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Chen Y, Phoon PHY, Hwang NC. Heparin Resistance During Cardiopulmonary Bypass in Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2022; 36:4150-4160. [PMID: 35927191 PMCID: PMC9225936 DOI: 10.1053/j.jvca.2022.06.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/09/2022] [Accepted: 06/17/2022] [Indexed: 12/15/2022]
Abstract
The use of heparin for anticoagulation has changed the face of cardiac surgery by allowing a bloodless and motionless surgical field throughout the introduction of cardiopulmonary bypass (CPB). However, heparin is a drug with complex pharmacologic properties that can cause significant interpatient differences in terms of responsiveness. Heparin resistance during CPB is a weighty issue due to the catastrophic consequences stemming from inadequate anticoagulation, and the treatment of it necessitates a rationalized stepwise approach due to the multifactorial contributions toward this entity. The widespread use of activated clotting time (ACT) as a measurement of anticoagulation during CPB is examined, as it may be a false indicator of heparin resistance. Heparin resistance also has been repeatedly reported in patients infected with COVID-19, which deserves further exploration in this pandemic era. This review aims to examine the variability in heparin potency, underlying mechanisms, and limitations of using ACT for monitoring, as well as provide a framework towards the current management of heparin resistance.
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Affiliation(s)
- Yufan Chen
- Department of Anaesthesiology, Singapore General Hospital, Singapore,Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore
| | - Priscilla Hui Yi Phoon
- Department of Anaesthesiology, Singapore General Hospital, Singapore,Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore.
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2
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Pavoni V, Gianesello L, Pazzi M, Dattolo P, Prisco D. Questions about COVID-19 associated coagulopathy: possible answers from the viscoelastic tests. J Clin Monit Comput 2022; 36:55-69. [PMID: 34264472 PMCID: PMC8280589 DOI: 10.1007/s10877-021-00744-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022]
Abstract
Abnormal coagulation parameters are often observed in patients with coronavirus disease 2019 (COVID-19) and the severity of derangement has been associated with a poor prognosis. The COVID-19 associated coagulopathy (CAC) displays unique features that include a high risk of developing thromboembolic complications. Viscoelastic tests (VETs), such as thromboelastometry (ROTEM), thromboelastography (TEG) and Quantra Hemostasis Analyzer (Quantra), provide "dynamic" data on clot formation and dissolution; they are used in different critical care settings, both in hemorrhagic and in thrombotic conditions. In patients with severe COVID-19 infection VETs can supply to clinicians more information about the CAC, identifying the presence of hypercoagulable and hypofibrinolysis states. In the last year, many studies have proposed to explain the underlying characteristics of CAC; however, there remain many unanswered questions. We tried to address some of the important queries about CAC through VETs analysis.
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Affiliation(s)
- Vittorio Pavoni
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, Largo Palagi, 1, 50139, Florence, Italy.
| | - Maddalena Pazzi
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Pietro Dattolo
- Nephrology Unit Florence 1, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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3
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Yoshinaga K, Otsuka Y, Furukawa T, Amitani S, Kimura N, Sanui M. Correlation between activated clotting time monitoring and heparin concentration measurement in a patient with antiphospholipid syndrome during cardiac valve surgery: a case report. JA Clin Rep 2021; 7:24. [PMID: 33715057 PMCID: PMC7956925 DOI: 10.1186/s40981-021-00427-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/18/2021] [Accepted: 03/04/2021] [Indexed: 11/16/2022] Open
Abstract
Background Anticoagulation management of patients with antiphospholipid syndrome (APS) undergoing cardiac surgery is challenging due to the prolongation of activated clotting time (ACT). Currently, no study has compared the utility of ACT monitoring using the Hemochron Jr. Signature+ and that of heparin concentration management using the Hemostasis Management System (HMS) Plus in patients with APS. Case presentation A 71-year-old woman with APS was scheduled to undergo an aortic valve replacement for aortic regurgitation. The ACT was measured using the Hemochron Jr. Signature+, and the heparin concentration was measured concurrently using the HMS Plus. ACT over 480 s corresponded to an adequate heparin concentration during cardiopulmonary bypass. The clinical course was uneventful, and no thrombotic or hemorrhagic complications were observed. Conclusion In the present patient with APS, the Hemochron Jr. Signature+ was useful as an anticoagulation management during cardiac valve surgery.
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Affiliation(s)
- Koichi Yoshinaga
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, 1-847, Amanumacho, Omiya-ku, Saitama-city, Saitama, 330-8503, Japan
| | - Yuji Otsuka
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, 1-847, Amanumacho, Omiya-ku, Saitama-city, Saitama, 330-8503, Japan.
| | - Taku Furukawa
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, 1-847, Amanumacho, Omiya-ku, Saitama-city, Saitama, 330-8503, Japan
| | - Shizuka Amitani
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, 1-847, Amanumacho, Omiya-ku, Saitama-city, Saitama, 330-8503, Japan
| | - Naoyuki Kimura
- Department of Cardiovascular Surgery, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, 1-847, Amanumacho, Omiya-ku, Saitama-city, Saitama, 330-8503, Japan
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4
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Salih T, Shovel L, Sathananthan C, Gupta A, Riddell A, Donohue C, Schofield N. Monitoring of heparin anticoagulation during complex aortic endovascular surgery. J Vasc Surg 2020; 71:1453-1454. [PMID: 32204846 DOI: 10.1016/j.jvs.2019.10.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/19/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Tom Salih
- Royal Free Hospital, London, United Kingdom
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Jigar Panchal H, Kent NJ, Knox AJS, Harris LF. Microfluidics in Haemostasis: A Review. Molecules 2020; 25:E833. [PMID: 32075008 PMCID: PMC7070452 DOI: 10.3390/molecules25040833] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 12/17/2022] Open
Abstract
Haemostatic disorders are both complex and costly in relation to both their treatment and subsequent management. As leading causes of mortality worldwide, there is an ever-increasing drive to improve the diagnosis and prevention of haemostatic disorders. The field of microfluidic and Lab on a Chip (LOC) technologies is rapidly advancing and the important role of miniaturised diagnostics is becoming more evident in the healthcare system, with particular importance in near patient testing (NPT) and point of care (POC) settings. Microfluidic technologies present innovative solutions to diagnostic and clinical challenges which have the knock-on effect of improving health care and quality of life. In this review, both advanced microfluidic devices (R&D) and commercially available devices for the diagnosis and monitoring of haemostasis-related disorders and antithrombotic therapies, respectively, are discussed. Innovative design specifications, fabrication techniques, and modes of detection in addition to the materials used in developing micro-channels are reviewed in the context of application to the field of haemostasis.
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Affiliation(s)
- Heta Jigar Panchal
- School of Biological and Health Sciences, Technological University Dublin (TU Dublin) - City Campus, Kevin Street, Dublin D08 NF82, Ireland; (H.J.P.); (A.J.S.K.)
| | - Nigel J Kent
- engCORE, Faculty of Engineering, Institute of Technology Carlow, Kilkenny Road, Carlow R93 V960, Ireland;
| | - Andrew J S Knox
- School of Biological and Health Sciences, Technological University Dublin (TU Dublin) - City Campus, Kevin Street, Dublin D08 NF82, Ireland; (H.J.P.); (A.J.S.K.)
| | - Leanne F Harris
- School of Biological and Health Sciences, Technological University Dublin (TU Dublin) - City Campus, Kevin Street, Dublin D08 NF82, Ireland; (H.J.P.); (A.J.S.K.)
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6
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Jeevarathinam AS, Pai N, Huang K, Hariri A, Wang J, Bai Y, Wang L, Hancock T, Keys S, Penny W, Jokerst JV. A cellulose-based photoacoustic sensor to measure heparin concentration and activity in human blood samples. Biosens Bioelectron 2018; 126:831-837. [PMID: 30602265 DOI: 10.1016/j.bios.2018.11.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 01/05/2023]
Abstract
Heparin is an indispensable drug in anticoagulation therapy but with a narrow therapeutic window, which dictates regular testing and dose adjustment. However, current monitoring tools have a long turnaround time or are operator intensive. In this work, we describe a cellulose-based photoacoustic sensor for heparin. The sensors have a turnaround time of 6 min for whole blood samples and 3 min for plasma samples regardless of heparin concentration. These sensors have a limit of detection of 0.28 U/ml heparin in human plasma and 0.29 U/ml in whole blood with a linear response (Pearson's r = 0.99) from 0 to 2 U/ml heparin in plasma and blood samples. The relative standard deviation was < 12.5% in plasma and < 17.5% in whole blood. This approach was validated with heparin-spiked whole human blood and had a linear correlation with the activated partial thromboplastin time (aPTT) (r = 0.99). We then studied 16 sets of clinical samples-these had a linear correlation with the activated clotting time (ACT) (Pearson's r = 0.86, P < 0.0001). The photoacoustic signal was also validated against the cumulative heparin dose (Pearson's r = 0.71, P < 0.0001). This approach could have applications in bed-side heparin assays for continuous heparin monitoring.
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Affiliation(s)
| | - Navin Pai
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States
| | - Kevin Huang
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States
| | - Ali Hariri
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States
| | - Junxin Wang
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States
| | - Yuting Bai
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States
| | - Lu Wang
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States
| | - Tiffany Hancock
- Cardiology Unit, VA Healthcare System, San Diego, La Jolla, CA 92161, United States
| | - Stanley Keys
- Cardiology Unit, VA Healthcare System, San Diego, La Jolla, CA 92161, United States
| | - William Penny
- Cardiology Unit, VA Healthcare System, San Diego, La Jolla, CA 92161, United States
| | - Jesse V Jokerst
- Department of NanoEngineering, University of California San Diego, La Jolla, CA 92093, United States; Materials Science Program and Department of Radiology, University of California San Diego, La Jolla, CA 92093, United States.
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7
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Kemna EW, Kuipers C, Oude Luttikhuis-Spanjer AM, Majoor S, Boudrie R, Speekenbrink RG, Hoffman R, Krabbe JG. A two site comparison of two point-of-care activated clotting time systems. Clin Chem Lab Med 2017; 55:e13-e16. [DOI: 10.1515/cclm-2016-0317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 06/07/2016] [Indexed: 11/15/2022]
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8
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Su J, Wang X, Song W, Bai X, Li C. Reducing oxidative stress and hepatoprotective effect of water extracts from Pu-erh tea on rats with high-fat diet. FOOD SCIENCE AND HUMAN WELLNESS 2016. [DOI: 10.1016/j.fshw.2016.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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9
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Harris LF, Castro-López V, Killard AJ. Coagulation monitoring devices: Past, present, and future at the point of care. Trends Analyt Chem 2013. [DOI: 10.1016/j.trac.2013.05.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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10
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Bromfield SM, Wilde E, Smith DK. Heparin sensing and binding – taking supramolecular chemistry towards clinical applications. Chem Soc Rev 2013; 42:9184-95. [DOI: 10.1039/c3cs60278h] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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11
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Meyer Dos Santos S, Zorn A, Guttenberg Z, Picard-Willems B, Kläffling C, Nelson K, Klinkhardt U, Harder S. A novel μ-fluidic whole blood coagulation assay based on Rayleigh surface-acoustic waves as a point-of-care method to detect anticoagulants. BIOMICROFLUIDICS 2013; 7:56502. [PMID: 24404078 PMCID: PMC3799685 DOI: 10.1063/1.4824043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 09/19/2013] [Indexed: 05/10/2023]
Abstract
A universal coagulation test that reliably detects prolonged coagulation time in patients, irrespective of the anticoagulant administered, has not been available to date. An easily miniaturised, novel μ-fluidic universal coagulation test employing surface acoustic waves (SAW) is presented here. SAW was employed to instantly mix and recalcify 6 μl citrated whole blood and image correlation analysis was used to quantify clot formation kinetics. The detection of clinically relevant anticoagulant dosing with old anticoagulants (unfractionated heparin, argatroban) and new anticoagulants (dabigatran, rivaroxaban) has been tested and compared to standard plasma coagulation assays. The applicability of this novel method has been confirmed in a small patient population. Coagulation was dose-proportionally prolonged with heparin, argatroban, dabigatran, and rivaroxaban, comparable to standard tests. Aspirin and clopidogrel did not interfere with the SAW-induced clotting time (SAW-CT), whereas the strong GPIIb/IIIa-inhibitor abciximab did interfere. Preliminary clinical data prove the suitability of the SAW-CT in patients being treated with warfarin, rivaroxaban, or dabigatran. The system principally allows assessment of whole blood coagulation in humans in a point-of-care setting. This method could be used in stroke units, emergency vehicles, general and intensive care wards, as well as for laboratory and home testing of coagulation.
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Affiliation(s)
- Sascha Meyer Dos Santos
- J.W. Goethe University Hospital, Institute for Clinical Pharmacology, Theodor-Stern-Kai 7 60590 Frankfurt
| | - Anita Zorn
- J.W. Goethe University Hospital, Institute for Clinical Pharmacology, Theodor-Stern-Kai 7 60590 Frankfurt
| | | | - Bettina Picard-Willems
- J.W. Goethe University Hospital, Institute for Clinical Pharmacology, Theodor-Stern-Kai 7 60590 Frankfurt
| | - Christina Kläffling
- J.W. Goethe University Hospital, Center for Internal Medicine-Cardiology, Theodor-Stern-Kai 7 60590 Frankfurt
| | - Karen Nelson
- J.W. Goethe University Hospital, Department of Vascular and Endovascular Surgery, Theodor-Stern-Kai 7 60590 Frankfurt
| | - Ute Klinkhardt
- J.W. Goethe University Hospital, Institute for Clinical Pharmacology, Theodor-Stern-Kai 7 60590 Frankfurt
| | - Sebastian Harder
- J.W. Goethe University Hospital, Institute for Clinical Pharmacology, Theodor-Stern-Kai 7 60590 Frankfurt
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12
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Said R, Regnault V, Hacquard M, Carteaux JP, Lecompte T. Platelet-dependent thrombography gives a distinct pattern of in vitro thrombin generation after surgery with cardio-pulmonary bypass: potential implications. Thromb J 2012; 10:15. [PMID: 22909275 PMCID: PMC3522546 DOI: 10.1186/1477-9560-10-15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 08/02/2012] [Indexed: 11/10/2022] Open
Abstract
Background Bleeding remains a potentially lethal complication of cardio-pulmonary bypass (CPB) surgery. The purpose of this study was to obtain a better insight into in vitro thrombin generation in the context of CPB. Methods We used Calibrated Automated Thrombography to assess blood coagulation of 10 low-risk patients operated for valve replacement with CPB, under 2 experimental conditions, one implicating platelets as platelet dysfunction has been described to occur during CPB. Results Our main finding was that CPB-induced coagulopathy was differently appreciated depending on the presence or absence of platelets: the decrease in thrombin generation was much less pronounced in their presence (mean endogenous thrombin potential change values before and after CPB were -3.9% in the presence of platelets and -39.6% in their absence). Conclusion Our results show that experimental conditions have a profound effect in the study of in vitro thrombin generation in the context of CPB.
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Affiliation(s)
- Rose Said
- Laboratoire d'Hématologie et Institut Cardiovasculaire Nancy, Centre Hospitalier Universitaire, Nancy, France.,Inserm U961, Nancy Université, Nancy, France
| | - Véronique Regnault
- Laboratoire d'Hématologie et Institut Cardiovasculaire Nancy, Centre Hospitalier Universitaire, Nancy, France.,Inserm U961, Nancy Université, Nancy, France
| | - Marie Hacquard
- Laboratoire d'Hématologie et Institut Cardiovasculaire Nancy, Centre Hospitalier Universitaire, Nancy, France.,EFS Lorraine Champagne, Nancy, France
| | - Jean-Pierre Carteaux
- Laboratoire d'Hématologie et Institut Cardiovasculaire Nancy, Centre Hospitalier Universitaire, Nancy, France
| | - Thomas Lecompte
- Laboratoire d'Hématologie et Institut Cardiovasculaire Nancy, Centre Hospitalier Universitaire, Nancy, France.,Inserm U961, Nancy Université, Nancy, France.,EFS Lorraine Champagne, Nancy, France.,Haematology Laboratory, CHU Nancy, Rue du Morvan, 54511, Vandoeuvre les Nancy Cedex, France
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13
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Gubala V, Harris LF, Ricco AJ, Tan MX, Williams DE. Point of Care Diagnostics: Status and Future. Anal Chem 2011; 84:487-515. [DOI: 10.1021/ac2030199] [Citation(s) in RCA: 832] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Vladimir Gubala
- Biomedical Diagnostics Institute, Dublin City University, Dublin 9, Ireland
| | - Leanne F. Harris
- Biomedical Diagnostics Institute, Dublin City University, Dublin 9, Ireland
| | - Antonio J. Ricco
- Biomedical Diagnostics Institute, Dublin City University, Dublin 9, Ireland
| | - Ming X. Tan
- Biomedical Diagnostics Institute, Dublin City University, Dublin 9, Ireland
| | - David E. Williams
- Biomedical Diagnostics Institute, Dublin City University, Dublin 9, Ireland
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14
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Hussein HM, Georgiadis AL, Qureshi AI. Point-of-care testing for anticoagulation monitoring in neuroendovascular procedures. AJNR Am J Neuroradiol 2011; 33:1211-20. [PMID: 21920856 DOI: 10.3174/ajnr.a2621] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
POC testing is defined as diagnostic testing at or near the site of patient care. Rapid measurement of the intensity of anticoagulation and, more recently, platelet inhibition allows dose titration of adjuvant medications such a heparin and antiplatelet agents during neuroendovascular procedures. However, knowledge among practicing physicians regarding the pathophysiologic basis of these measurements and variations in knowledge about the differences among devices is often limited. This review discusses the role of anticoagulation in endovascular procedures and the currently available POC tests for anticoagulation monitoring.
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Affiliation(s)
- H M Hussein
- Department of Neurology, Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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15
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Jones PM, Bainbridge D, Dobkowski W, Harle CC, Murkin JM, Fernandes PS, Kiaii B. Comparison of MAX-ACT and K-ACT Values When Using Bivalirudin Anticoagulation During Minimally Invasive Hybrid Off-Pump Coronary Artery Bypass Graft Surgery. J Cardiothorac Vasc Anesth 2011; 25:415-8. [DOI: 10.1053/j.jvca.2010.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Indexed: 01/21/2023]
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16
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Abstract
Bleeding is a considerable clinical problem during and after pediatric heart surgery. While the primary cause of bleeding is surgical trauma, its treatment is often complicated by the presence of coagulopathy. The principle causes of coagulopathy are discussed to provide a context for treatment. The role of laboratory and point of care tests, which aim to identify the cause of bleeding in the individual patient, is also discussed. An attempt is made to examine the current evidence for available therapies, including use of blood products and, more recently proposed, approaches based on human or recombinant factor concentrates.
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Affiliation(s)
- Philip Arnold
- Jackson Rees Department of Paediatric Anaesthesia, Alder Hey Children's Hospital, Eaton Road, Liverpool, UK.
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17
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Lewandrowski EL, Van Cott EM, Gregory K, Jang IK, Lewandrowski KB. Clinical evaluation of the i-STAT kaolin activated clotting time (ACT) test in different clinical settings in a large academic urban medical center: comparison with the Medtronic ACT Plus. Am J Clin Pathol 2011; 135:741-8. [PMID: 21502428 DOI: 10.1309/ajcpsf8asgonnqm6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Historically, it has been difficult for hospitals to change methods for activated clotting time (ACT) testing because of differences in ACT values obtained with different instruments, wide differences in target ranges used in different procedures, and the difficulty of performing crossover studies at the bedside in critical care situations. There are limited published data comparing the i-STAT (Abbott Point of Care, Princeton, NJ) kaolin ACT with the Medtronic ACT Plus (Medtronic, Minneapolis, MN). The i-STAT system can perform ACT testing in addition to testing of a number of critical care analytes and may offer potential advantages over other ACT analyzers. Comparison of ACT values on 121 simultaneous split-sample tests yielded an R(2) of 0.88 with i-STAT = 0.79 Medtronic + 72.0. The Pearson correlation was R = 0.94, indicating statistically significant correlation between the 2 methods. Based on this comparison, we were able to implement the i-STAT ACT throughout our institution without changing target ranges for any individual procedure.
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18
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McMillan D, Brady P, Foot C, Levy R, Thomson A. The team focus on improving blood transfusion. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2011; 43:P65-P67. [PMID: 21449243 PMCID: PMC4680100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The current literature pertaining to associated morbidity and mortality with homologous blood transfusion in the surgical patient seems to be pointing only in one direction, which is we must start reducing our patients exposure to homologous blood and products. There appears to be ever mounting evidence of increases in infraction, stroke, transfusion related lung injury, infection, and death that authors are associating with transfusion. A number of authors are reporting success in reducing their patients' requirements for homologous transfusion simply by working as a team or what is known as a multidisciplinary approach and following set transfusion protocols and algorithms. At our institution we have taken note of these reports and have taken the first steps in the formation of a Cardiac Surgical Transfusion Management Group where all specialties involved in the decision making process of transfusion in the cardiac surgical patient can have representation and be directly involved in the establishment of protocols, transfusion algorithms, and a transfusion audit system. The main goal of this group is to implement a change in transfusion practice and to assess the impact the change has had on transfusion requirements and make appropriate recommendations to the treating specialists.
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Affiliation(s)
- D McMillan
- Cardiopulmonary Perfusion and Autotransfusion Unit, Department of Anaesthesia and Pain Management, Royal North Shore Hospital, Sydney, Australia.
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19
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20
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Girdauskas E, Kempfert J, Kuntze T, Borger MA, Enders J, Fassl J, Falk V, Mohr FW. Thromboelastometrically guided transfusion protocol during aortic surgery with circulatory arrest: A prospective, randomized trial. J Thorac Cardiovasc Surg 2010; 140:1117-24.e2. [DOI: 10.1016/j.jtcvs.2010.04.043] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Revised: 01/06/2010] [Accepted: 04/03/2010] [Indexed: 11/29/2022]
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21
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Perry DJ, Fitzmaurice DA, Kitchen S, Mackie IJ, Mallett S. Point-of-care testing in haemostasis. Br J Haematol 2010; 150:501-14. [PMID: 20618331 DOI: 10.1111/j.1365-2141.2010.08223.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Point-of-care testing (POCT) in haematology has seen a significant increase in both the spectrum of tests available and the number of tests performed annually. POCT is frequently undertaken with the belief that this will reduce the turnaround time for results and so improve patient care. The most obvious example of POCT in haemostasis is the out-of-hospital monitoring of the International Normalized Ratio in patients receiving a vitamin K antagonist, such as warfarin. Other areas include the use of the Activated Clotting Time to monitor anticoagulation for patients on cardio-pulmonary bypass, platelet function testing to identify patients with apparent aspirin or clopidogrel resistance and thrombelastography to guide blood product replacement during cardiac and hepatic surgery. In contrast to laboratory testing, POCT is frequently undertaken by untrained or semi-trained individuals and in many cases is not subject to the same strict quality control programmes that exist in the central laboratory. Although external quality assessment programmes do exist for some POCT assays these are still relatively few. The use of POCT in haematology, particularly in the field of haemostasis, is likely to expand and it is important that systems are in place to ensure that the generated results are accurate and precise.
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Affiliation(s)
- David J Perry
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK.
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Mauldin FW, Viola F, Hamer TC, Ahmed EM, Crawford SB, Haverstick DM, Lawrence MB, Walker WF. Adaptive force sonorheometry for assessment of whole blood coagulation. Clin Chim Acta 2010; 411:638-44. [PMID: 20096680 DOI: 10.1016/j.cca.2010.01.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Revised: 01/12/2010] [Accepted: 01/14/2010] [Indexed: 12/01/2022]
Abstract
BACKGROUND Viscoelastic diagnostics that monitor the hemostatic function of whole blood (WB), such as thromboelastography, have been developed with demonstrated clinical utility. By measuring the cumulative effects of all components of hemostasis, viscoelastic diagnostics have circumvented many of the challenges associated with more common tests of blood coagulation. METHODS We describe a new technology, called sonorheometry, that adaptively applies acoustic radiation force to assess coagulation function in WB. The repeatability (precision) of coagulation parameters was assessed using citrated WB samples. A reference range of coagulation parameters, along with corresponding measurements from prothrombin time (PT) and partial thromboplastin time (PTT), were obtained from WB samples of 20 healthy volunteers. In another study, sonorheometry monitored anticoagulation with heparin (0-5 IU/ml) and reversal from varied dosages of protamine (0-10 IU/ml) in heparinized WB (2 IU/ml). RESULTS Sonorheometry exhibited low CVs for parameters: clot initiation time (TC1), <7%; clot stabilization time (TC2), <6.5%; and clotting angle (theta), <3.5%. Good correlation was observed between clotting times, TC1 and TC2, and PTT (r=0.65 and 0.74 respectively; n=18). Linearity to heparin dosage was observed with average linearity r>0.98 for all coagulation parameters. We observed maximum reversal of heparin anticoagulation at protamine to heparin ratios of 1.4:1 from TC1 (P=0.6) and 1.2:1 from theta (P=0.55). CONCLUSIONS Sonorheometry is a non-contact method for precise assessment of WB coagulation.
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Affiliation(s)
- F William Mauldin
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
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Westbrook AJ, Olsen J, Bailey M, Bates J, Scully M, Salamonsen RF. Protocol Based on Thromboelastograph (TEG) Out-Performs Physician Preference Using Laboratory Coagulation Tests to Guide Blood Replacement During and After Cardiac Surgery: A Pilot Study. Heart Lung Circ 2009; 18:277-88. [DOI: 10.1016/j.hlc.2008.08.016] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Revised: 07/03/2008] [Accepted: 08/28/2008] [Indexed: 10/21/2022]
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Uzlova SG, Guria KG, Guria GT. Acoustic determination of early stages of intravascular blood coagulation. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2008; 366:3649-3661. [PMID: 18644769 DOI: 10.1098/rsta.2008.0109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The blood coagulation system (BCS) is a complex biological system playing a principal role in the maintenance of haemostasis. Insufficient activity of the BCS may lead to bleeding and blood loss (e.g. in the case of haemophilia). On the other hand, excessive activity may cause intravascular blood coagulation, thromboses and embolization. Most of the methods currently used for BCS monitoring suffer from the major disadvantage of being invasive. The purpose of the present work is to demonstrate the feasibility of using ultrasonic methods for non-invasive registration of the early stages of blood coagulation processes in intensive flows. With this purpose, a special experimental set-up was designed, facilitating the simultaneous detection of optical and acoustic signals during the clotting process. It was shown that (i) as microemboli appear in the flow during the early stage of blood coagulation, the intensity of the Doppler signal increases twofold, and (ii) microemboli formation in the early stages of blood clotting always reveals itself through an acoustic contrast. Both of these effects are well defined, so we hope that they may be used for non-invasive BCS monitoring in clinical practice.
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Ganter MT, Hofer CK. Coagulation monitoring: current techniques and clinical use of viscoelastic point-of-care coagulation devices. Anesth Analg 2008; 106:1366-75. [PMID: 18420846 DOI: 10.1213/ane.0b013e318168b367] [Citation(s) in RCA: 463] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Perioperative monitoring of blood coagulation is critical to better understand causes of hemorrhage, to guide hemostatic therapies, and to predict the risk of bleeding during the consecutive anesthetic or surgical procedures. Point-of-care (POC) coagulation monitoring devices assessing the viscoelastic properties of whole blood, i.e., thrombelastography, rotation thrombelastometry, and Sonoclot analysis, may overcome several limitations of routine coagulation tests in the perioperative setting. The advantage of these techniques is that they have the potential to measure the clotting process, starting with fibrin formation and continue through to clot retraction and fibrinolysis at the bedside, with minimal delays. Furthermore, the coagulation status of patients is assessed in whole blood, allowing the plasmatic coagulation system to interact with platelets and red cells, and thereby providing useful additional information on platelet function. Viscoelastic POC coagulation devices are increasingly being used in clinical practice, especially in the management of patients undergoing cardiac and liver surgery. Furthermore, they provide useful information in a large variety of clinical scenarios, e.g., massive hemorrhage, assessment of hypo- and hypercoagulable states, guiding pro- and anticoagulant therapies, and in diagnosing of a surgical bleeding. A surgical etiology of bleeding has to be considered when viscoelastic test results are normal. In summary, viscoelastic POC coagulation devices may help identify the cause of bleeding and guide pro- and anticoagulant therapies. To ensure optimal accuracy and performance, standardized procedures for blood sampling and handling, strict quality controls and trained personnel are required.
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Affiliation(s)
- Michael T Ganter
- Department of Anesthesia and Perioperative Care, University of CA San Francisco, San Francisco, California, USA
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Ganter MT, Monn A, Tavakoli R, Klaghofer R, Zollinger A, Hofer CK. Kaolin-Based Activated Coagulation Time Measured by Sonoclot in Patients Undergoing Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2007; 21:524-8. [PMID: 17678778 DOI: 10.1053/j.jvca.2006.12.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2006] [Indexed: 11/11/2022]
Abstract
OBJECTIVES In vivo data for the kaolin-based ACT test from the Sonoclot Analyzer (SkACT, Sienco Inc, Arvada, CO) are lacking. The aim of this study was to compare SkACT with an established kaolin-based ACT from Hemochron (HkACT) and anti-Xa activity in patients undergoing cardiopulmonary bypass (CPB). DESIGN Prospective observational study. SETTING Community hospital. PARTICIPANTS Fifty patients scheduled for elective cardiac surgery. INTERVENTIONS Blood samples were taken before CPB at baseline (T0) and after heparinization (T1 and T2), on CPB after administration of aprotinin (5, 15, 30, 60 minutes; T3-T6), and at the end after protamine infusion (T7). MEASUREMENTS AND MAIN RESULTS A total of 375 blood samples were analyzed. ACT measurements were comparable for SkACT and HkACT at each measurement time point. Overall bias +/- standard deviation between SkACT and HkACT was -19 +/- 75 seconds (-2.4% +/- 11.7%). Mean bias between SkACT and HkACT at each time point ranged from -35 to 3 seconds (-4.5% to 2.6%) and showed no statistical significance over time. Heparin sensitivity of SkACT and HkACT, defined as (ACT(Tx)-ACT(T0))/(anti-Xa(Tx)-anti-Xa(T0)), significantly increased for measurements during CPB (p < 0.001) but without significant difference between the 2 methods. Test variability was comparable for both ACT measurement techniques. Overall test variability was 7.5% +/- 7.4% for SkACT and 7.8% +/- 11% for HkACT. CONCLUSIONS Accuracy and performance of SkACT and HkACT were comparable for heparin monitoring in patients undergoing CPB for elective cardiac surgery. However, both tests were affected significantly after initiating CPB and aprotinin infusion.
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Affiliation(s)
- Michael T Ganter
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94110, USA.
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Bauters A, Mazoyer E. Apport de la thromboélastométrie rotative (Rotem®) pour l'exploration de l'hémostase: Intérêt en pratique clinique. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1773-035x(07)80264-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Mengistu AM, Wolf MW, Boldt J, Röhm KD, Lang J, Piper SN. Evaluation of a new platelet function analyzer in cardiac surgery: a comparison of modified thromboelastography and whole-blood aggregometry. J Cardiothorac Vasc Anesth 2007; 22:40-6. [PMID: 18249329 DOI: 10.1053/j.jvca.2007.02.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2006] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Impaired hemostasis of multiple etiologies are often present in patients undergoing cardiopulmonary bypass (CPB) surgery. Platelet dysfunction is considered to be important in the early postoperative period. Therefore, a new whole-blood platelet function analyzer was compared with thromboelastography in predicting postoperative hemostatic outcomes as measured by blood loss and blood product use. DESIGN Prospective study. SETTING Teaching hospital. PARTICIPANTS The study enrolled 54 patients scheduled for coronary artery bypass surgery with CPB. INTERVENTIONS Coagulation and platelet function were assessed preoperatively, after CPB, at 3 hours, and at 24 hours after surgery by using thromboelastography and impedance aggregometry. Patients were divided into a transfused and nontransfused group on the basis of postoperative transfusion requirements. Postoperative blood loss and requirements of blood transfusions were documented until 24 hours postoperatively. MEASUREMENTS AND MAIN RESULTS Twenty-five patients (46%) received postoperative blood transfusions. Impaired hemostasis occurred after CPB detected by thromboelastography (p < 0.01) and impedance aggregometry (p < 0.01). In contrast to thromboelastography, preoperative adenosine diphosphate-mediated aggregometry correlated with postoperative requirements for blood transfusion (Spearman r = -0.302, p < 0.05) and was significantly lower in patients receiving allogeneic blood transfusion compared with nontransfused patients (p < 0.05). Neither aggregometry nor thromboelastography was correlated with postoperative blood loss. CONCLUSION Impedance aggregometry as well as thromboelastography are able to detect impaired hemostasis after CPB. In contrast to thromboelastography, aggregometry using a new whole-blood aggregometer identified patients with a reduced risk for postoperative transfusion requirements.
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Affiliation(s)
- Andinet M Mengistu
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Ludwigshafen, Ludwigshafen, Germany.
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Tan K, Booth D, Newell SJ, Dear PRF, Hughes C, Richards M. Point-of-care testing of neonatal coagulation. ACTA ACUST UNITED AC 2006; 28:117-21. [PMID: 16630216 DOI: 10.1111/j.1365-2257.2006.00765.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of this validation study was to compare prothrombin time (PT) and activated partial thromboplastin time (APTT) results from a point-of-care testing (POCT) device (Rapidpoint Coag) with those from standard laboratory tests. The subjects were newborn infants needing coagulation screen for any clinical indications within a regional neonatal intensive care unit. The level of agreement between POCT and laboratory measurements of PT and APTT was determined. For PT: the bias was from -7.6 to 12.4 s and precision was 5.0 s. For the detection of prolonged PT at a level of 16 s, the sensitivity was 0.70, specificity was 0.57 and the positive predictive value (PPV) was 0.62. For APTT: the bias was from -39.1 to 23.7 s, and precision was 15.7 s. For the detection of prolonged APTT at a level of 55 s, the sensitivity was 0.80, specificity was 0.95 and the PPV was 0.80. The POCT device tested has limited utility as a cot-side device for screening for a prolongation of the APTT in the newborn but is not sensitive for screening for prolongation of the PT.
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Affiliation(s)
- K Tan
- Neonatal Unit, St James's University Hospital, Leeds, UK.
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Song H, Li HW, Munson MS, Van Ha TG, Ismagilov RF. On-chip titration of an anticoagulant argatroban and determination of the clotting time within whole blood or plasma using a plug-based microfluidic system. Anal Chem 2006; 78:4839-49. [PMID: 16841902 PMCID: PMC1851927 DOI: 10.1021/ac0601718] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This paper describes extending plug-based microfluidics to handling complex biological fluids such as blood, solving the problem of injecting additional reagents into plugs, and applying this system to measuring of clotting time in small volumes of whole blood and plasma. Plugs are droplets transported through microchannels by fluorocarbon fluids. A plug-based microfluidic system was developed to titrate an anticoagulant (argatroban) into blood samples and to measure the clotting time using the activated partial thromboplastin time (APTT) test. To carry out these experiments, the following techniques were developed for a plug-based system: (i) using Teflon AF coating on the microchannel wall to enable formation of plugs containing blood and transport of the solid fibrin clots within plugs, (ii) using a hydrophilic glass capillary to enable reliable merging of a reagent from an aqueous stream into plugs, (iii) using bright-field microscopy to detect the formation of a fibrin clot within plugs and using fluorescent microscopy to detect the production of thrombin using a fluorogenic substrate, and (iv) titration of argatroban (0-1.5 microg/mL) into plugs and measurement of the resulting APTTs at room temperature (23 degrees C) and physiological temperature (37 degrees C). APTT measurements were conducted with normal pooled plasma (platelet-poor plasma) and with donor's blood samples (both whole blood and platelet-rich plasma). APTT values and APTT ratios measured by the plug-based microfluidic device were compared to the results from a clinical laboratory at 37 degrees C. APTT obtained from the on-chip assay were about double those from the clinical laboratory but the APTT ratios from these two methods agreed well with each other.
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Abstract
PURPOSE To review the perioperative management of antithrombotic therapy in cardiac surgery, including the management of cardiopulmonary bypass (CPB) and off-pump surgery. METHODS A review of the relevant English literature over the period 1975-2005 was undertaken, in addition to a review of international practices in antithrombotic therapy in cardiac surgery. PRINCIPAL FINDINGS Cardiopulmonary bypass is required in most procedures and makes anticoagulation mandatory. Anticoagulation is, usually, achieved with unfractionnated heparin (UFH). Unfractionated heparin is monitored by point-of-care (POC) testing, such as the activated clotting time or the determination of heparin concentration. The target values of both tests remain empirical, with no clearly validated thresholds. The target value needs to be adjusted according to the POC test, given significant variations between devices and activators. After CABG, the need for antiplatelet therapy is well demonstrated, in order to limit the risk of postoperative death or ischemic events, and improve venous graft patency. Immediately after valvular surgery, antithrombotic therapy should take into account the specific risk carried by each patient and by each prosthetic device. The risk of venous thromboembolism, though poorly defined, is also present in the postoperative period and may require additional attention. Given the frequent exposure to UFH, occurrence of heparin-induced thrombocytopenia is not infrequent in these patients and requires careful individual management. CONCLUSIONS Antithrombotic therapy is an essential component of cardiac surgery. Yet, with the exception of antiplatelet agents in CABG patients, antithrombotic therapy is often based on the clinical experience of medical teams more than on an evidence-based assessment of the literature.
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Dalbert S, Ganter MT, Furrer L, Klaghofer R, Zollinger A, Hofer CK. Effects of heparin, haemodilution and aprotinin on kaolin-based activated clotting time: in vitro comparison of two different point of care devices. Acta Anaesthesiol Scand 2006; 50:461-8. [PMID: 16548858 DOI: 10.1111/j.1399-6576.2006.00990.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND During cardiopulmonary bypass (CPB), measurement of kaolin-based activated clotting time (kACT) is a standard practice in monitoring heparin-induced anticoagulation. Despite the fact that the kACT test from the Sonoclot Analyzer (SkACT) has been commercially available for several years, no published data on the performance of SkACT are available. Thus, the aim of this in vitro study was to compare SkACT with an established kACT from Hemochron (HkACT). METHODS Blood was withdrawn from 25 patients before elective cardiac surgery. SkACT and HkACT were measured in duplicate after in vitro administration of heparin (0, 1, 2 and 3 U/ml), calcium-free lactated Ringer's solution (25% and 50% haemodilution) and aprotinin (200 kIU/ml). RESULTS A total of 600 duplicate kACT measurements were obtained from 25 cardiac surgery patients. Overall, mean bias +/- SD between SkACT and HkACT was 7 +/- 70 s (1.3% +/- 14.1%). Administration of heparin, haemodilution and aprotinin induced a comparable effect on both activated clotting time (ACT) tests. Mean bias ranged from -4 +/- 39 s (-1.7% +/- 12.9%) to 4 +/- 78 s (3.2% +/- 15.6%) for heparinzed blood samples after haemodilution or aprotinin application and increased after combined aprotinin administration and haemodilution. After haemodilution and administration of aprotinin, both ACT tests were less reliable for values >480 s in heparinized blood samples. CONCLUSION Accuracy and performance of SkACT and HkACT were comparable after in vitro administration of heparin, aprotinin and haemodilution. Both ACT tests were considerably affected by aprotinin and haemodilution.
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Affiliation(s)
- S Dalbert
- Institute of Anaesthesiology and Intensive Care Medicine, Triemli City Hospital Zurich, Zurich, Switzerland
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Lang T, Bauters A, Braun SL, Pötzsch B, von Pape KW, Kolde HJ, Lakner M. Multi-centre investigation on reference ranges for ROTEM thromboelastometry. Blood Coagul Fibrinolysis 2005; 16:301-10. [PMID: 15870552 DOI: 10.1097/01.mbc.0000169225.31173.19] [Citation(s) in RCA: 380] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Reagent-supported thromboelastometry (TEM) with the ROTEM Whole Blood Haemostasis Analyser is an enhancement of thromboelastography, a method that is increasingly used for the point of care monitoring of acute perioperative bleeding disorders. We investigated the reference ranges of two activated tests (INTEM and EXTEM) and a test analysing specifically the fibrin component of coagulation (FIBTEM) in a multi-centre approach. The reference ranges obtained for the clotting time (CT), clot formation time (CFT), alpha angle (ALP), maximum clot firmness (MCF) and clot lysis parameters were comparable from centre to centre. INTEM: CT equals; 137-246 s, CFT equals; 40-100 s, MCF equals; 52-72 mm. EXTEM: CT equals; 42-74 s, CFT equals; 46-148 s, MCF equals; 49-71 mm. FIBTEM: MCF equals; 9-25 mm. ROTEM whole blood coagulation correlated weakly with a trend towards enhanced coagulation in females compared with males and in advanced age. The repeatability (within-run imprecision) of the results was dependent on the test with the following coefficients of variation: 1-5% (clot firmness, alpha angle), 3-12% (CT, CFT), 6-13% (FIBTEM clot firmness). Citrated blood samples were stable for ROTEM analysis stored within 6 h from drawing. In summary, the data showed that ROTEM thromboelastometry yields consistent values between centres and that providing general orientating reference ranges seems to be possible.
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Affiliation(s)
- Thomas Lang
- Clinical Institute of Medical and Chemical Laboratory Diagnostic, University Clinic of Graz, Austria
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Ganter MT, Dalbert S, Graves K, Klaghofer R, Zollinger A, Hofer CK. Monitoring Activated Clotting Time for Combined Heparin and Aprotinin Application: An In Vitro Evaluation of a New Aprotinin-Insensitive Test Using SONOCLOT. Anesth Analg 2005; 101:308-314. [PMID: 16037133 DOI: 10.1213/01.ane.0000173209.76933.be] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED The kaolin-based activated clotting time (ACT) is commonly used for monitoring heparin-induced anticoagulation alone and combined with aprotinin during cardiopulmonary bypass. However, aprotinin prolongs ACT measurements. Recently, a new so-called 'aprotinin-insensitive' ACT test (SaiACT) has been developed for the SONOCLOT analyzer. In this study we evaluated and compared this new test for the SONOCLOT analyzer in vitro with an established kaolin-based ACT from HEMOCHRON (HkACT). Twenty-five patients undergoing elective valve surgery donated 80 mL of blood after induction of anesthesia. The blood was withdrawn in citrated tubes and processed to analyze effects of heparin (0, 1, 2, and 3 U x mL(-1)), aprotinin (0, 200 kIU x mL(-1)), and 25% hemodilution with calcium-free lactated Ringer's solution on ACT measurements. A total of 400 blood samples were analyzed and ACT was measured in a wide, clinically relevant range in duplicate with SaiACT and HkACT. Addition of aprotinin to heparinized blood samples induced no significant changes of SaiACT measurements. By contrast, HkACT readings increased significantly: aprotinin prolonged HkACT in heparinized blood samples by 20% +/- 37% (2 U x mL(-1)) and 24% +/- 18% (3 U x mL(-1)), respectively, and in vitro hemodilution increased this effect. IMPLICATIONS Current standard techniques to measure heparin-induced anticoagulation during cardiopulmonary bypass are affected by aprotinin, a drug widely used in this setting. The aim of this study was to investigate in vitro a new, so-called 'aprotinin-insensitive' test from SONOCLOT to measure heparin-induced anticoagulation more reliably in combination with aprotinin.
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Affiliation(s)
- Michael T Ganter
- *Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA; †Institute of Anesthesiology and Intensive Care Medicine and ‡Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland; and §Department of Psychosocial Medicine, University Hospital Zurich, Zurich, Switzerland
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Jude B, Lasne D, Mouton C, de Moerloose P. Surveillance de l'anticoagulation des circulations extracorporelles par l'héparine non fractionnée : quels sont les problèmes non résolus ? ACTA ACUST UNITED AC 2004; 23:589-96. [PMID: 15234724 DOI: 10.1016/j.annfar.2004.02.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2003] [Accepted: 02/15/2004] [Indexed: 11/27/2022]
Abstract
Cardiac surgery with extracorporeal circulation induces major alterations of haemostasis and requires high level of anticoagulation, usually achieved by unfractionated heparin infusion. Optimization of anticoagulant regimen, through adapted biological monitoring, can probably improve postoperative course, at least for postoperative haemostatic status. Despite increasing knowledge on extracorporeal circulation-induced haemostatic abnormalities and the development of new biological devices for heparin monitoring, the optimal level of anticoagulation remains matter of debate, as well as the monitoring procedures. This critical review presents the current available data on heparin anticoagulation and monitoring in this specific context, and underlines the pending issues about anticoagulation management during extracorporeal bypass.
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Affiliation(s)
- B Jude
- Institut d'hématologie biologique et d'hémobiologie-transfusion, CHRU de Lille, boulevard du Professeur-Leclercq, 59037 Lille, France.
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