Assembly of the Heparin Removal Device for patients with suspected adverse reaction to protamine sulphate

Perfusion ◽  
2000 ◽  
Vol 15 (5) ◽  
pp. 453-456
Author(s):  
D Jegger ◽  
H T Tevaearai ◽  
J Horisberger ◽  
X M Mueller ◽  
I Seigneuil ◽  
...  
Keyword(s):  
Adverse Reaction ◽  
Adverse Reactions ◽  
Ex Vivo ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Postoperative Bleeding ◽  
Protamine Sulphate ◽  
Suspected Adverse Reaction ◽  
Alternative Means ◽  
Activated Coagulation Time

Protamine sulphate is routinely used after cardiopulmonary bypass (CPB) to restore the patient’s baseline coagulatory state. However, adverse reactions are encountered, and alternative means to neutralize heparin are, therefore, necessary. The Heparin Removal Device (HRD) constitutes an extracorporeal circuit that allows ex vivo deheparinization by mean of a polycationic ligand that binds heparin molecules. This paper presents the setup of the HRD circuit. It is illustrated by the report of a 68-year-old man with a known severe crustacean allergy. The patient (78 kg, 170 cm) was admitted for elective coronary artery bypass graft surgery. It was decided that the HRD would be used as a precaution in order to avoid the risks of using protamine sulphate. The CPB time and aortic crossclamp time were 70 and 40 min, respectively. At the end of CPB, the device was inserted and processing started. Activated coagulation time values were monitored over a 130 min period and diminished from 480 to 300 s after 45 min, 220 s after 90 min, and settled at 150 s. Haemostasis was acceptable and processing stopped. The operation was terminated and the patient transferred to the intensive care unit. Clinical evolution was excellent, with minimal postoperative bleeding. The HRD presents an alternative to protamine sulphate when this drug is contraindicated for a certain patient population who might have a suspected, known or emergency adverse reaction.

INDICATORS OF INCREASED RISK FOR EXCESSIVE BLEEDING AFTER CARDIOPULMONARY BYPASS SURGERY

1987 ◽  
Author(s):  
W A Rock ◽  
C W Pearce ◽  
R F Weichert ◽  
W Johnson
Keyword(s):  
Platelet Count ◽  
Bypass Surgery ◽  
Antihypertensive Drugs ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Postoperative Bleeding ◽  
T Test ◽  
Smoking History ◽  
Increased Risk ◽  
Risk For Bleeding

A prospective study of 565 consecutive cases of cardiopulmonary (CP) bypass surgery (in 26 months) wasmade to identify indicators for excessive postoperative bleeding ("bleeders" defined as greater than 400 ml from 1st to 3rd hours in recovery). Patients were studied before, during, and after surgery, with datarecorded on a computerized format for analysis (Table). preoperative indicators of increased postop bleeding risk included surgical complexity; complex-valve or coronary artery bypass graft (CABG) (X2,p<.01), preop use of any antibiotic (P<.05), and use of aorticballonpump (P<<.001). Previous myocardialinfarction diabetes mellitus, hypertension, obesity, smoking history,use of verapamil, digoxin, antihypertensive drugs, preophematocrit, platelet count, and fibrinogen did notpredict bleeders. Intraoperative indicators for increased risk included poor tissue strength (P<.01) and blood added to pump (P<.001). Intraoperative pump run time, cross-clamp time. hematocrit, platelet count,and fibirinogen were not indicators for increased risk for bleeding. Postoperative indicators included bleeding into leg and chest bandages (P<.005), chest tube drainage with clots (P<.001), platelet count (t-test, P<.05); and fibrinogen (t-test, P<.05). The postop hematocrit and prolongation of aPTT did notcharacterize bleeders. This analysis suggests that the intrinsic health of the patient, the strength of the heart, the complexity or the surgery, and the use of certain medications may be better indicators of a risk for bleeding tha are factors relatedonly to CP bypass surgery.

scholarly journals High Altitude: A Possible Reason for Postoperative Bleeding after Coronary Artery Bypass Graft Operations

2015 ◽  
Vol 05 (04) ◽  
pp. 79-86
Author(s):  
Burcin Abud ◽  
Süreyya Talay ◽  
Kemal Karaarslan ◽  
Soysal Turhan ◽  
Celal Selcuk Ünal ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Coronary Artery Bypass Graft ◽  
High Altitude ◽  
Coronary Artery Bypass ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Postoperative Bleeding ◽  
Artery Bypass Graft

scholarly journals Aprotinin Decreases Postoperative Bleeding and Number of Transfusions in Patients on Clopidogrel Undergoing Coronary Artery Bypass Graft Surgery

Circulation ◽  
2005 ◽  
Vol 112 (9_supplement) ◽  
Author(s):  
Jan van der Linden ◽  
Gabriella Lindvall ◽  
Ulrik Sartipy
Keyword(s):  
Coronary Artery ◽  
Coronary Artery Bypass Graft ◽  
Unstable Angina ◽  
Coronary Artery Bypass ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Postoperative Bleeding ◽  
Artery Bypass Graft ◽  
Perioperative Bleeding ◽  
The Impact

Background— Clopidogrel, an irreversible platelet inhibitor, is used to treat patients with unstable angina. These patients often present for coronary artery bypass graft surgery (CABG) and are at increased risk for perioperative bleeding. The current investigation evaluates the impact of aprotinin on bleeding and transfusion requirements in clopidogrel-treated patients undergoing CABG. Methods and Results— Seventy-five consecutive patients with unstable angina, administered clopidogrel <5 days before CABG, were randomized. Using a double-blind design, patients received full-dose aprotinin (n =37) or saline (n =38). Elapsed times between the last dose of clopidogrel and start of the operation were similar between the 2 groups [aprotinin, 58±28 hour (mean± SD); control, 54±27 hour; P =0.86], as were age (aprotinin, 66.4±10 years; control, 68.3±10 years; P =0.51), number of distal anastomoses (aprotinin, 3.6±1.0; control, 3.7±1.0; P =0.79), operative times (aprotinin, 192±48 minutes; control, 200±53 minutes; P =0.55), and lowest intraoperative hemoglobin level (aprotinin, 87±14 g/L; control, 88±14 g/L; P =0.60). Postoperative bleeding was 760±350 mL in aprotinin-treated patients versus 1200±570 mL ( P <0.001) in control. During the hospital stay, patients in the aprotinin group received 1.2±1.5 and 0.1±0.4 U of erythrocytes and platelets, respectively, versus 2.8±3.2 ( P =0.02) and 0.9±1.4 ( P =0.002) units in the control. In the aprotinin group, 53% of patients received transfusions, whereas 79% of controls were exposed to blood products ( P =0.02). Conclusions— Intraoperative aprotinin decreases postoperative bleeding and the number of transfusions in patients undergoing CABG and treated with clopidogrel <5 days before surgery.

Antiplatelet Activity of Clopidogrel in Coronary Artery Bypass Graft Surgery Patients

1999 ◽  
Vol 82 (11) ◽  
pp. 1417-1421 ◽  
Author(s):  
R. Limet ◽  
J. L. David
Keyword(s):  
Coronary Artery ◽  
Platelet Aggregation ◽  
Coronary Artery Bypass Graft ◽  
Coronary Artery Bypass ◽  
Bleeding Time ◽  
Ex Vivo ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Artery Bypass Graft ◽  
Dose Regime

SummaryClopidogrel is a recently introduced platelet ADP receptor antagonist, belonging to the thienopyridine derivatives, like its analogue ticlopidine. Its potential advantage is to be safer than ticlopidine. At 75 mg/od clopidogrel significantly inhibits platelet aggregation in ambulatory patients with symptomatic atherosclerotic disease and it prevents the recurrence of ischemic events more efficiently than aspirin. Its adequate dose in more acute situations remained to be determined. Therefore, sixty two patients with coronary artery disease were randomly assigned in four groups treated, within 24 h after coronary artery bypass graft, by clopidogrel 50 mg/od, 75 mg/od or 100 mg/od or by ticlopidine 250 mg/bid which was considered as the reference. The tolerance of clopidogrel was fairly good during the whole period of the study. Bleeding time and ex-vivo platelet aggregation induced by ADP 2 μM and 5 μM were performed at day -1, +9 and +28 after surgery. Like ticlopidine, the three dose levels of clopidogrel significantly inhibited ex-vivo platelet activity and prolonged the bleeding time at day 28. However, unlike ticlopidine, the inhibitory effects of clopidogrel were not significant at day 9, especially with 75 mg/od, a dose which was found to significantly protect patients in a chronic situation. Hence, although the clinical outcome for patients included in this limited study was the same in the four groups, these results suggest that the dose regime of clopidogrel should be more extensively investigated during the early period following coronary artery bypass graft, facing an overproduction of young and hyperreactive platelets. By analogy, the dose regime should be also investigated in other situations with an acute risk of arterial thrombotic occlusion.

Predictiveness of different preoperative risk assessments for postoperative bleeding after coronary artery bypass grafting surgery

Perfusion ◽  
2020 ◽  
pp. 026765912094132
Author(s):  
Eren Gunertem ◽  
Salim Urcun ◽  
Arda Aybars Pala ◽  
Ali Baran Budak ◽  
Murat Abdulhamid Ercisli ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Coronary Artery Bypass Graft ◽  
Coronary Artery Bypass ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Postoperative Bleeding ◽  
Scoring Systems ◽  
Bleeding Risk ◽  
Risk Assessments ◽  
Artery Bypass Graft

Aim: Postoperative bleeding is a significant cause of morbidity and mortality in patients undergoing cardiac surgery. Studies have been conducted, and guidelines have been published regarding patient blood management and aiming to prevent blood loss in the perioperative period. Various bleeding risk assessments were developed for preoperative period. We aimed to examine the correlations of scoring systems in the literature with the amount of postoperative bleeding in patients undergoing first time coronary artery bypass graft surgery, and to show the most suitable preoperative bleeding risk assessment for coronary artery bypass graft patients. Methods: The study included 550 consecutive patients who underwent coronary artery bypass graft operation. The inclusion criteria were considered as patients to be older than 18 years old and to undergo elective or emergent myocardial revascularization using cardiopulmonary bypass. All variables required for scoring systems were recorded. The initial results of the study were determined as the amount of chest tube drainage, the use of blood products, the change in hematocrit level, reoperation due to bleeding, duration of ventilation, duration of intensive care unit stay, and hospital stay. Mortality which occurred during first 30 days after operation was considered as operative mortality. Operative mortality was accepted as the primary endpoint. Secondary endpoints were massive bleeding and high amount of transfusion. Results: Data were obtained from a series of 550 consecutive patients treated with isolated coronary artery bypass graft. It was seen that PAPWORTH and WILL-BLEED risk assessments responded better for E-CABG grade 2 and 3 bleeding compared to other risk assessments. TRACK, TRUST, and ACTA-PORT scales were found to have low ability to distinguish patients with E-CABG bleeding grade 2 and 3. Conclusion: Predicting postoperative bleeding and transfusion rates with preoperative risk scores in patients undergoing coronary artery bypass graft surgery will provide valuable information to physicians for establishing a proper patient blood management protocol and this will decrease excessive transfusions, unnecessary reoperations as well as improve postoperative outcomes.

Effect of high or low protamine dosing on postoperative bleeding following heparin anticoagulation in cardiac surgery

2016 ◽  
Vol 116 (08) ◽  
pp. 251-261 ◽  
Author(s):  
Michael I. Meesters ◽  
Dennis Veerhoek ◽  
Fellery de Lange ◽  
Jacob-Willem de Vries ◽  
Jan R. de Jong ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Blood Loss ◽  
Thrombin Generation ◽  
Controlled Trial ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Postoperative Bleeding ◽  
Postoperative Blood Loss ◽  
Open Label

SummaryWhile experimental data state that protamine exerts intrinsic anticoagulation effects, protamine is still frequently overdosed for heparin neutralisation during cardiac surgery with cardiopulmonary bypass (CPB). Since comparative studies are lacking, we assessed the influence of two protamine-to-heparin dosing ratios on perioperative haemostasis and bleeding, and hypothesised that protamine overdosing impairs the coagulation status following cardiac surgery. In this open-label, multicentre, single-blinded, randomised controlled trial, patients undergoing on-pump coronary artery bypass graft surgery were assigned to a low (0.8; n=49) or high (1.3; n=47) protamine-to-heparin dosing group. The primary outcome was 24-hour blood loss. Patient haemostasis was monitored using rotational thromboelastometry and a thrombin generation assay. The low protamine-to-heparin dosing ratio group received less protamine (329 ± 95 vs 539 ± 117 mg; p<0.001), while post-protamine activated clotting times were similar among groups. The high dosing group revealed increased intrinsic clotting times (236 ± 74 vs 196 ± 64 s; p=0.006) and the maximum post-protamine thrombin generation was less suppressed in the low dosing group (38 ± 40% vs 6 ± 9%; p=0.001). Postoperative blood loss was increased in the high dosing ratio group (615 ml; 95% CI 500–830 ml vs 470 ml; 95% CI 420–530 ml; p=0.021) when compared to the low dosing group, respectively. More patients in the high dosing group received fresh frozen plasma (11% vs 0%; p=0.02) and platelet concentrate (21% vs 6%; p=0.04) compared to the low dosing group. Our study confirms in vitro data that abundant protamine dosing is associated with increased postoperative blood loss and higher transfusion rates in cardiac surgery.

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