1
|
Mansour A, Berahou M, Odot J, Pontis A, Parasido A, Reizine F, Launey Y, Garlantézec R, Flecher E, Lecompte T, Nesseler N, Gouin-Thibault I. Antithrombin Levels and Heparin Responsiveness during Venoarterial Extracorporeal Membrane Oxygenation: A Prospective Single-center Cohort Study. Anesthesiology 2024; 140:1153-1164. [PMID: 38271619 PMCID: PMC11097948 DOI: 10.1097/aln.0000000000004920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Unfractionated heparin, administered during venoarterial extracorporeal membrane oxygenation to prevent thromboembolic events, largely depends on plasma antithrombin for its antithrombotic effects. Decreased heparin responsiveness seems frequent on extracorporeal membrane oxygenation; however, its association with acquired antithrombin deficiency is poorly understood. The objective of this study was to describe longitudinal changes in plasma antithrombin levels during extracorporeal membrane oxygenation support and evaluate the association between antithrombin levels and heparin responsiveness. The hypothesis was that extracorporeal membrane oxygenation support would be associated with acquired antithrombin deficiency and related decreased heparin responsiveness. METHODS Adults receiving venoarterial extracorporeal membrane oxygenation were prospectively included. All patients received continuous intravenous unfractionated heparin using a standardized protocol (target anti-Xa 0.3 to 0.5 IU/ml). For each patient, arterial blood was withdrawn into citrate-containing tubes at 11 time points (from hour 0 up to day 7). Anti-Xa (without dextran or antithrombin added) and antithrombin levels were measured. The primary outcome was the antithrombin plasma level. In the absence of consensus, antithrombin deficiency was defined as a time-weighted average of antithrombin less than or equal to 70%. Data regarding clinical management and heparin dosage were collected. RESULTS Fifty patients, including 42% postcardiotomy, were included between April 2020 and May 2021, with a total of 447 samples. Median extracorporeal membrane oxygenation duration was 7 (interquartile range, 4 to 12) days. Median antithrombin level was 48% (37 to 60%) at baseline. Antithrombin levels significantly increased throughout the follow-up. Time-weighted average of antithrombin levels was 63% (57 to 73%) and was less than or equal to 70% in 32 (64%) of patients. Overall, 45 (90%) patients had at least one antithrombin value less than 70%, and 35 (70%) had at least one antithrombin value less than 50%. Antithrombin levels were not significantly associated with heparin responsiveness evaluated by anti-Xa assay or heparin dosage. CONCLUSIONS Venoarterial extracorporeal membrane oxygenation support was associated with a moderate acquired antithrombin deficiency, mainly during the first 72 h, that did not correlate with heparin responsiveness. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Center of Clinical Investigation, Research Institute for Environmental and Occupational Health, University Hospital Federation Survival Optimization in Organ Transplantation, Univ Rennes, Rennes, France
| | - Mathilde Berahou
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Joscelyn Odot
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Adeline Pontis
- Department of Hematology, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Center of Clinical Investigation, Research Institute for Environmental and Occupational Health, University Hospital Federation Survival Optimization in Organ Transplantation, Univ Rennes, Rennes, France
| | - Alessandro Parasido
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Florian Reizine
- Department of Medical Intensive Care, University Hospital of Rennes, Rennes, France
| | - Yoann Launey
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Ronan Garlantézec
- Department of Epidemiology and Public Health, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Center of Clinical Investigation, Research Institute for Environmental and Occupational Health, University Hospital Federation Survival Optimization in Organ Transplantation, Univ Rennes, Rennes, France
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou, University Hospital of Rennes, University of Rennes, Signal and Image Treatment Laboratory, National Institute of Health and Medical Research U1099, Rennes, France
| | - Thomas Lecompte
- Department of Hematology, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Nicolas Nesseler
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Center of Clinical Investigation, Nutrition, Metabolism, Cancer Mixed Research Unit, University Hospital Federation Survival Optimization in Organ Transplantation, Univ Rennes, Rennes, France
| | - Isabelle Gouin-Thibault
- Department of Hematology, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Research Institute for Environmental and Occupational Health, Rennes, France
| |
Collapse
|
2
|
Kodaka M, Ichikawa J, Komori M. Relationship between perioperative cardiopulmonary bypass time, platelet count, fibrinogen level, rotational thromboelastometry data, antithrombin level, and blood loss volume and the effects of deep hypothermic circulatory arrest: An observational study. Perfusion 2024; 39:816-822. [PMID: 36877936 DOI: 10.1177/02676591231161762] [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: 03/08/2023]
Abstract
INTRODUCTION We hypothesized that perioperative fibrinogen level, platelet count, and rotational thromboelastometry (ROTEM) data values decrease in proportion to cardiopulmonary bypass (CPB) time, particularly in patients who underwent deep hypothermic circulatory arrest (DHCA). METHODS A total of 160 patients were enrolled and divided into the following three groups depending on CPB time: <2-h, 2- 3-h, and >3-h groups. Blood samples were obtained during CPB weaning. Platelet count, ROTEM data, fibrinogen level, and antithrombin level were determined. For propensity matching, we selected 15 patients who underwent DHCA and 15 patients who did not undergo DHCA and used propensity scores to match CPB time and other characteristics. RESULTS The <2-h, 2-3-h, and >3-h groups included 74, 63, and 23 patients, respectively. No significant differences in platelet count and fibrinogen level were observed between the groups. Antithrombin level and amplitude of clot firmness at 10 min in the EXTEM and FIBTEM tests were lowest in the >3-h group. Similarly, blood loss volume and transfusion volume were highest in the >3-h group. Significant differences in platelet count, ROTEM data, lowest esophageal and bladder temperatures, and transfusion volume were observed between patients who underwent DHCA and patients who did not undergo DHCA. CONCLUSIONS The longer the CPB time, the greater the perioperative blood loss volume and transfusion volume, particularly if CPB time is greater than 3 hours. Sub-group analysis revealed that DHCA affects perioperative platelet count and function as well as blood loss volume.
Collapse
Affiliation(s)
- M Kodaka
- Department of Anesthesiology and Intensive Care, Tokyo Women's Medical University Medical Center Adachi, Adachi-ku, Tokyo, Japan
| | - J Ichikawa
- Department of Anesthesiology and Intensive Care, Tokyo Women's Medical University Medical Center Adachi, Adachi-ku, Tokyo, Japan
| | - M Komori
- Department of Anesthesiology and Intensive Care, Tokyo Women's Medical University Medical Center Adachi, Adachi-ku, Tokyo, Japan
| |
Collapse
|
3
|
Levy JH, Sniecinski RM, Maier CL, Despotis GJ, Ghadimi K, Helms J, Ranucci M, Steiner ME, Tanaka KA, Connors JM. Finding a common definition of heparin resistance in adult cardiac surgery: communication from the ISTH SSC subcommittee on perioperative and critical care thrombosis and hemostasis. J Thromb Haemost 2024; 22:1249-1257. [PMID: 38215912 DOI: 10.1016/j.jtha.2024.01.001] [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: 11/13/2023] [Revised: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 01/14/2024]
Abstract
Ensuring adequate anticoagulation for patients requiring cardiac surgery and cardiopulmonary bypass (CPB) is important due to the adverse consequences of inadequate anticoagulation with respect to bleeding and thrombosis. When target anticoagulation is not achieved with typical doses, the term heparin resistance is routinely used despite the lack of uniform diagnostic criteria. Prior reports and guidance documents that define heparin resistance in patients requiring CPB and guidance documents remain variable based on the lack of standardized criteria. As a result, we conducted a review of clinical trials and reports to evaluate the various heparin resistance definitions employed in this clinical setting and to identify potential standards for future clinical trials and clinical management. In addition, we also aimed to characterize the differences in the reported incidence of heparin resistance in the adult cardiac surgical literature based on the variability of both target-activated clotting (ACT) values and unfractionated heparin doses. Our findings suggest that the most extensively reported ACT target for CPB is 480 seconds or higher. Although most publications define heparin resistance as a failure to achieve this target after a weight-based dose of either 400 U/kg or 500 U/kg of heparin, a standardized definition would be useful to guide future clinical trials and help improve clinical management. We propose the inability to obtain an ACT target for CPB of 480 seconds or more after 500 U/kg as a standardized definition for heparin resistance in this setting.
Collapse
Affiliation(s)
- Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Roman M Sniecinski
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - George J Despotis
- Departments of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Clinical Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - Julie Helms
- University Hospital, Medical Intensive Care Unit, Nouvel Hôpital Civil, Strasbourg, France; French National Institute of Health and Medical Research, Regenerative Nanomedicine, Strasbourg, France
| | - Marco Ranucci
- Department of Cardiothoracic, Anesthesia and Intensive Care, Policlinico San Donato, Milan, Italy
| | - Marie E Steiner
- Department of Pediatrics, Divisions of Hematology/Oncology and Critical Care, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jean M Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
4
|
Yamashiro T, Takami Y, Takagi Y. Contributing factors to heparin resistance during cardiopulmonary bypass. J Artif Organs 2024:10.1007/s10047-024-01435-1. [PMID: 38367099 DOI: 10.1007/s10047-024-01435-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 01/18/2024] [Indexed: 02/19/2024]
Abstract
Since the risk factors for heparin resistance (HR) before cardiopulmonary bypass (CPB) have not been fully clarified, this study investigated the contributing factors for HR after the initial unfractionated heparin (UFH) dose of 500 IU/kg. We retrospectively analyzed the data of 371 patients who underwent CPB surgery, with the initial UFH dose of 500 IU/kg, between May 2017 and December 2021. We defined HR as the failure to achieve activated clotting time (ACT) of > 480 s after the initial UFH dose of 500 IU/kg. HR was observed in 36 patients (9.7%) (HR group), while HR was not observed in 335 patients (control group). The HR group included significantly more patients with preoperative use of UFH, with significantly higher white blood cell counts, fibrinogen, fibrinogen degradation products, D-dimer, and C-reactive protein, and lower hemoglobin and albumin. The multivariable logistic regression analysis identified albumin (OR: 3.09, 95% CI 1.3504-7.0845, p = 0.0075) and fibrinogen (OR: 0.99, 95% CI 0.9869-0.9963, p = 0.0003) as independent predictors for HR. Using the Youden index, the cutoffs of albumin and fibrinogen were calculated as 3.8 g/dL and 303 mg/dL, respectively. The receiver operating characteristic curves showed the predictive performance of albumin (area under the curve (AUC): 0.78, sensitivity: 65%, specificity: 81%) and fibrinogen (AUC: 0.77, sensitivity: 56%, specificity: 88%). The incidence of HR after the initial UFH dose of 500 IU/kg was 9.7%. The preoperative albumin < 3.8 g/dL and fibrinogen > 303 mg/dL were independent predictors for HR.
Collapse
Affiliation(s)
- Tomoaki Yamashiro
- Department of Clinical Engineering, Fujita Health University Hospital, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan.
| | - Yoshiyuki Takami
- Department of Cardiovascular Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan.
| | - Yasushi Takagi
- Department of Cardiovascular Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| |
Collapse
|
5
|
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.
Collapse
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.
| |
Collapse
|
6
|
Ito K, Sasaki K, Ono M, Suzuki T, Sakamoto K, Okamoto H, Katori N, Momose N, Araki Y, Tojo K, Ieko M, Komiyama Y, Saiki Y. Investigation of real-world heparin resistance and anticoagulation management prior to cardiopulmonary bypass: report from a nationwide survey by the Japanese Association for Thoracic Surgery heparin resistance working group. Gen Thorac Cardiovasc Surg 2024; 72:8-14. [PMID: 37195584 PMCID: PMC10766675 DOI: 10.1007/s11748-023-01936-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/14/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE Heparin resistance is often encountered during cardiopulmonary bypass. Heparin dose and activated clotting time target values for the initiation of cardiopulmonary bypass are not yet universally standardized; further no consensus exists on the management of heparin resistance. This study aimed to investigate the current real-world practice on heparin management and anticoagulant treatment for heparin resistance in Japan. METHODS A questionnaire survey was conducted at medical institutions nationwide with which The Japanese Society of Extra-Corporeal Technology in Medicine members are affiliated, targeting surgical cases with cardiopulmonary bypass performed from January 2019 through December 2019. RESULTS Among 69% (230/332) of the participating institutions, the criterion for heparin resistance was defined as "the target activated clotting time value not reached even with an additional dose of heparin administration". Cases of heparin resistance were reported in 89.8% (202/225) of the responded institutions. Of note, 75% (106/141) of the responded institutions reported heparin resistance associated with antithrombin activity ≥ 80%. Antithrombin concentrate was used in 38.4% (238/619 responses) or third dose of heparin in 37.8% (234/619 responses) for advanced heparin resistance treatment. Antithrombin concentrate was found to be effective in resolving heparin resistance in patients having normal, as well as lower antithrombin activity. CONCLUSION Heparin resistance has occurred in many cardiovascular centers, even among patients with normal antithrombin activities. Interestingly, the administration of antithrombin concentrate resolved heparin resistance, regardless of the baseline antithrombin activity value.
Collapse
Affiliation(s)
- Koki Ito
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan
| | - Konosuke Sasaki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Takaaki Suzuki
- Department of Pediatric Cardiac Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Kisaburo Sakamoto
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hirotsugu Okamoto
- Department of Anesthesiology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Nobuyuki Katori
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoki Momose
- Department of Medical Center, Jichi Medical University, Saitama, Japan
| | - Yasuyuki Araki
- Department of Clinical Engineering, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Keiichi Tojo
- Department of Medical Engineering, Kitasato University Hospital, Sagamihara, Japan
| | - Masahiro Ieko
- Department of Hematology, Iwate Prefectural Chubu Hospital, Kitakami, Japan
| | - Yutaka Komiyama
- Faculty of Health and Medical Sciences, Hokuriku University, Kanazawa, Japan
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan.
| |
Collapse
|
7
|
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.
Collapse
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.
| |
Collapse
|
8
|
Kimura Y, Okahara S, Abo K, Koyama Y, Kuriyama M, Ono K, Hidaka H. Infective Endocarditis Is a Risk Factor for Heparin Resistance in Adult Cardiovascular Surgical Procedures: A Retrospective Study. J Cardiothorac Vasc Anesth 2021; 35:3568-3573. [PMID: 34144872 DOI: 10.1053/j.jvca.2021.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Heparin resistance (HR), defined as a decrease in heparin responsiveness, can result in adverse events with prolonged duration of surgery. Although some clinical risk factors have been suggested, the relationship with the surgical diagnosis is unclear. The aim of present study was to elucidate the clinical predictors of HR including the surgical diagnosis. DESIGN This retrospective cohort study determined the incidence of HR (defined as activated clotting time [ACT] <400 seconds after 250-350 IU/kg of heparin administration) and heparin sensitivity index (HSI) was calculated from the rate of change in ACT per heparin dose. Preoperative demographic data, medication history, and laboratory data also were analyzed. SETTING Single institution, tertiary care hospital. PARTICIPANTS Adult patients who underwent cardiovascular surgery with cardiopulmonary bypass between January 2012 and September 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 287 patients, 88 (30.7%) were classified as HR. In univariate analysis, infective endocarditis (IE), platelet count, and serum fibrinogen and albumin levels were associated with HR. After adjustment for baseline ACT and initial heparin dose, IE (odds ratio 4.57, [95% CI: 1.10-19.1]; p = 0.037) and albumin ≤3.5 g/dL (3.17, [1.46-6.93]; p = 0.004) were associated independently with HR. Patients with IE had significantly lower HSI than those with other diseases. All HR patients were treated with additional heparin, and 17 of them received human antithrombin-III concentrate. CONCLUSIONS Infective endocarditis and preoperative hypoalbuminemia were associated independently with HR. The optimal anticoagulation strategy for patients with these risk factors requires further investigations based on the authors' findings.
Collapse
Affiliation(s)
- Yoshikazu Kimura
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan.
| | - Shuji Okahara
- Department of Intensive Care Medicine, Okayama University Hospital, Okayama, Japan
| | - Kanae Abo
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan
| | - Yusuke Koyama
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan
| | - Mitsuhito Kuriyama
- Department of Cardiovascular Surgery, Saiseikai Imabari Hospital, Ehime, Japan
| | - Kazumi Ono
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School, Okayama, Japan
| | - Hidekuni Hidaka
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan
| |
Collapse
|
9
|
Preoperative Low-Molecular-Weight Heparin Prophylaxis Associated with Increased Heparin Resistance Frequency in On-Pump Coronary Artery Bypass Graft Surgery. Cardiol Res Pract 2019; 2019:4310407. [PMID: 31143477 PMCID: PMC6501132 DOI: 10.1155/2019/4310407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 12/09/2018] [Accepted: 03/18/2019] [Indexed: 11/21/2022] Open
Abstract
Background Unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) are being used for preoperative management of critical coronary artery disease. However, preoperative UFH therapy may cause a reduction in antithrombin concentrations, leading to various degrees of heparin resistance (HR). The main purpose of this study is to investigate the effects of preoperative LMWH on HR during cardiopulmonary bypass (CPB). Methods Data were retrospectively reviewed from adult patients that underwent on-pump coronary artery bypass graft (CABG) surgery. Four hundred fifty-seven patients underwent CABG, and 139 of them, who had isolated on-pump CABG, were included in the study. The heparin sensitivity index was calculated if activated clotting time levels were discovered below 400 seconds. Values less than 1.3 were accepted as HR. Results Of 139 patients who underwent on-pump CABG, preoperative LMWH was administered in 59 patients (56.8%). Intraoperative HR occurred in 29 patients (20.9%). Patients who received preoperative LMWH had an increased risk of developing HR compared with patients who did not receive LMWH (odds ratio 4.8 and 95% confidence interval 1.7–13.5). CPB duration and aortic clamp duration were significantly longer in patients who developed intraoperative HR when compared to those in patients who did not develop HR. Conclusion Preoperative treatment with LMWH may cause intraoperative HR. Corrective and preventive arrangements with close follow-up should be performed in this group of patients.
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Jooste EH, Scholl R, Wu YH, Jaquiss RDB, Lodge AJ, Ames WA, Homi HM, Machovec KA, Greene NH, Donahue BS, Shah N, Benkwitz C. Double-Blind, Randomized, Placebo-Controlled Trial Comparing the Effects of Antithrombin Versus Placebo on the Coagulation System in Infants with Low Antithrombin Undergoing Congenital Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 33:396-402. [PMID: 30072263 DOI: 10.1053/j.jvca.2018.05.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine whether precardiopulmonary bypass (CPB) normalization of antithrombin levels in infants to 100% improves heparin sensitivity and anticoagulation during CPB and has beneficial effects into the postoperative period. DESIGN Randomized, double-blinded, placebo-controlled prospective study. SETTING Multicenter study performed in 2 academic hospitals. PARTICIPANTS The study comprised 40 infants younger than 7 months with preoperative antithrombin levels <70% undergoing CPB surgery. INTERVENTIONS Antithrombin levels were increased with exogenous antithrombin to 100% functional level intraoperatively before surgical incision. MEASUREMENTS AND MAIN RESULTS Demographics, clinical variables, and blood samples were collected up to postoperative day 4. Higher first post-heparin activated clotting times (sec) were observed in the antithrombin group despite similar initial heparin dosing. There was an increase in heparin sensitivity in the antithrombin group. There was significantly lower 24-hour chest tube output (mL/kg) in the antithrombin group and lower overall blood product unit exposures in the antithrombin group as a whole. Functional antithrombin levels (%) were significantly higher in the treatment group versus placebo group until postoperative day 2. D-dimer was significantly lower in the antithrombin group than in the placebo group on postoperative day 4. CONCLUSION Supplementation of antithrombin in infants with low antithrombin levels improves heparin sensitivity and anticoagulation during CPB without increased rates of bleeding or adverse events. Beneficial effects may be seen into the postoperative period, reflected by significantly less postoperative bleeding and exposure to blood products and reduced generation of D-dimers.
Collapse
Affiliation(s)
- Edmund H Jooste
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Rebecca Scholl
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Yi-Hung Wu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Robert D B Jaquiss
- Department of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center and Children's Medical Center, Dallas, TX
| | - Andrew J Lodge
- Division of Congenital Cardiac Surgery, Department of Cardiothoracic Surgery, Duke University Medical Center, Durham
| | - Warwick A Ames
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - H Mayumi Homi
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Kelly A Machovec
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Nathaniel H Greene
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Brian S Donahue
- Division of Pediatric Cardiac Anesthesiology, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Nirmish Shah
- Division of Pediatric Hematology/Oncology, Duke University Medical Center, Durham, NC
| | - Claudia Benkwitz
- Department of Anesthesia and Perioperative Care, UCSF Benioff Children's Hospital, San Francisco, CA
| |
Collapse
|
12
|
Kawatsu S, Sasaki K, Sakatsume K, Takahara S, Hosoyama K, Masaki N, Suzuki Y, Hayatsu Y, Yoshioka I, Sakuma K, Adachi O, Akiyama M, Kumagai K, Motoyoshi N, Kawamoto S, Saiki Y. Predictors of Heparin Resistance Before Cardiovascular Operations in Adults. Ann Thorac Surg 2018; 105:1316-1321. [DOI: 10.1016/j.athoracsur.2018.01.068] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 01/02/2018] [Accepted: 01/22/2018] [Indexed: 10/17/2022]
|
13
|
Nakamura S, Honjo O, Crawford-Lean L, Foreman C, Sano M, O’Leary JD. Predicting Heparin Responsiveness in Children Before Cardiopulmonary Bypass. Anesth Analg 2018; 126:1617-1623. [DOI: 10.1213/ane.0000000000002785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
14
|
Annich GM, Zaulan O, Neufeld M, Wagner D, Reynolds MM. Thromboprophylaxis in Extracorporeal Circuits: Current Pharmacological Strategies and Future Directions. Am J Cardiovasc Drugs 2017; 17:425-439. [PMID: 28536932 DOI: 10.1007/s40256-017-0229-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The development of extracorporeal devices for organ support has been a part of medical history and progression since the late 1900s. These types of technology are primarily used and developed in the field of critical care medicine. Unfractionated heparin, discovered in 1916, has really been the only consistent form of thromboprophylaxis for attenuating or even preventing the blood-biomaterial reaction that occurs when such technologies are initiated. The advent of regional anticoagulation for procedures such as continuous renal replacement therapy and plasmapheresis have certainly removed the risks of systemic heparinization and heparin effect, but the challenges of the blood-biomaterial reaction and downstream effects remain. In addition, regional anticoagulation cannot realistically be applied in a system such as extracorporeal membrane oxygenation because of the high blood flow rates needed to support the patient. More recently, advances in the technology itself have resulted in smaller, more compact extracorporeal life support (ECLS) systems that can-at certain times and in certain patients-run without any form of anticoagulation. However, the majority of patients on ECLS systems require some type of systemic anticoagulation; therefore, the risks of bleeding and thrombosis persist, the most devastating of which is intracranial hemorrhage. We provide a concise overview of the primary and alternate agents and monitoring used for thromboprophylaxis during use of ECLS. In addition, we explore the potential for further biomaterial and technologic developments and what they could provide when applied in the clinical arena.
Collapse
Affiliation(s)
- Gail M Annich
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, 555 University Avenue, M5G 1X8, Toronto, ON, Canada.
| | - Oshri Zaulan
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, 555 University Avenue, M5G 1X8, Toronto, ON, Canada
| | - Megan Neufeld
- Department of Chemistry, Colorado State University, Fort Collins, Colorado, USA
| | - Deborah Wagner
- Departments of Pharmacology and Anesthesia, University of Michigan, Ann Arbor, Michigan, USA
| | - Melissa M Reynolds
- Department of Chemistry, School of Biomedical Engineering, Chemical and Biological Engineering, Colorado State University, Fort Collins, Colorado, USA
| |
Collapse
|
15
|
Lander H, Zammert M, FitzGerald D. Anticoagulation management during cross-clamping and bypass. Best Pract Res Clin Anaesthesiol 2016; 30:359-70. [DOI: 10.1016/j.bpa.2016.07.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 07/20/2016] [Indexed: 01/28/2023]
|
16
|
Levy JH, Sniecinski RM, Welsby IJ, Levi M. Antithrombin: anti-inflammatory properties and clinical applications. Thromb Haemost 2015; 115:712-28. [PMID: 26676884 DOI: 10.1160/th15-08-0687] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 11/08/2015] [Indexed: 12/14/2022]
Abstract
Many humoral and cellular components participate in bidirectional communication between the coagulation and inflammation pathways. Natural anticoagulant proteins, including antithrombin (AT), tissue factor pathway inhibitor, and protein C, suppress proinflammatory mediators. Conversely, inflammation blunts anticoagulant activity and, when uncontrolled, promotes systemic inflammation-induced coagulation, such as those that occur in disseminated intravascular coagulation and severe sepsis. This review discusses the mechanisms of action and clinical use of AT concentrate in critically ill patients and in the settings of perioperative anticoagulation management for surgery and obstetrics. AT is a serine protease inhibitor with broad anticoagulant activity and potent anti-inflammatory properties. In clinical conditions associated with hereditary or acquired AT deficiency, administration of AT concentrate has been shown to restore proper haemostasis and attenuate inflammation. Of note, AT modulates inflammatory responses not only by inhibiting thrombin and other clotting factors that induce cytokine activity and leukocyte-endothelial cell interaction, but also by coagulation-independent effects, including direct interaction with cellular mediators of inflammation. An increasing body of evidence suggests that AT concentrate may be a potential therapeutic agent in certain clinical settings associated with inflammation. In addition to the well-known anticoagulation properties of AT for the treatment of hereditary AT deficiency, AT also possesses noteworthy anti-inflammatory properties that could be valuable in treating acquired AT deficiency, which often result in thrombotic states associated with an inflammatory component.
Collapse
Affiliation(s)
- Jerrold H Levy
- Jerrold H. Levy, MD, FAHA, FCCM, DUMC 3094, Durham, NC 27710, USA, Tel.: +1 919 681 6614, Fax: +1 919 681 8994, E-mail:
| | | | | | | |
Collapse
|
17
|
Antithrombin activity and heparin response in neonates and infants undergoing congenital cardiac surgery: a retrospective cohort study. Can J Anaesth 2015; 63:38-45. [DOI: 10.1007/s12630-015-0500-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 08/03/2015] [Accepted: 09/17/2015] [Indexed: 10/23/2022] Open
|
18
|
Hoenicka M, Rupp P, Müller-Eising K, Deininger S, Kunert A, Liebold A, Gorki H. Anticoagulation management during multivessel coronary artery bypass grafting: a randomized trial comparing individualized heparin management and conventional hemostasis management. J Thromb Haemost 2015; 13:1196-206. [PMID: 25954849 DOI: 10.1111/jth.12999] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Individualized heparin management (IHM) uses heparin dose-response curves to improve hemostasis management during cardiac surgery as compared with activated clotting time-based methods. OBJECTIVES IHM was compared with conventional hemostasis management (CHM) in a randomized, prospective study (ID DRKS00007580). METHODS One-hundred and twenty patients undergoing multivessel coronary artery bypass grafting (CABG) were enrolled. Heparin and protamine consumption, blood losses, blood transfusions and administration of hemostatic agents were recorded. Time courses of platelet counts and of coagulation parameters were determined. Coagulation was analyzed at intensive care unit (ICU) arrival by thromboelastometry. RESULTS IHM patients received significantly lower initial heparin doses (289.3IU kg(-1) [interquartile range (IQR) 221.5-376.2 IU kg(-1) ] versus 350.5 IU kg(-1) [IQR 346.8-353.7 IU kg(-1) ], P < 0.0001) but similar total heparin doses (418.5 IU kg(-1) [IQR 346.9-590.5 IU kg(-1) ] versus 435.8 IU kg(-1) [IQR 411.7-505.1 IU kg(-1) ]). IHM patients received significantly less protamine, resulting in protamine/total heparin ratios of 0.546 [IQR 0.469-0.597] versus 0.854 [IQR 0.760-0.911] in CHM patients (P < 0.0001). Activated partial thromboplastin time (50.5 s [IQR 40.0-60.0 s] versus 37.0 s [IQR 33.0-40.0 s], P < 0.0001), activated clotting time (136 s [IQR 129.0-150.5 s] versus 126.5 s [IQR 120.3-134.0 s], P = 0.0002) and INTEM clotting times (215 s [IQR 192-237] versus 201 s [IQR 191-216 s], P = 0.0397) were significantly longer in IHM patients than in CHM patients at ICU arrival, with no difference in prothrombin time (P = 0.538). IHM patients lost significantly more blood within 12 h postoperatively (420 mL [IQR 337.5-605.0 mL] versus 345 mL [IQR 230.0-482.5 mL], P = 0.0041), and required significantly more hemostatic agents to control bleeding. Red blood cell transfusion requirements and time courses of platelet counts did not differ between groups. CONCLUSIONS Multivessel CABG patients did not benefit from IHM in comparison with our established protocol based on activated clotting time.
Collapse
Affiliation(s)
- M Hoenicka
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - P Rupp
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - K Müller-Eising
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - S Deininger
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - A Kunert
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - A Liebold
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - H Gorki
- Department of Cardio-Thoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| |
Collapse
|
19
|
Sniecinski RM, Levy JH. Anticoagulation management associated with extracorporeal circulation. Best Pract Res Clin Anaesthesiol 2015; 29:189-202. [PMID: 26060030 DOI: 10.1016/j.bpa.2015.03.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 03/20/2015] [Indexed: 11/25/2022]
Abstract
The use of extracorporeal circulation requires anticoagulation to maintain blood fluidity throughout the circuit, and to prevent thrombotic complications. Additionally, adequate suppression of hemostatic activation avoids the unnecessary consumption of coagulation factors caused by the contact of blood with foreign surfaces. Cardiopulmonary bypass represents the greatest challenge in this regard, necessitating profound levels of anticoagulation during its conduct, but also quick, efficient reversal of this state once the surgical procedure is completed. Although extracorporeal circulation has been around for more than half a century, many questions remain regarding how to best achieve anticoagulation for it. Although unfractionated heparin is the predominant agent used for cardiopulmonary bypass, the amount required and how best to monitor its effects are still unresolved. This review discusses the use of heparin, novel anticoagulants, and the monitoring of anticoagulation during the conduct of cardiopulmonary bypass.
Collapse
Affiliation(s)
- Roman M Sniecinski
- Emory University School of Medicine, Department of Anesthesiology, 1364 Clifton Rd, NE, Atlanta, GA 30322, USA.
| | - Jerrold H Levy
- Cardiothoracic Anesthesia and Critical Care, Duke University Medical Center, 2301 Erwin Road, 5691H HAFS, Durham, NC 27710, USA.
| |
Collapse
|
20
|
Antithrombin III supplementation on extracorporeal membrane oxygenation: impact on heparin dose and circuit life. ASAIO J 2014; 60:57-62. [PMID: 24296776 DOI: 10.1097/mat.0000000000000010] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Antithrombin III (ATIII) is used during extracorporeal membrane oxygenation (ECMO) based on physiologic rationale and studies during cardiopulmonary bypass. In February 2008, our institution began using ATIII as replacement for low ATIII activity (<70%) in patients supported with ECMO. We hypothesized that ATIII supplementation would reduce heparin infusion rates, increase unfractionated heparin anti-Xa levels, and prolong ECMO circuit life. Data from 40 consecutive patients (45 deployments) requiring ECMO support for >72 hours with venoarterial ECMO from January 1, 2007, through December 31, 2008, were collected. Antithrombin III concentrate was administered for ATIII activity <70% at the discretion of the attending physician. The primary outcome was whether the heparin infusion rate was reduced by 10% or more as a result of ATIII administration. No difference in heparin infusion rate (p = 0.245) as a result of ATIII administration was observed. Anti-Xa levels were lower before ATIII administration (p< 0.001) and were increased after ATIII administration (p < 0.001). There was an increased frequency of circuit failure in ATIII treatment group compared with nontreatment group (p = 0.018). Neither heparin responsiveness nor circuit life was enhanced by daily ATIII supplementation for activity <70%. Future studies are warranted to evaluate the effectiveness of antithrombin replacement.
Collapse
|
21
|
Hilberath JN, Thomas ME, Smith T, Jara C, Fitzgerald DJ, Wilusz K, Liu X, Muehlschlegel JD. Blood volume measurement by hemodilution: association with valve disease and re-evaluation of the Allen Formula. Perfusion 2014; 30:305-11. [PMID: 25125291 DOI: 10.1177/0267659114547250] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Total blood volume (TBV) assessment is central to the management of cardiac surgical patients with cardiopulmonary bypass (CPB). The widely accepted Allen Formula lacks accuracy in estimating TBV in these patients. Moreover, the impact of commonly encountered cardiac disease states on TBV has not been systematically investigated. The aim of this study was to determine TBV by hemodilution (TBVHD) for patients with valve disease, compare TBVHD to algorithms frequently used during cardiac surgery and to modify the Allen Formula to better fit today's patient population. METHODS TBVHD was prospectively measured upon initiation of CPB. Ninety-six patients were grouped into 4 cohorts by preoperative diagnosis and compared to Allen and weight-based formulae in a univariate analysis: mitral regurgitation (MR), coronary artery disease requiring bypass surgery (CABG) and aortic stenosis (AS) ± CABG. The independent effects of height and weight on TBV were correlated to the original Allen Formula by multiple linear regression. RESULTS Patients with MR had significantly larger TBVHD compared to patients with AS, CABG or both. The smallest TBVHD was found in the patients with AS and CABG. The modified Allen Formula had an excellent model fit (R(2) = 0.88 and R(2) = 0.95 for males and females, respectively; p<0.001) while the classic formula overestimated TBV by 30% in males and females. For males, height impacted TBV calculations the most whereas weight was the predominant determinant in females. CONCLUSION Blood volume assessment via the Allen Formula or bodyweight overestimated TBV in cardiac surgical patients, with potential implications on their management. The assumption that MR frequently presents with increased intravascular volume was confirmed whereas AS patients with coronary disease had a relatively smaller TBV. Lastly, a modified Allen Formula to better reflect today's patient population was derived to reproducibly improve accuracy in mathematical estimates of TBV.
Collapse
Affiliation(s)
- J N Hilberath
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - M E Thomas
- Department of Anesthesiology, Warren Alpert School of Medicine, Rhode Island Hospital, Providence, USA
| | - T Smith
- Department of Cardiac Perfusion, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - C Jara
- Department of Cardiovascular Perfusion, Duke University Medical Center, Durham, USA
| | - D J Fitzgerald
- Department of Cardiac Perfusion, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - K Wilusz
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - X Liu
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - J D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| |
Collapse
|
22
|
Bechtel A, Huffmyer J. Anesthetic Management for Cardiopulmonary Bypass. Semin Cardiothorac Vasc Anesth 2014; 18:101-16. [DOI: 10.1177/1089253214529607] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiopulmonary bypass has revolutionized the practice of cardiac surgery and allows safe conduct of increasingly complex cardiac surgery. A brief review of the bypass circuit is undertaken in this review. A more thorough review of the anesthetic management is accomplished including choice of anesthetic medications and their effects. The inflammatory response to cardiopulmonary bypass is reviewed along with interventions that may help ameliorate the inflammation.
Collapse
|
23
|
Bagheri K, Honarmand A, Safavi M, Kashefi P, Sayadi L, Mohammadinia L. The evaluations of frequency distribution heparin resistance during coronary artery bypass graft. Adv Biomed Res 2014; 3:53. [PMID: 24627861 PMCID: PMC3950837 DOI: 10.4103/2277-9175.125798] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 11/05/2012] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Heparin is one of the most important medication that is used in coronary artery bypass graft (CABG) operations, but some patients demonstrate heparin resistance (HR) during CABG. Heparin resistance was defined as at least one activated clothing time <400 seconds after heparinization and/or the need for purified antithrombin III (AT-III) administration. The goal of this study was the investigation of HR prevalence in our country and relation between HR and post-operative CABG complications. MATERIALS AND METHODS One hundred patients that candidate for CABG were selected and surveyed for HR and complications. The data entered to computer and analyzed by SPSS soft ware. The Chi-square and student t-tests were used for data analysis. RESULTS The prevalence of heparin resistance in our study was 3%. There was no relation among bleeding, cardiac arrest and HR. Bleeding happened in 13 patients of which 1 person was in HR group (33.3%) and 12 in non HR group (12.4%) (P = 0.34). Cardiac arrest happened in 8 patients, 1 person was in HR group (33.3%) and 7 in non HR group (7.2%) (P = 0.22). According our data there were no relation among HR and gender and ventilator dependency time. CONCLUSIONS HR is a nearly prevalent complication among patients that undergone CABG that may led to some complications such as bleeding and cardiac arrest. In our study, we did not find significant relation among them, but in frequency these complications were higher in HR group.
Collapse
Affiliation(s)
- Kaivan Bagheri
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azim Honarmand
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammadreza Safavi
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parviz Kashefi
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Lale Sayadi
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Leila Mohammadinia
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
24
|
Gadhinglajkar S, Sreedhar R, Varma P, Pal S. Plasma exchange transfusion for management of altered heparin responsiveness before cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2013; 27:e58-60. [PMID: 24054198 DOI: 10.1053/j.jvca.2013.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Shrinivas Gadhinglajkar
- Department of Anesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | | | | | | |
Collapse
|
25
|
Antithrombin activity and outcomes in patients undergoing cardiac surgery with cardiopulmonary bypass. Blood Coagul Fibrinolysis 2013; 24:454-7. [DOI: 10.1097/mbc.0b013e32835d5422] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
26
|
Dietrich W, Busley R, Spannagl M, Braun S, Schuster T, Lison S. The Influence of Antithrombin Substitution on Heparin Sensitivity and Activation of Hemostasis During Coronary Artery Bypass Graft Surgery. Anesth Analg 2013; 116:1223-30. [DOI: 10.1213/ane.0b013e31827d0f6b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
27
|
Finley A, Greenberg C. Review article: heparin sensitivity and resistance: management during cardiopulmonary bypass. Anesth Analg 2013; 116:1210-22. [PMID: 23408671 DOI: 10.1213/ane.0b013e31827e4e62] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Heparin resistance during cardiac surgery is defined as the inability of an adequate heparin dose to increase the activated clotting time (ACT) to the desired level. Failure to attain the target ACT raises concerns that the patient is not fully anticoagulated and initiating cardiopulmonary bypass may result in excessive activation of the hemostatic system. Although antithrombin deficiency has generally been thought to be the primary mechanism of heparin resistance, the reasons for heparin resistance are both complex and multifactorial. Furthermore, the ACT is not specific to heparin's anticoagulant effect and is affected by multiple variables that are commonly present during cardiac surgery. Due to these many variables, it remains unclear whether decreased heparin responsiveness as measured by the ACT represents inadequate anticoagulation. Nevertheless, many clinicians choose a target ACT to assess anticoagulation, and interventions aimed at achieving the target ACT are routinely performed in the setting of heparin resistance. Treatments for heparin resistance/alterations in heparin responsiveness include additional heparin or antithrombin supplementation. In this review, we discuss the variability of heparin potency, heparin responsiveness as measured by the ACT, and the current management of heparin resistance.
Collapse
Affiliation(s)
- Alan Finley
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 25 Courtenay Drive, Charleston, SC 29425, USA.
| | | |
Collapse
|
28
|
Bosch YP, Weerwind PW, Nelemans PJ, Maessen JG, Mochtar B. An Evaluation of Factors Affecting Activated Coagulation Time. J Cardiothorac Vasc Anesth 2012; 26:563-8. [DOI: 10.1053/j.jvca.2012.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Indexed: 11/11/2022]
|
29
|
Sniecinski RM, Chandler WL. Activation of the Hemostatic System During Cardiopulmonary Bypass. Anesth Analg 2011; 113:1319-33. [DOI: 10.1213/ane.0b013e3182354b7e] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
30
|
Muedra V, Bonanad S, Gómez M, Villalonga V, Sánchez F, Llopis JE. Relationships between antithrombin activity, anticoagulant efficacy of heparin therapy and perioperative variables in patients undergoing cardiac surgery requiring cardiopulmonary bypass. Perfusion 2011; 26:487-95. [PMID: 21665912 DOI: 10.1177/0267659111412999] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION A study on 149 cardiopulmonary bypass (CPB) patients was performed to elucidate possible relationships between antithrombin (AT) activity and a subject's clinical profile or surgery characteristics. METHODS An initial dose (300 IU/kg) of heparin was administered before CPB. Additional boluses (100 IU/kg) were administered if the activated clotting time (ACT)≤460 s. AT activity and hematological parameters were determined preoperatively, during and after CPB, and at 12, 24, 36, and 48 hours post-intervention. RESULTS 29.5% patients required an additional dose of heparin during CPB. Preoperative AT was 96.5 ± 13.9% in all but 4 patients. AT was significantly lower during CPB and upon leaving the operating room (59.7%-80.0%). A small, but significant, inverse correlation was observed between AT at the end of CPB and the patient's age, as well as between basal preoperative AT and total heparin administered. CONCLUSIONS Patient's age could be a moderate indicator of AT activity drop and low preoperative AT activity could be a sign of reduced anticoagulant efficacy of heparin during CPB.
Collapse
Affiliation(s)
- V Muedra
- Department of Anesthesia, Critical Care and Pain Therapy, La Ribera University Hospital, Alzira, Valencia, Spain.
| | | | | | | | | | | |
Collapse
|
31
|
Bibliography-Editors' selection of current word literature. Coron Artery Dis 2010; 22:45-7. [PMID: 21160292 DOI: 10.1097/mca.0b013e328342fc9d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
32
|
Lund PE, Wassbäck G, Thomas O, Carlsson T, Schött U. Comparison of two infusion rates of antithrombin concentrate in cardiopulmonary bypass surgery. Perfusion 2010; 25:305-12. [DOI: 10.1177/0267659110377677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Antithrombin concentrate (AT) is used to treat heparin resistance (HR) in cardiac surgery. It is usually given slowly due to the fear of anaphylaxis. This may delay cardiac catheterisation and the start of cardiopulmonary bypass (CPB). HR is often defined as the failure to reach or maintain a target activated clotting time (ACT) despite a standard dose of heparin. It is not generally possible to predict which patients will display HR, although there are known risk factors. Routine early administration of AT before heparinisation is probably not cost-effective. Infusing AT relatively quickly after demonstrating HR may be more cost-effective, while not delaying surgery. The aim of this study is to investigate the safety and side effects of a faster infusion of AT. Methods: Forty patients undergoing elective heart surgery were included and randomised to two groups in a double-blind fashion. Each group received 1000 IU of AT intravenously (IV). One group received a slow infusion (100 IU/min) before full-dose heparinisation. The other group received a fast infusion (250 IU/min). Haemodynamic and respiratory data were recorded. Any adverse effects were noted. Thrombin-antithrombin, anti-Xa and antithrombin levels in plasma were measured. Results: No anaphylaxis occurred in either group. No differences were found regarding haemodynamics, respiration or laboratory results. Two patients experienced major haemorrhage and recovered; there were two deaths, thought to be unrelated to the study drugs. Conclusion: AT can be infused at a rate of 250 IU/min. This is faster than the current recommendation of 100 IU/min. This rate of infusion allows restricting AT infusion to those patients who display HR, without delaying surgery. Optimal anticoagulant therapy for CPB probably includes point-of-care measurement of ACT and plasma AT and small, but rapid, infusions of AT in heparin-resistant patients.
Collapse
Affiliation(s)
- Philip E. Lund
- Örebro University Hospital, Department of Cardiothoracic Anaesthesiology and Intensive Care, Örebro, Sweden
| | | | | | - Tony Carlsson
- Örebro University Hospital, Department of Cardiothoracic Anaesthesiology and Intensive Care, Örebro, Sweden
| | - Ulf Schött
- Lund University Skane University Hospital, Department of Anaesthesiology and Intensive Care, Lund, Sweden,
| |
Collapse
|