Influence of Body Mass Index on the Activated Clotting Time Under Weight-Based Heparin Dose

Background: A critical aspect of cardiopulmonary bypass (CPB) is to achieve full anticoagulation to prevent thrombosis and consumptive coagulation without using excessive amount of heparin. This can be achieved with heparin dose response (HDR) test in vitro to calculate an individualized heparin bolus to reach a target activated clotting time (ACT) and heparin concentration. However, we often observe that the measured ACT (mACT) with the calculated heparin bolus gives significant errors, both positive (mACT is higher than expected) and negative (mACT is lower), from expected ACT (eACT). Methods: We performed a retrospective study of 250 patients who underwent cardiac surgery to attain an error distribution of the mACT from eACT with calculated heparin bolus. In addition, it is aimed to identify possible patterns of baseline ACT (bACT), calculated heparin concentration (CHC) and HDR slope that are associated with the significant positive and negative errors. Results: We found that individualized heparin bolus by HDR test is consistently underestimated while it gave a significant number of positive and negative errors. Further analysis indicates that significant negative errors correlate with high bACT and slope and low CHC while significant positive errors with low bACT and slope and high CHC. Conclusion: The mACT can be substantially different from eACT. The accuracy of the HDR test appears to be dependent upon bACT, slope, and CHC. Based on our analysis, we provide several recommendations and a flow chart to improve the quality of individualized heparin management on CPB.

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Anti-Factor Xa Assay Is a Superior Correlate of Heparin Dose Than Activated Partial Thromboplastin Time or Activated Clotting Time in Pediatric Extracorporeal Membrane Oxygenation*

Pediatric Critical Care Medicine ◽

10.1097/pcc.0000000000000028 ◽

2014 ◽

Vol 15 (2) ◽

pp. e72-e79 ◽

Cited By ~ 65

Author(s):

Anna Liveris ◽

Ricardo A. Bello ◽

Patricia Friedmann ◽

Melissa A. Duffy ◽

Deepa Manwani ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Partial Thromboplastin Time ◽

Factor Xa ◽

Activated Partial Thromboplastin Time ◽

Clotting Time ◽

Heparin Dose ◽

Membrane Oxygenation ◽

Activated Clotting Time

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In vitro and in vivo effects of hemodilution on kaolin-based activated clotting time predicted heparin requirement using a heparin dose–response technique

Journal of Anesthesia ◽

10.1007/s00540-016-2227-9 ◽

2016 ◽

Vol 30 (6) ◽

pp. 923-928 ◽

Cited By ~ 3

Author(s):

Junko Ichikawa ◽

Satoshi Hagihira ◽

Testu Mori ◽

Mitsuharu Kodaka ◽

Keiko Nishiyama ◽

...

Keyword(s):

Dose Response ◽

Clotting Time ◽

Heparin Dose ◽

Activated Clotting Time ◽

In Vivo Effects

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Conventional Weight-Based versus Low-Dose Regimen of Heparin Administration to Achieve Target Activated Clotting Time on Cardiopulmonary Bypass in Pakistani Population

Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University ◽

10.48036/apims.v17i1.498 ◽

2021 ◽

Vol 17 (1) ◽

pp. 34-39

Author(s):

Musfireh Siddiqeh ◽

Wajahat Javed Mirza ◽

Javed Iqbal ◽

Imran Khan ◽

Ali R Mangi

Keyword(s):

Cardiopulmonary Bypass ◽

Low Dose ◽

Clotting Time ◽

Heparin Dose ◽

Pakistani Population ◽

Activated Clotting Time ◽

Heparin Administration ◽

Group A ◽

Group B ◽

Additional Dosage

Objective: A weight-based dose of heparin is calculated to achieve target ACT (Activated clotting time) for establishing CPB (cardiopulmonary bypass). Whether a target ACT can be achieved with lower dose of heparin in Pakistani population was the aim of this study. Methodology: The cross-sectional comparative study was conducted at Rawalpindi Institute of Cardiology, Department of Cardiac Surgery from 1st January 2019 to 1st January 2020. Three hundred thirty-six (336) patients undergoing elective open-heart surgeries on CPB were included in this study. Patients receiving weight-based heparin dose were placed in Group-A, while those on low-dose heparin were placed in Group-B. ACT was considered to have reached the target value in range of 400-480 seconds, values between 481-1500 seconds were considered excessive, whereas ACT of >1500 was regarded as potentially high-risk for peri-operative bleeding . Results: 14.1% (n= 28) of Group-A patients achieved target ACT, whereas 58.3% (n=116) exceeded the target of 480. In 25.1% (n=50), ACT values were beyond the measuring capacity of the assay machine i.e. >1500. Only 2.5% (n=5) required additional dosage of heparin. Target ACT in Group B was achieved in 19.7% (n= 27), 55.5% (n=76) had excessive ACT values, whereas in 16.8% (n= 23), it was >1500. 9.5% (n=13) required an additional dosage of Heparin. Conclusion: In Pakistani population, a target ACT can be achieved with significantly lower dose than the conventional weight-based heparin dose. Larger studies, preferably randomized controlled trials are needed to determine the optimal heparin dose calculation for safe anti-coagulation during CPB.

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Anticoagulation and Pediatric Extracorporeal Membrane Oxygenation: Impact of Activated Clotting Time and Heparin Dose on Survival

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2006.09.054 ◽

2007 ◽

Vol 83 (3) ◽

pp. 912-920 ◽

Cited By ~ 72

Author(s):

Christopher W. Baird ◽

David Zurakowski ◽

Barbara Robinson ◽

Sanjiv Gandhi ◽

Leighann Burdis-Koch ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Clotting Time ◽

Heparin Dose ◽

Membrane Oxygenation ◽

Activated Clotting Time

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Relationship of Activated Clotting Time to Heparin Dose Depends on the Type of Cuvette Used With the Hemochron Signature Elite

Point of Care The Journal of Near-Patient Testing & Technology ◽

10.1097/poc.0b013e3182a1a54c ◽

2013 ◽

Vol 12 (3) ◽

pp. 150-152

Author(s):

Lisa Senzel ◽

David Fiorella ◽

Henry H. Woo ◽

Antonios Gasparis ◽

Jay L. Bock

Keyword(s):

Clotting Time ◽

Heparin Dose ◽

Activated Clotting Time ◽

Relationship Of

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A Multistate Kalman Filter for Neonatal Clotting Time Prediction and Early Detection of Coagulation Disturbances

Methods of Information in Medicine ◽

10.1055/s-0038-1634177 ◽

1999 ◽

Vol 38 (02) ◽

pp. 113-118 ◽

Cited By ~ 1

Author(s):

J. van der Velde ◽

W. B. Geven ◽

C. Festen ◽

A. L. M. Verbeek ◽

A. F. J. de Haan

Keyword(s):

Kalman Filter ◽

Standard Deviation ◽

Early Detection ◽

Extracorporeal Membrane Oxygenation ◽

Clotting Time ◽

Heparin Dose ◽

Filter Technique ◽

Time Prediction ◽

Activated Clotting Time ◽

A Prospective Study

AbstractThe multistate Kalman filter was applied to develop a heparin dose proposal system and to detect coagulation disturbances during neonatal extracorporeal membrane oxygenation (ECMO). A system containing this filter was based on the activated clotting time (ACT) values and the heparin doses administered every hour during ECMO. If the ACT value can be predicted accurately from the previous heparin dose, a heparin dose proposal can be given to achieve or maintain the required ACT level. The analysis was done on 6,356 ACT level measurements in 44 ECMO neonates. The multistate Kalman filter technique showed an unbiased prediction of ACT, with a standard deviation of 23 seconds. Two out of three cases of disseminated intravascular coagulation (DIC) were detected. ACT values were predicted sufficiently accurately by the multistate Kalman filter technique to justify a prospective study on the performance of the heparin dose proposal system and its ability to detect DIC.

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The impact of oral direct thrombin inhibitors on activated clotting time during catheter ablation in patients with atrial fibrillation

EP Europace ◽

10.1093/europace/euab116.159 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

T Mine ◽

R Kitagaki ◽

E Fukuhara ◽

M Ishihara

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Thrombin Inhibitors ◽

Bleeding Complications ◽

Direct Thrombin Inhibitors ◽

Clotting Time ◽

Heparin Dose ◽

Activated Clotting Time ◽

Heparin Administration ◽

The Impact

Abstract Funding Acknowledgements Type of funding sources: None. Background Direct thrombin inhibitors (DTIs) unlike factor Xa-inhibitors (Xa-inhibitors) is associated with fewer bleeding complications than warfarin in patients who had catheter ablation (CA) for atrial fibrillation (AF). However, the mechanisms remains unclear, and activated clotting time (ACT) is used to control heparin-dose for thromboembolic prevention during CA. Methods: We retrospectively studied 543 patients taking direct oral anticoagulant (DOAC) who underwent CA for AF (375 males, age 67 ± 10, 251 non-paroxysmal AF, 142 DTIs). Patients with off-label usage of DOAC were excluded. ACT was measured before (Pre-ACT) and after (post-ACT) initial heparin administration (3000U + 100U/kg), and total heparin-dose was evaluated. Results: Pre-ACT and post-ACT were extended in patients with DTIs (150 ± 21 vs 123 ± 15; P < 0.0001 and 322 ± 39 vs 309 ± 42 sec; P = 0.0013). Patients with Xa-inhibitors required higher total heparin-dose (199 ± 43 vs 175 ± 34 U/kg; P < 0.0001). During and after CA, none had thromboembolic events and 14 patients (3 DTIs, 11 Xa-inhibitor) showed bleeding events (Figure). Conclusions: ACT is extended in patients taking DTIs. Xa-inhibitors might have anticoagulant effects which are not reflected in ACT. Abstract Figure.

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COMPARISON OF HEPARIN DOSE RESPONSE TO ACTIVATED CLOTTING TIME IN INFANTS AND CHILDREN FOR CARDIAC SURGERY

Anesthesia & Analgesia ◽

10.1097/00000539-199804001-00073 ◽

1998 ◽

Vol 86 (Supplement) ◽

pp. 73SCA

Author(s):

EB Mossad ◽

K Marchant ◽

PM Bokesch ◽

JJ Niezgoda ◽

RBB Mee ◽

...

Keyword(s):

Cardiac Surgery ◽

Dose Response ◽

Infants And Children ◽

Clotting Time ◽

Heparin Dose ◽

Activated Clotting Time ◽

In Infants And Children

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Use of Thromboelastogram in Venovenous Extracorporeal Membrane Oxygenation for a Patient with Pulmonary Hemorrhage due to Microscopic Polyangiitis

Case Reports in Critical Care ◽

10.1155/2019/7241264 ◽

2019 ◽

Vol 2019 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Chak-Kwan Tong ◽

Jun Jin ◽

Qian Du

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Microscopic Polyangiitis ◽

Pulmonary Hemorrhage ◽

Activated Partial Thromboplastin Time ◽

Clotting Time ◽

Heparin Dose ◽

Heparin Infusion ◽

Membrane Oxygenation ◽

Activated Clotting Time ◽

Venovenous Extracorporeal Membrane Oxygenation

Systemic heparinisation is required for extracorporeal membrane oxygenation therapy, to prevent clotting of circuit and formation of thrombus in patient. Activated clotting time (ACT) or activated partial thromboplastin time (aPTT) has been the mainstay of monitoring of heparin dose. Thromboelastogram (TEG) is increasingly being used again in recent years with the advancement in technology. Its clinical usefulness in the monitoring of anticoagulation of ECMO therapy is demonstrated in the case presented. Our patient suffered from severe hemoptysis due to active microscopic polyangiitis and respiratory failure. Heparin infusion was given at the initiation of ECMO support without further aggravation of hemoptysis. Dose of heparin was adjusted successfully with the integration of the clotting profile and TEG results.

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