Hemostasis Changes During Cardiopulmonary Bypass Surgery

Abstract

A number of hemostasis parameters were studied in a total of 63 patients undergoing cardiopulmonary bypass (CPB) for open heart surgery. In 33 patients fibrinogen, Factors II, V, VIII:C, X, XI, antithrombin, plasminogen, alpha 2-antiplasmin, and platelet counts were assayed before surgery, during maximal hypothermia, at the end of the bypass procedure, before and after protamine sulfate infusion, in the intensive care unit, and 48 hours postoperatively. All factors assayed decreased markedly when the patients were placed on the bypass machine, the drop fairly well paralleling the decrease in hematocrit. During bypass the factors remained low, although a slight tendency toward an increase was noted. Only platelet counts remained low with a decreasing trend until the end of bypass. In the intensive care unit a second decrease in fibrinogen, Factors II and V and antithrombin was noted. This drop was unrelated to four patients who experienced a greater blood loss during this time than the others. Forty-eight hours postoperatively, a marked increase could be found in all clotting factors and near normal levels were measured. Platelet counts remained low, however. The decrease in factors rarely dropped into a range where one would expect a compromised hemostasis (less than 30%). Although antithrombin levels decreased below 60%, no difficulties with heparinization were encountered. Several factors were assayed manually and by automated analyzer (Multistat III), and excellent correlations were found between both procedures. Also a good correlation was found between the activated whole blood clotting times and quantitative heparin assays. In 30 additional patients platelet function was studied before surgery, after thoracotomy, after heparin administration, after initiation of bypass, at maximal hypothermia, before and after protamine sulfate infusion, and 24 hours postoperatively. Platelet counts once again decreased as patients were placed on the CPB machine and remained low throughout the procedure. Mean platelet volumes were unchanged until protamine was given. At that time, a significant drop in mean platelet volume was recorded. Twenty-four hours postoperatively the volumes were normal again. Platelet aggregation studies were performed on a whole blood aggregometer using two concentrations of ADP, collagen, and ristocetin as aggregation inducers. A significant decrease in aggregability was seen when the patients were connected to the CPB apparatus.(ABSTRACT TRUNCATED AT 400 WORDS)

Bleeding risk assessment using whole blood impedance aggregometry and rotational thromboelastometry in patients following cardiac surgery

“…[7]. Extracorporeal circulation and heparin may induce many abnormalities in the coagulation system, including thrombocytopenia [2], platelet dysfunction [8,9], coagulation factor deficiencies [10], residual heparin after protamine administration [11], and fibrinolysis [12]. Microvascular bleeding caused by dysfunctional platelets and an impaired coagulation cascade occur after CPB secondary to foreign surface contact [13].…”

Effect of Clopidogrel Premedication in Off-Pump Cardiac Surgery

“…15,16,19 Bleeding after CABG can be a combination of inadequate surgical hemostasis, coagulation, and platelet abnormalities. 20 Exposure to cardiopulmonary bypass (CPB) causes dilutional thrombocytopenia, 21,22 coagulopathy, 23 sheer-induced platelet dysfunction, 22,24 a systemic inflammatory response, and activation of plasminogen. 25,26 The safety and efficacy of off-pump CABG (OPCAB) have been confirmed through numerous reports.…”

Detection and treatment of coronary artery disease in liver transplant candidates

“…Initiation of cardiopulmonary bypass causes hemodilution of platelets and coagulation factors, as well as quantitative and qualitative platelet abnormalities that compromise an already poor hemostatic system in a patient with cirrhosis. 42 Anticoagulation with heparin may put the patient at further risk for bleeding. All these factors place a patient with cirrhosis at risk for gastrointestinal bleeding or bleeding related to surgical trauma.…”