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Anticoagulation management in patients undergoing open heart surgery by activated clotting time and whole blood heparin concentration

Franco Annalisa

Crescenzi Giuseppe

Department of Cardiovascular Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy

De Simone Francesco

Unit of Extracorporeal Circulation, San Raffaele Hospital, Milan, Italy

Torracca Lucia

Department of Cardiac Surgery, San Raffaele Hospital, Milan, Italy

Zangrillo Alberto

Department of Cardiovascular Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy

Objective: To investigate the changes in perioperative anticoagulation management using a heparin-concentration-based system (HMS), and its effect on postoperative outcome. Methods: A total of 39 patients undergoing elective primary open heart surgery were randomly assigned to a heparin-concentration-based system approach (study group: 17 patients) or a standard ACT-based anticoagulation system (control group: 22 patients). Measurements and main results: Patients in the study group received a statistically significant higher dose of heparin (median 29 000 IU with IQR 22 500 33 500 IU versus median 19 000 IU with IQR 17 775 21 500 IU; p <0.001) and a smaller dose of protamine (median 170 mg with IQR 145 190 mg versus median 200 mg with IQR 180-250 mg; p=0.008) compared to the control group. Postoperative platelet count was significantly higher in the study group (164± 45x10⁹/L versus 125±27 x 10⁹/L, p=0.002). None of the study patients, but six patients in the control group required transfusion of blood products (p=0.02). No differences were recorded in postoperative antithrombin activity, bleeding, and other clinical outcomes. Conclusion: he HMS system, by facilitating maintenance of a stable heparin concentration, and by determining an appropriate dose of protamine, is associated with reduced platelet consumption and does not increase AT-III consumption and postoperative bleeding.

References

• Gravlee GP, Case LD, Angert KC, Rogers AT, Millerb GS. Variability of the activated coagulation time . Anesth Analg 1988; 67: 469-472 .[Free Full Text]
• Cohen EJ, Cameriengo LJ, Dearing JP. Activated clotting times and cardiopulmonary bypass: the effect of hemodilution and hypothermia upon activated clotting time . J Extracorp Tech 1980; 12: 139-141 .
• Casati V, Della Valle P, Benussi S et al. Effects of tranexamic acid on postoperative bleeding and related hematochemical variables in coronary surgery: comparison between on-pump and off-pump techniques . J Thorac Cardiovasc Surg 2004; 128: 83-91 .[Abstract/Free Full Text]
• Buckberg GD, Beyersdorf F, Allen BS, Robertson JM. Integrated myocardial management: background and initial application . J Card Surg 1995; 10: 68-89 .[Web of Science][Medline] [Order article via Infotrieve]
• Jobes DR, Schwartz AJ, Ellison N, Andrews R, Ruffini RA, Ruffini JJ. Monitoring heparin anticoagulation and its neutralization . Ann Thorac Surg 1980; 31: 161-166 .
• Boldt J, Schindler E, Osmer C, Wittstock M, Stertmann WA, Hempelmann G. Influence of different anticoagulation regimens on platelet function during cardiac surgery . Br J Anesth 1994; 73: 639-644 .[Abstract/Free Full Text]
• Moorehead MT, Westengard JC, Bull BS. Platelet involvement in the activated coagulation time of heparinized blood . Anesth Analg 1984; 63: 394-398 .[Abstract/Free Full Text]
• Wahr JA, Yun JH, Yang VC, Lee LM, Fu B, Meyerhoff ME. A new method of measuring heparin levels in whole blood by protamine titration using a heparin-responsive electrochemical sensor . J Cardiothorac Vasc Anesth 1996; 10: 447-450 .[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Despotis GJ, Joist JH, Goodnough LT, Santoro SA, Spitznagel E. Whole blood heparin concentration measurement by automated protamine titration agree with plasma anti-Xa measurements . J Thorac Cardiovasc Surg 1996; 170: 611-613 .
• Koster A, Fisher T, Praus M et al. Hemostatic activation and inflammatory response during cardiopulmonary bypass. Impact of heparin management . Anesthesiology 2002; 97: 837-841 .[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Stafford-Smith M, Lefrak EA, Qazi AG et al. Efficacy and safety of heparinase I versus protamine in patients undergoing coronary artery bypass grafting with and without cardiopulmonary bypass . Anesthesiology 2005; 103: 229-240 .[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Ammar T, Fisher TF. The effects of heparinase1 and protamine on platelet reactivity . Anesthesiology 1997; 86: 1382-1386 .[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• DeLaria GA, Tyner JJ, Hayes CL, Armstrong BW. Heparin-protamine mismatch: a controllable factor in bleeding after open heart surgery . Arch Surg 1994; 129: 944-950 .[Abstract]
• Jobes DR, Aitken GL, Shaffer GW. Increased accuracy and precision of heparin and protamine dosing reduces blood loss and transfusion in patients under-going primary cardiac operations . J Thorac Cardiovasc Surg 1995; 110: 36-45 .[Abstract/Free Full Text]
• Shigeta O, Kojima H, Hiramatsu Y et al. Low dose protamine based on heparin-protamine titration method reduces platelet dysfunction after cardiopulmonary bypass . J Thorac Cardiovasc Surg 1999; 118: 354-360 .[Abstract/Free Full Text]
• Welsby IJ, Newman MF, Philips-Bute B, Messier RH, Kakkis ED, Stafford-Smith M. Hemodynamic changes after protamine administration: association with mortality after coronary artery bypass surgery . Anesthesiology 2005; 102: 308-314 .[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Despotis GJ, Joist JH, Hogue CW Jr et al. The impact of heparin concentration and activated clotting time monitoring on blood conservation: a prospective, randomised evaluation in patients undergoing cardiac operation . J Thorac Cardiovasc Surg 1995; 110: 46-54 .[Abstract/Free Full Text]

Perfusion, Vol. 21, No. 5, 285-290 (2006)
DOI: 10.1177/0267659106074770


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This Article Abstract Free Full Text (Free PDF) Free Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Saved Citations Download to citation manager Request Permissions Request Reprints Add to My Marked Citations Citing Articles Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by Federico, P. Articles by Alberto, Z. Search for Related Content PubMed PubMed Citation Articles by Federico, P. Articles by Alberto, Z. Social Bookmarking                         What's this?