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

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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Arterial Complications following Cardiac Catheterization in Children Less than 10 kg

Asian Cardiovascular and Thoracic Annals ◽

10.1177/021849230201000208 ◽

2002 ◽

Vol 10 (2) ◽

pp. 129-132 ◽

Cited By ~ 30

Author(s):

Ziad R Bulbul ◽

Mohammed Omar Galal ◽

Elsayed Mahmoud ◽

Bettina Narden ◽

Laszlo Solymar ◽

...

Keyword(s):

Cardiac Catheterization ◽

Safe Procedure ◽

Clotting Time ◽

Arterial Access ◽

Activated Clotting Time ◽

Arterial Complications ◽

Heparin Administration ◽

Group A ◽

Group B ◽

Double Blinded

We sought to determine if a higher dose of heparin would reduce arterial complications in patients weighing 10 kg or less undergoing cardiac catheterization to investigate congenital heart disease. Sixty patients were given either 100 (group A) or 150 (group B) IU·kg−1 of heparin in a double-blinded randomized manner. Initial arterial access was established using a 4F cannula in all patients. Mean activated clotting time measured 20 minutes following heparin administration was significantly lower in group A than in group B (199 versus 251 seconds). Only 3 out of 60 patients (5%) required treatment for loss of femoral pulse. The age, weight, activated clotting time, length of catheterization procedure, time taken to establish arterial access, and the duration of arterial cannulation were comparable between the groups. Weight under 4 kg, age under 1 month, and cannula size larger than 4F were identified as independent risk factors for the development of arterial complications. Arterial access using a 4F cannula is a safe procedure in children weighing 10 kg or less. The incidence of significant arterial complications is low, and they do not appear to be preventable by a higher dose of heparin.

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Factors associated with errors in the heparin dose response test: recommendations to improve individualized heparin management in cardiopulmonary bypass

Perfusion ◽

10.1177/0267659120952977 ◽

2020 ◽

pp. 026765912095297

Author(s):

Min-Ho Lee ◽

William Riley

Keyword(s):

Cardiopulmonary Bypass ◽

Dose Response ◽

Clotting Time ◽

Critical Aspect ◽

Heparin Dose ◽

Factors Associated ◽

Heparin Concentration ◽

Activated Clotting Time

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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Does Priming Implementation with Low-dose Albumin Reduce Postoperative Bleeding following Cardiopulmonary Bypass?

The International Journal of Artificial Organs ◽

10.1177/039139880302600306 ◽

2003 ◽

Vol 26 (3) ◽

pp. 211-216 ◽

Cited By ~ 11

Author(s):

F. Onorati ◽

G. Santarpino ◽

A. Renzulli ◽

M. De Feo ◽

L.S. De Santo ◽

...

Keyword(s):

Cardiopulmonary Bypass ◽

Low Dose ◽

Postoperative Bleeding ◽

Ringer Lactate ◽

Versus Group ◽

Significant Difference ◽

Group A ◽

The Mean ◽

Group B ◽

Lactate Solution

This study aimed to assess whether low doses of albumin in the priming solution for cardiopulmonary bypass (CPB) reduce postoperative bleeding. Three-hundred and seventy-seven patients undergoing CPB were retrospectively assigned to group A (154 patients, CPB primed with 20 ml/kg Ringer Lactate solution + 0.75mg/kg albumin 20%) and group B (223 patients with 20 ml/kg Ringer Lactate). A significant difference was found in terms of reoperations for bleeding (group A 0/154 versus group B 9/223; P=0.033). The mean number of blood derivatives transfused per patient was higher in group B than in group A (p <0.001). Platelet count after CPB was higher in group A than in group B (175±52×103/μl versus 131±70×103/μl; P=0.045). The amount of postoperative bleeding was 525ml versus 680ml at 24hrs (p <0.001), 819ml versus 1102ml at 48hrs, (p <0.001), 963ml versus 1294ml at 72hrs, (p <0.045) (group A versus group B respectively). Crystalloid priming with low-dose albumin reduces postoperative bleeding.

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

Journal of Thoracic and Cardiovascular Surgery ◽

10.1016/s0022-5223(19)38872-5 ◽

1983 ◽

Vol 85 (2) ◽

pp. 174-185 ◽

Cited By ~ 55

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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Factors influencing activated clotting time following heparin administration for the initiation of cardiopulmonary bypass

General Thoracic and Cardiovascular Surgery ◽

10.1007/s11748-020-01435-x ◽

2020 ◽

Vol 69 (1) ◽

pp. 38-43

Author(s):

Satoshi Matsushita ◽

Akinori Kishida ◽

Yoshihito Wakamatsu ◽

Hiroshi Mukaida ◽

Hirohide Yokokawa ◽

...

Keyword(s):

Cardiopulmonary Bypass ◽

Clotting Time ◽

Factors Influencing ◽

Activated Clotting Time ◽

Heparin Administration

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Global cerebral infarction after aortic arch replacement surgery in a patient with postoperatively revealed factor XII deficiency: a case report

Journal of Medical Case Reports ◽

10.1186/s13256-020-02470-1 ◽

2020 ◽

Vol 14 (1) ◽

Author(s):

Keisuke Yoshida ◽

Shiori Tanaka ◽

Yuki Sato ◽

Kazuhiro Watanabe ◽

Kenichi Muramatsu ◽

...

Keyword(s):

Cardiopulmonary Bypass ◽

Cerebral Infarction ◽

Acute Type ◽

Factor Xii ◽

Clotting Time ◽

Type A Aortic Dissection ◽

Factor Xii Deficiency ◽

Replacement Surgery ◽

Activated Clotting Time ◽

Heparin Administration

Abstract Background This case report presents a case of a patient with global cerebral infarction of uncertain etiology following an emergency surgery for acute type A aortic dissection. As a result, factor XII deficiency was revealed postoperatively. To date, there have been several reports of cardiovascular surgery in patients with factor XII deficiency. However, all previous reports were of patients whose factor XII deficiency had been detected preoperatively; therefore, before this, there had been no reports of complications associated with factor XII deficiency following cardiovascular surgery. Case presentation We report a case of emergency aortic arch replacement surgery for acute type A aortic dissection in a 57-year-old Japanese man. A blood test prior to the surgery showed coagulopathy, a platelet count of 117 × 109/L, a prothrombin time–international normalized ratio of 1.78, an activated partial thromboplastin time of 69.7 seconds, and fibrinogen < 50 mg/dl. A smaller-than-usual dose of heparin (8000 IU) was administered because the patient’s activated clotting time was extremely prolonged (> 999 seconds). After the heparin administration, the activated clotting time, measured every 30–60 minutes, remained unchanged (> 999 seconds); therefore, additional heparin was not administered during the surgery, and there was no clinical problem during cardiopulmonary bypass. However, a diagnosis of global cerebral infarction was made on the first postoperative day. An additional blood coagulation test performed on postoperative day 9 revealed factor XII deficiency (8.0%). Regarding the reason that global cerebral infarction occurred in the present case, two reasons were considered: One was factor XII deficiency itself, and the other was low-dose heparin administration during the cardiopulmonary bypass due to excessively prolonged activated clotting time caused by factor XII deficiency. Conclusions Factor XII deficiency should be considered in patients with prolonged activated clotting time and spontaneous thrombosis in vascular surgeries. Moreover, the present case emphasizes that management of heparin during cardiopulmonary bypass should not be performed on the basis of activated clotting time monitoring alone, especially in a case with prolonged activated clotting time.

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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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