338 received a blood transfusion, with 1035 units being used. Eighteen percent of individuals (145) received a low ratio, 50% (404) received a moderate ratio and 32% (254) a high ratio. Using the moderate group as a reference, the low dose group was 56.5% less likely to have received a RBC transfusion (OR 0.435; 95% CI 0.270:0.703 p=0.001) while the high dose group carried a 241% increased association with transfusion (OR 3.412; 95% CI 2.399:4.853 p<0.001). For those transfused, a lower protamine:heparin ratio was associated with a lower number of units transfused, lesser haemoglobin differential and less mediastinal drain output. CONCLUSION Higher doses of intra-operative protamine relative to heparin are associated with greater risk of transfusion and post-operative bleeding.
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Affiliation(s)
- Stephen A Kunz
- 1 Department of Cardiac Surgery, Austin Health, Heidelberg, Victoria, Australia.,2 School of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Lachlan F Miles
- 3 Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Damian J Ianno
- 2 School of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | | | - George Matalanis
- 1 Department of Cardiac Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Rinaldo Bellomo
- 2 School of Medicine, The University of Melbourne, Parkville, Victoria, Australia.,4 Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Siven Seevanayagam
- 1 Department of Cardiac Surgery, Austin Health, Heidelberg, Victoria, Australia
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Meesters MI, Veerhoek D, de Lange F, de Vries JW, de Jong JR, Romijn JWA, Kelchtermans H, Huskens D, van der Steeg R, Thomas PWA, Burtman DTM, van Barneveld LJM, Vonk ABA, Boer C. Effect of high or low protamine dosing on postoperative bleeding following heparin anticoagulation in cardiac surgery. Thromb Haemost 2018; 116:251-61. [DOI: 10.1160/th16-02-0117] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 05/06/2016] [Indexed: 11/05/2022]
Abstract
SummaryWhile experimental data state that protamine exerts intrinsic anticoagulation effects, protamine is still frequently overdosed for heparin neutralisation during cardiac surgery with cardiopulmonary bypass (CPB). Since comparative studies are lacking, we assessed the influence of two protamine-to-heparin dosing ratios on perioperative haemostasis and bleeding, and hypothesised that protamine overdosing impairs the coagulation status following cardiac surgery. In this open-label, multicentre, single-blinded, randomised controlled trial, patients undergoing on-pump coronary artery bypass graft surgery were assigned to a low (0.8; n=49) or high (1.3; n=47) protamine-to-heparin dosing group. The primary outcome was 24-hour blood loss. Patient haemostasis was monitored using rotational thromboelastometry and a thrombin generation assay. The low protamine-to-heparin dosing ratio group received less protamine (329 ± 95 vs 539 ± 117 mg; p<0.001), while post-protamine activated clotting times were similar among groups. The high dosing group revealed increased intrinsic clotting times (236 ± 74 vs 196 ± 64 s; p=0.006) and the maximum post-protamine thrombin generation was less suppressed in the low dosing group (38 ± 40% vs 6 ± 9%; p=0.001). Postoperative blood loss was increased in the high dosing ratio group (615 ml; 95% CI 500–830 ml vs 470 ml; 95% CI 420–530 ml; p=0.021) when compared to the low dosing group, respectively. More patients in the high dosing group received fresh frozen plasma (11% vs 0%; p=0.02) and platelet concentrate (21% vs 6%; p=0.04) compared to the low dosing group. Our study confirms in vitro data that abundant protamine dosing is associated with increased postoperative blood loss and higher transfusion rates in cardiac surgery.
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Bianchini EP, Sebestyen A, Abache T, Bourti Y, Fontayne A, Richard V, Tamion F, Plantier JL, Doguet F, Borgel D. Inactivated antithombin as anticoagulant reversal in a rat model of cardiopulmonary bypass: a potent and potentially safer alternative to protamine. Br J Haematol 2018; 180:715-720. [DOI: 10.1111/bjh.15091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 11/07/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Elsa P. Bianchini
- INSERM; UMR-S1176; Univ. Paris-Sud; Université Paris-Saclay; Le Kremlin-Bicêtre France
| | - Alexandre Sebestyen
- Department of Thoracic and Cardiovascular Surgery; Inserm U1096; Normandie Univ; UNIROUEN; Rouen University Hospital; Rouen France
| | | | - Yasmine Bourti
- INSERM; UMR-S1176; Univ. Paris-Sud; Université Paris-Saclay; Le Kremlin-Bicêtre France
| | | | - Vincent Richard
- Department of Pharmacology; Inserm U1096; Normandie Univ; UNIROUEN; Rouen University Hospital; Rouen France
| | - Fabienne Tamion
- Department of Intensive Care; Inserm U1096; Normandie Univ; UNIROUEN; Rouen University Hospital; Rouen France
| | | | - Fabien Doguet
- Department of Thoracic and Cardiovascular Surgery; Inserm U1096; Normandie Univ; UNIROUEN; Rouen University Hospital; Rouen France
| | - Delphine Borgel
- INSERM; UMR-S1176; Univ. Paris-Sud; Université Paris-Saclay; Le Kremlin-Bicêtre France
- APHP; Laboratoire d'Hématologie; Hôpital Universitaire Necker-Enfants Malades; Paris France
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Dynamic and Quantitative Assessment of Blood Coagulation Status with an Oscillatory Rheometer. APPLIED SCIENCES-BASEL 2018. [DOI: 10.3390/app8010084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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