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

Esposito, Giovanni; Culliford, Alfred T.; Colvin, Stephen B.; Thomas, Stephen J.; Lackner, Henriette; Spencer, Frank C.

doi:10.1016/s0022-5223(19)38872-5

Cited by 84 publications

(29 citation statements)

References 17 publications

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“…A surprisingly good correlation (0.886) was found ( Table 3), suggesting that the ACT is an acceptable assay during CPB, although more precise heparinization and better neutralization can undoubtedly be achieved by quantitative heparin assays. Our data also support the findings of Esposito et al 12 that traces of heparin after neutralization with protamine cannot be measured by the ACT.…”

Section: Discussionsupporting

confidence: 92%

“…10,16,21,28 Heparin administered before and during CPB is still the most commonly used mode of anticoagulation, and most centers seem to feel comfortable with the ACT as the means of monitoring heparin therapy. Forman and Bayer 14 recommend this procedure for all forms of heparin treatment and Esposito et al 12 found the ACT "as the best available measurement for anticoagulation" during CPB. Others, 42,46,47 in contrast, advocate the use of quantitative heparin assays during CPB, not only to avoid occasional "false" ACT values due to changes in the clotting system, especially very high Factor VIII:C levels, but also monitor more precisely heparin during CPB and more accurately calculate the dose of protamine sulfate needed to neutralize heparin.…”

Section: Discussionmentioning

confidence: 99%

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Hemostasis Changes During Cardiopulmonary Bypass Surgery

Mammen¹,

Koets²,

Washington³

et al. 1985

Semin Thromb Hemost

305

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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)

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Hemostasis Changes During Cardiopulmonary Bypass Surgery

Mammen¹,

Koets²,

Washington³

et al. 1985

Semin Thromb Hemost

305

View full text Add to dashboard Cite

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“…We usually used several empirical protocols to determine the protamine dosage for the neutralization of heparin anticoagulation as follows: (1) giving a fixed amount of protamine per body weight, e.g., 3 mg/kg [9]; (2) giving protamine in a fixed ratio to total heparin dose, e.g., protamine/heparin ‫ס‬ 1.3:1.0; (3) giving a calculated protamine dosage by a two-point heparin dose-response curve based on activated coagulation time (ACT) values measured at before and 5 min after heparin administration [10,11]. Although protocols (1) and (2) are simple, biodegradation of heparin is not considered.…”

mentioning

confidence: 99%

Hemostatic effects of low-dose protamine following cardiopulmonary bypass

et al. 2000

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Twenty-eight patients undergoing cardiac surgery were prospectively studied and were assigned to two groups. The patients received 0.8-(Group L) or 2.0-fold (Group H) dose of protamine for the neutralization after cardiopulmonary bypass (CPB) which was determined by Hepcon HMS assay system in which the reagent chamber containing the concentration of protamine that completely neutralized the heparin had the shortest clotting time. Mean dose of protamine was 1.60 ± 0.50 mg kg −1 in Group L, and 3.56 ± 1.48 mg kg −1 , respectively. Activated clotting times (ACT) were comparable between the two groups through this study period. In Group H, platelet counts significantly decreased to 69% of that before protamine administration, and plasma platelet factor 4 level significantly increased to approximate 2-fold of that before protamine administration just after protamine administration, respectively. However, these phenomena were not observed in Group L. In addition, these hemostatic changes occurred transiently just after protamine administration. We conclude that the low-dose protamine may prevent transient platelet depletion following CPB. Low-dose protamine can neutralize anticoagulation effect of heparin sufficiently and may mitigate protamine-induced platelet dysfunction. Am.

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“…Proposed detrimental effects of transfusion-associated immune system modulation include increased cancer recurrence, perioperative infections, multiorgan system failure, and overall mortality, but these effects are controversial [22]. Transfusion, however, potentially can attenuate the immune response based on one of several potential mechanisms, including: a reduction in CD8 suppressor T cell function and number CD4 T helper cell number NK cell number and function Macrophage number and function, MLC response Response to mitogen, Cell-mediated cytotoxicity [23] Although several studies have demonstrated an independent effect (ie, using multivariate statistical models) of transfusion on increased perioperative infection ratesfour to five times) in numerous different surgical populations (ie, trauma [24][25][26][27], hip arthroplasty [25,28], spinal [29], colorectal [30][31][32][33][34][35][36] and cardiac [37][38][39]), the immune-modulatory effect of transfusion on the incidence of perioperative infection remains controversial. In addition, a recent meta-analysis involving review of 20 peer-reviewed articles and 13,152 patients revealed that transfusion was associated with perioperative infection (odds ratio of 3.45, range 1.43 to 15.15) [27].…”

Section: Citrate-related Hypocalcemia (Ie With Rapid Infusion) Inadvmentioning

confidence: 99%

Transfusion Risks and Transfusion-related Pro-inflammatory Responses

Despotis

Zhang

Lublin

2007

Hematology/Oncology Clinics of North America

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Despite improvements in blood screening and administration techniques, serious adverse events related to transfusion continue to occur, albeit at a much lower incidence. In addition to the development and implementation of new screening and blood purification/modification techniques and implementation of an optimal blood management program, the incidence and consequences of transfusion reactions can be reduced by a basic understanding of transfusion-related complications. Although acute hemolytic transfusion reactions, transfusion-associated anaphylaxis and sepsis, and transfusion-associated acute lung injury occur infrequently, diligence in administration of blood and monitoring for development of respective signs/symptoms can minimize the severity of these potentially life-threatening complications. In addition, emerging blood-banking techniques such as psoralen-UV inactivation of pathogens and use of patient identification systems may attenuate the incidence of adverse events related to transfusion. With respect to optimizing blood management by means of an effective blood management program involving pharmacologic and nonpharmacologic strategies, the ability to reduce use of blood products and to decrease operative time or re-exploration rates has important implications for disease prevention, blood inventory and costs, and overall health care costs.

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

Cited by 84 publications

References 17 publications

Hemostasis Changes During Cardiopulmonary Bypass Surgery

Hemostasis Changes During Cardiopulmonary Bypass Surgery

Hemostatic effects of low-dose protamine following cardiopulmonary bypass

Transfusion Risks and Transfusion-related Pro-inflammatory Responses

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