Heparin Administration And Precision Protamine Reversal In Coronary Bypass Surgery

1981 ◽  
Author(s):  
Charles Markham
Keyword(s):  
Blood Loss ◽  
Coronary Bypass ◽  
Testing Procedure ◽  
Published Data ◽  
Clotting Time ◽  
Test Protocol ◽  
Precise Control ◽  
Activated Clotting Time ◽  
Heparin Administration ◽  
Recalcification Time

A two-tiered testing procedure was developed which uses the activated clotting time (ACT) dose-response curve for the initialization and maintenance of heparinization while using the whole blood activated recalcification time (wBART) for a more precise control of protamine neutralization. The wBART, the most sensitive test for heparin induced hypocoagulability, parallels the ACT and is prolonged by protamine excess, allowing a rapid and accurate titration procedure. This twotiered test protocol results in decreased protamine usage and less blood loss compared to published data in a comparable patient population.The protocol was applied to a study with 55 by-pass patients to compare two commercial beef lung heparins with respect to anticoagulant effectiveness, intraoperative ACT levels, total heparin usage, post-operative blood loss and protamine requirements. Platelet counts were also monitored before and following surgery. No statistically significant differences were observed between the two heparin products in any of these parameters. Details of the two-tiered protocol and the beef lung heparin study will be presented.

scholarly journals More effective anticoagulation during non-cardiac arterial procedures using Activated Clotting Time guided heparin administration

2021 ◽  
Author(s):  
Orkun Doganer ◽  
Arno M. Wiersema ◽  
Maurice Pierie ◽  
Jan D. Blankensteijn ◽  
Kak Khee Yeung ◽  
...  
Keyword(s):  
Clotting Time ◽  
Activated Clotting Time ◽  
Heparin Administration

Abstract 16805: Assessing Correlation and Agreement in Activated Clotting Time (ACT) Measurement Using Hemochron Signature Elite

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Ankita Aggarwal ◽  
Anubhav Jain ◽  
Arjun Bhardwaj ◽  
Nishit Choksi
Keyword(s):  
Clinical Decision Making ◽  
Clinical Decision ◽  
P Value ◽  
Clotting Time ◽  
Paired Samples ◽  
Activated Clotting Time ◽  
Cardiac Procedures ◽  
Heparin Administration ◽  
Device Reliability ◽  
Before And After

Introduction & Hypothesis: ACT is the preferred mode of assessing degree of anti-coagulation during cardiac catheterization. Studies have shown significant variability in ACT measurement with different company analysers. We aimed to assess correlation and agreement between two instruments of the same company, Hemochron Signature Elite. Method: Paired samples were collected before and after heparin administration for each patient. Each paired sample was collected and entered into the two instruments tagged A & B using the same syringe and at the same time. Results: A total of 46 samples were included in the study. There was a significant correlation between the two instruments (r= 0.92, p- value 0.02). However, the two devices had significant discordance with a mean bias of 11.1 , 95% CI 0.77 to 24.9 and limits of agreement -35.8 to 58.1. Mean ACT between the two devices was significantly different (231 vs 248, p-value 0.01). Inter-device reliability was 30%. There was a more than 10% difference in about 30% of the paired samples and more than 20% difference in 9% of the samples. Conclusion: Significant correlation but discordance exists in ACT measurement even between the same type of device. This may affect clinical decision making during cardiac procedures and need further investigation.

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

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.

Influence of High-dose Aprotinin on Anticoagulation, Heparin Requirement, and Celite- and Kaolin-Activated Clotting Time in Heparin-pretreated Patients Undergoing Open-Heart Surgery

1995 ◽  
Vol 83 (4) ◽  
pp. 679-689. ◽  
Author(s):  
W. Dietrich ◽  
G. Dilthey ◽  
M. Spannagl ◽  
M. Jochum ◽  
S. L. Braun ◽  
...  
Keyword(s):  
Blood Loss ◽  
Thrombin Generation ◽  
Plasma Concentrations ◽  
Postoperative Blood Loss ◽  
High Dose ◽  
Clotting Time ◽  
Activated Clotting Time ◽  
High Dose Aprotinin ◽  
Group A ◽  
Fibrin Monomers

Background Aprotinin causes a prolongation of the celite-activated clotting time (CACT), but not of the kaolin-activated clotting time (KACT). Therefore, concern has been raised regarding the reliability of CACT to monitor anticoagulation in the presence of aprotinin. The current study was designed to test the efficacy of aprotinin to improve anticoagulation, and to investigate whether the prolongation of CACT reflects true anticoagulation or is an in vitro artifact. To elucidate this antithrombotic effect of aprotinin, this study was done in patients prone to reduced intraoperative heparin sensitivity. Methods In a prospective, randomized, double-blind clinical trial, 30 male patients scheduled for elective primary coronary revascularization and treated with heparin for at least 10 days preoperatively, received either high-dose aprotinin (group A) or placebo (group C). The CACT and KACT were determined, but only CACT was used to control anticoagulation with heparin. Parameters of coagulation that are indicators of thrombin generation and activity (F1+2 prothrombin fragments, thrombin-antithrombin III complex, and fibrin monomers), parameters of fibrinolysis (D-dimers), aprotinin, and heparin plasma concentrations were measured. Postoperative blood loss and allogeneic blood transfused were recorded. Results Total heparin administered was 36,200 units (95% confidence interval: 31,400-41,000; group C) compared with 27,700 (25,500-29,800) units (group A; P < 0.05). Hemostatic activation during cardiopulmonary bypass (CPB) was significantly reduced in group A compared with group C. After 60 min of CPB, all parameters were significantly different (P < 0.05) between the groups (group C vs. group A): F1+2 prothrombin fragments, 9.7 (8.9-11.7) ng/ml versus 7.5 (6.2-8.6) ng/ml; thrombin-anti-thrombin III complex (TAT), 53 (42-68) ng/ml versus 29 (23-38) ng/ml; and fibrin monomers, 23 (12-43) ng/ml versus 8 (3-17) ng/ml. Fibrinolysis was also attenuated; D-dimers at the end of operation were 656 (396-1,089) and 2,710 (1,811-4,055) ng/ml for groups A and C, respectively (P < 0.05). The CACT 5 min after the onset of CPB was 552 (485-627) versus 869 (793-955) s for groups C and A, respectively (P < 0.05), whereas the KACT showed no differences between the groups (569 [481-675] vs. 614 [541-697] s for groups C and A, respectively; P = NS). The 24-h blood loss was 1,496 (1,125-1,995) versus 597 (448-794) ml for groups C and A, respectively (P < 0.05). Conclusions Aprotinin treatment in combination with heparin leads to less thrombin generation during CPB. Aprotinin has anticoagulant properties. Celite-activated ACT is reliable for monitoring anticoagulation in the presence of aprotinin, because the prolonged CACT in the aprotinin group reflects improved anticoagulation. Kaolin-activated ACT does not reflect this effect of aprotinin.

Evaluation of a New Point-of-care Test that Measures PAF-mediated Acceleration of Coagulation in Cardiac Surgical Patients

1996 ◽  
Vol 85 (6) ◽  
pp. 1311-1323. ◽  
Author(s):  
George J. Despotis ◽  
Vladimir Levine ◽  
Kriton S. Filos ◽  
Samuel A. Santoro ◽  
J. Heinrich Joist ◽  
...  
Keyword(s):  
At Risk ◽  
Blood Loss ◽  
Platelet Transfusion ◽  
Point Of Care ◽  
Postoperative Blood Loss ◽  
Clotting Time ◽  
Point Of Care Test ◽  
Activated Clotting Time ◽  
Patients At Risk ◽  
Excessive Blood Loss

Background This study was designed to evaluate a new point-of-care test (HemoSTATUS) that assesses acceleration of kaolin-activated clotting time (ACT) by platelet activating factor (PAF) in patients undergoing cardiac surgery. Our specific objectives were to determine whether HemoSTATUS-derived measurements correlate with postoperative blood loss and identify patients at risk for excessive blood loss and to characterize the effect of desmopressin acetate (DDAVP) and/or platelet transfusion on these measurements. Methods Demographic, operative, blood loss and hematologic data were recorded in 150 patients. Two Hepcon instruments were used to analyze ACT values in the absence (channels 1 and 2: Ch1 and Ch2) and in the presence of increasing doses of PAF (1.25, 6.25, 12.5, and 150 nM) in channels 3-6 (Ch3-Ch6). Clot ratio (CR) values were calculated with the following formula for each respective PAF concentration: clot ratio = 1-(ACT/control ACT). These values also were expressed as percent of maximal (%M = clot ratio/0.51 x 100) using the mean CRCh6 (0.51) obtained in a reference population. Results When compared with baseline clot ratios before anesthetic induction, a marked reduction in clot ratios was observed in both Ch5 and Ch6 after protamine administration, despite average platelet counts greater than 100 K/microliter. There was a high degree of correlation between clot ratio values and postoperative blood loss (cumulative chest tube drainage in the first 4 postoperative hours) with higher concentrations of PAF: CRCh6 (r = -0.80), %M of CRCh6 (r = -0.82), CRCh5 (r = -0.70), and %M of CRCh5 (r = -0.85). A significant (P < 0.01) improvement in clot ratios was observed with time after arrival in the intensive care unit in both Ch5 and Ch6, particularly in patients receiving DDAVP and/or platelets. Conclusions Activated clotting time-based clot ratio values correlate significantly with postoperative blood loss and detect recovery of PAF-accelerated coagulation after administration of DDAVP or platelet therapy. The HemoSTATUS assay may be useful in the identification of patients at risk for excessive blood loss and who could benefit from administration of DDAVP and/or platelet transfusion.

Platelet-activated Clotting Time Does Not Measure Platelet Reactivity during Cardiac Surgery 

1999 ◽  
Vol 91 (2) ◽  
pp. 362-368 ◽  
Author(s):  
Linda Shore-Lesserson ◽  
Tameshwar Ammar ◽  
Marietta DePerio ◽  
Frances Vela-Cantos ◽  
Cherie Fisher ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Blood Loss ◽  
Chest Tube ◽  
Platelet Reactivity ◽  
Thrombin Receptor ◽  
Clotting Time ◽  
Platelet Dysfunction ◽  
Tube Drainage ◽  
Activated Clotting Time ◽  
Protamine Administration

Background Platelet dysfunction is a major contributor to bleeding after cardiopulmonary bypass (CPB), yet it remains difficult to diagnose. A point-of-care monitor, the platelet-activated clotting time (PACT), measures accelerated shortening of the kaolin-activated clotting time by addition of platelet activating factor. The authors sought to evaluate the clinical utility of the PACT by conducting serial measurements of PACT during cardiac surgery and correlating postoperative measurements with blood loss. Methods In 50 cardiac surgical patients, blood was sampled at 10 time points to measure PACT. Simultaneously, platelet reactivity was measured by the thrombin receptor agonist peptide-induced expression of P-selectin, using flow cytometry. These tests were temporally analyzed. PACT values, P-selectin expression, and other coagulation tests were analyzed for correlation with postoperative chest tube drainage. Results PACT and P-selectin expression were maximally reduced after protamine administration. Changes in PACT did not correlate with changes in P-selectin expression at any time interval. Total 8-h chest tube drainage did not correlate with any coagulation test at any time point except with P-selectin expression after protamine administration (r = -0.4; P = 0.03). Conclusions The platelet dysfunction associated with CPB may be a result of depressed platelet reactivity, as shown by thrombin receptor activating peptide-induced P-selectin expression. Changes in PACT did not correlate with blood loss or with changes in P-selectin expression suggesting that PACT is not a specific measure of platelet reactivity.

scholarly journals Clinical monitoring of activated clotting time during cardiothoracic surgery: comparing the Hemochron® Response and Hemochron® Signature Elite

Perfusion ◽  
2021 ◽  
pp. 026765912110493
Author(s):  
Roland F Hoffmann ◽  
Sandra Horsten ◽  
Massimo A Mariani ◽  
Adrianus J de Vries
Keyword(s):  
Measurement Errors ◽  
Artery Bypass ◽  
Repeated Measurements ◽  
Arterial Line ◽  
Positive Bias ◽  
Clotting Time ◽  
Activated Clotting Time ◽  
Heparin Administration ◽  
Response Versus ◽  
Protamine Administration

Introduction: The Activated Clotting Time (ACT) is commonly used to manage anticoagulation during cardiac surgery. The aim of this study was to compare the older manually operated Hemochron® Response and the automated Hemochron® Signature Elite. Methods: In this observational study the clinically relevant differences of both devices were investigated simultaneously, using duplicate measurements, in 29 patients who underwent a Coronary Artery Bypass Grafting (CABG) or Aortic Valve Replacement (AVR) in order to determine reliability, bias, and to detect which method has the lowest variation. Blood samples were obtained from the arterial line prior to surgery, after administration of 300 IU/kg heparin, 5 minutes after initiation of cardiopulmonary bypass and successively every 30 minutes, and after protamine administration. Results: A total of 202 measurements were performed. Of these 10 measurements were out of range in the Response and 9 in the Elite. About 27 single unstable magnet errors were seen in the Response versus no measurement errors in the Elite. No statistically significant differences between the Response (p = 0.22, Wilcoxon rank) and Elite (p = 0.064) duplicates were observed. The Response values were consistently higher during heparinization than the Elite measurements (p = 0.002, repeated measurements) with an average positive bias of around 56 seconds during heparinization (Bland-Altman). Overall, the coefficient of variation (CoV) increased during heparinization. Conclusion: The Elite was more reliable, but the variation was higher for the Elite than the Response. The observed positive bias in the Response compared to the Elite could affect heparin administration during surgery making the two systems not interchangeable.

scholarly journals Evaluation of a New Sonoclot Device for Heparin Management in Cardiac Surgery

2016 ◽  
Vol 23 (1) ◽  
pp. 20-26 ◽  
Author(s):  
Omer Dzemali ◽  
Michael T. Ganter ◽  
Alicja Zientara ◽  
Kirk Graves ◽  
Renate Behr ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Glass Bead ◽  
Percentage Error ◽  
Altman Analysis ◽  
Clotting Time ◽  
Bland Altman Analysis ◽  
New Device ◽  
Activated Clotting Time ◽  
Heparin Administration ◽  
Target Values

Background: Sonoclot is used to measure kaolin-based activated clotting time (kACT) for heparin management. Apart from measuring kACT, the device assesses the patient’s coagulation status by glass bead–activated tests (gbACTs; measuring also clot rate [CR] and platelet function [PF]). Recently, a new version of the Sonoclot has been released, and the redesign may result in performance changes. The aim of this study was to evaluate and compare the performance of the new (S2) and the previous (S1) Sonoclot. Methods: The S1 was used in the routine management of 30 patients undergoing elective cardiac surgery. Blood samples were taken at baseline (T1), after heparin administration (200 U/kg, 100 U/kg; T2 and T3), during cardiopulmonary bypass (T4), after protamine infusion (T5), and before intensive care unit transfer (T6). Kaolin-based activated clotting time and gbACTs were measured in duplicate by both the old and the new device and performance compared by Bland-Altman analysis and percentage error calculation. Results: A total of 300 kACT and 180 gbACTs were available. Bland-Altman analysis for kACT revealed that S2 consistently reported results in shorter time compared to S1 (overall = −14.7%). Comparing S2 and S1, the glass bead–activated tests showed mean percentage differences of −18.9% (gbACTs), +37.4% (CR), and −3.7% (PF). Conclusion: Since clotting is faster in the new S2 compared to S1, shorter clotting times have to be considered in clinical practice. The use of S2 kACT in heparin management will result in higher heparin and protamine dosing unless heparin kACT target values are adjusted to correct for the differences in results between S1 and S2.

scholarly journals The role of the activated clotting time in heparin administration and neutralization for cardiopulmonary bypass

1983 ◽  
Vol 85 (2) ◽  
pp. 174-185 ◽  
Author(s):  
Rick A. Esposito ◽  
Alfred T. Culliford ◽  
Stephen B. Colvin ◽  
Stephen J. Thomas ◽  
Henriette Lackner ◽  
...  
Keyword(s):  
Cardiopulmonary Bypass ◽  
Clotting Time ◽  
Activated Clotting Time ◽  
Heparin Administration
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