The effect of protamine dosing variation on bleeding and transfusion after heparinisation for cardiopulmonary bypass

Kunz, Stephen; Miles, Lachlan F; Ianno, Damian; Mirowska-Allen, Kelly; Matalanis, George; Bellomo, Rinaldo; Seevanayagam, Siven

doi:10.1177/0267659118763043

Cited by 19 publications

(20 citation statements)

References 29 publications

(34 reference statements)

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“…Accumulating evidence supports lower ratios, such as 0.6-1 mg/kg protamine per 100 IU/kg of heparin, as being associated with decreased transfusion and chest drain output. 48,50 Because there is inherent variability related to the ACT measurement itself, values within approximately 10% of the initial baseline are accepted as normal. 51 Importantly, an elevated ACT may not indicate residual heparin effect, as it is a whole blood clotting test.…”

Section: Heparin Management and Protamine Reversalmentioning

confidence: 99%

Managing the coagulopathy associated with cardiopulmonary bypass

Bartoszko

Karkouti

2021

Journal of Thrombosis and Haemostasis

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Cardiopulmonary bypass (CPB) has allowed for significant surgical advancements, but accompanying risks can be significant and must be expertly managed. One of the foremost risks is coagulopathic bleeding. Increasing levels of bleeding in cardiac surgical patients at the time of separation from CPB are associated with poor outcomes and mortality. CPB‐associated coagulopathy is typically multifactorial and rarely due to inadequate reversal of systemic heparin alone. The components of the bypass circuit induce systemic inflammation and multiple disturbances of the coagulation and fibrinolytic systems. Anticipating coagulopathy is the first step in managing it, and specific patient and procedural risk factors have been identified as predictors of excessive bleeding. Medication management pre‐procedure is critical, as patients undergoing cardiac surgery are commonly on anticoagulants or antiplatelet agents. Important adjuncts to avoid transfusion include antifibrinolytics, and perfusion practices such as red cell salvage, sequestration, and retrograde autologous priming of the bypass circuit have varying degrees of evidence supporting their use. Understanding the patient's coagulation status helps target product replacement and avoid larger volume transfusion. There is increasing recognition of the role of point‐of‐care viscoelastic and functional platelet testing. Common pitfalls in the management of post‐CPB coagulopathy include overdosing protamine for heparin reversal, imperfect laboratory measures of thrombin generation that result in normal or near‐normal laboratory results in the presence of continued bleeding, and delayed recognition of surgical bleeding. While challenging, the effective management of CPB‐associated coagulopathy can significantly improve patient outcomes.

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Section: Heparin Management and Protamine Reversalmentioning

confidence: 99%

Managing the coagulopathy associated with cardiopulmonary bypass

Bartoszko

Karkouti

2021

Journal of Thrombosis and Haemostasis

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“…This concern raises from cardiopulmonary bypass (CPB) use during heart surgery and, while performing heart and lung surgery simultaneously, the more complicated surgical procedure. Potential bleeding might relate to excessive heparin use, inadequate heparin neutralization, or platelet dysfunction during CPB (38,39). Bleeding might arise from the area of the lung resection, extensive mediastinal lymph node dissection and, not less frequently, intrapulmonary hemorrhage (20,40).…”

Section: Discussionmentioning

confidence: 99%

“…Many disadvantages of CPB have been described. With higher doses of heparin, CPB could increase the risk of bleeding (39). Manufactured from synthetic materials, CPB circuits could impair platelet function and enhance systemic in ammatory response syndrome (43).…”

Section: Discussionmentioning

confidence: 99%

Perioperative outcomes of combined heart surgery and lung tumor resection: A systematic review and meta-analysis

Cheng

Jiang

et al. 2020

Preprint

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Objective: The coexistence of concomitant lesions of the heart and lungs needed surgical intervention is increasing. Simultaneous cardiac surgery with pulmonary resection can solve the lesions at the same time, thus avoiding the second operation. However, concern exists regarding the potentially increased mortality and complication rate of simultaneous surgery and the adequacy of lung exposure during heart surgery. Therefore, we performed a meta-analysis to evaluate the perioperative mortality and complication rate of combined heart surgery and lung tumor resection.Methods: A comprehensive literature search was performed in July 2020. PubMed, Embase and Web of Science databases were searched to collect studies reported the perioperative outcomes of combined heart surgery and lung tumor resection. Two reviewers independently screened literatures, extracted data and assessed the risk of bias of included studies. Pooled proportion and its 95% confidence intervals (95% CI) was performed by R version 3.6.1 using the meta package.Results: A total of 536 patients from 29 studies were included in this analysis. Overall, the results of this meta-analysis showed that the pooled proportion of operative mortality was 0.01 (95% CI: 0.00, 0.03) and the pooled proportion of postoperative complications was 0.40 (95% CI: 0.24, 0.57) for patients underwent combined cardiothoracic surgery. Subgroup analysis by lung pathology revealed that, for lung cancer patients, the pooled proportion of anatomical lung resection was 0.99 (95% CI: 0.95, 1.00), and the pooled proportion of systematic lymph node dissection or sampling was 1.00 (95% CI: 1.00, 1.00). Subgroup analysis by heart surgery procedures found that the pooled proportion of postoperative complications of coronary artery bypass grafting (CABG) patients using off-pump method was 0.17 (95% CI: 0.01, 0.43), while the pooled proportion of on-pump method was 0.61 (95% CI: 0.38, 0.82).Conclusion: This study presented that combined heart surgery and lung tumor resection had a low mortality rate and an acceptable complication rate. Subgroup analysis revealed most lung cancer patients underwent uncompromised anatomical resection and mediastinal lymph node sampling or dissection during combined cardiothoracic surgery, and showed off-pump CABG could potentially reduce the complication rate compared with on-pump CABG. While further researches are still needed.

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“…Recent investigations suggest that a heparin-to-protamine ratio between 0.6 and 1.0 may be optimal. 18,19…”

Section: Methodsmentioning

confidence: 99%

“…Recent investigations suggest that a heparin-to-protamine ratio between 0.6 and 1.0 may be optimal. 18,19 Antifibrinolytics utilized included tranexamic acid and aprotinin. Tranexamic acid was administered either as a 2-g bolus pre-CPB or as a 1-g bolus and a 500-mgper-hour infusion until the end of the operation (as per departmental protocol).…”

Section: Exposuresmentioning

confidence: 99%

Thrombotic risk in central venoarterial extracorporeal membrane oxygenation post cardiac surgery

et al. 2020

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Introduction: Post-cardiotomy cardiogenic shock is an accepted indication for venoarterial extracorporeal membrane oxygenation. The true incidence and risk factors for the development of thrombosis in this setting remain unclear. Methods: Patients supported with central venoarterial extracorporeal membrane oxygenation due to ventricular dysfunction precluding weaning from cardiopulmonary bypass were retrospectively identified. Electronic records from a single institution spanning a 4-year period from January 2015 to December 2018 were interrogated to assess the incidence of thrombosis. The relationship to exposures including intracardiac stasis and procoagulant usage was explored. Results: Twenty-four patients met the inclusion criteria and six suffered major intracardiac thrombosis. All cases of thrombosis occurred early, and none survived to hospital discharge. The lack of left ventricular ejection conferred a 46% risk of developing thrombosis compared to 0% if ejection was maintained (p = 0.0093). Aprotinin use was also associated with thrombus formation (p = 0.035). There were no significant differences between numbers of patients receiving other procoagulants when grouped by thrombosis versus no thrombosis. Conclusion: Stasis is the predominant risk factor for intracardiac thrombosis. This occurs rapidly and the outcome is poor. As a result, we suggest early left ventricular decompression. Conventional management of post-bypass coagulopathy seems safe if the aortic valve is opening.

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The effect of protamine dosing variation on bleeding and transfusion after heparinisation for cardiopulmonary bypass

Abstract: Higher doses of intra-operative protamine relative to heparin are associated with greater risk of transfusion and post-operative bleeding.

Cited by 19 publications

References 29 publications

Managing the coagulopathy associated with cardiopulmonary bypass

Managing the coagulopathy associated with cardiopulmonary bypass

Perioperative outcomes of combined heart surgery and lung tumor resection: A systematic review and meta-analysis

Thrombotic risk in central venoarterial extracorporeal membrane oxygenation post cardiac surgery

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