Journal of Cardiothoracic and Vascular Anesthesia
Original ArticleHeparin Dose and Point-of-Care Measurements of Hemostasis in Cardiac Surgery—Results of a Randomized Controlled Trial
Section snippets
Patients
Sixty-three consecutive patients undergoing elective CABG with CPB were enrolled into this prospective, randomized, controlled, single-center study between February 3, 2012, and March 11, 2015. The Ethics Committee of the Hospital District of Helsinki and Uusimaa, Helsinki, Finland, approved the study. All patients gave written informed consent to participate in the study. Exclusion criteria were as follows: urgent surgery; redo surgery; concomitant cardiac surgery in addition to CABG;
Study Population
The patient characteristics were comparable between the study groups (Table 1). There were no differences in comorbidities, medications, or preoperative laboratory values between the study groups (data not shown). No major adverse events (eg, stroke, myocardial infarction, venous thromboembolism, acute kidney injury or resternotomy) occurred during the study. The surgical data are presented in Table 2.
Heparin and Protamine Dose
Total heparin dose (median 54,300 [IQR 46,950-62,250] IU v median 27,000 [IQR 24,420-34,920]
Discussion
In patients who received either a high or a conventional dose of heparin during CPB, there were no significant dose-dependent differences in TEM ExTEM CT, ExTEM MCF, or FibTEM MCF values, except for a small difference in ExTEM CT at 3 hours after protamine administration. Strikingly, all of the median TEM values studied in citrated blood were within the normal ranges reported by the manufacturer at all time points.22 Likewise, platelet aggregation in hirudin-anticoagulated whole blood did not
Conclusions
In the present randomized clinical trial, the whole blood POC assays TEM and MEA did not demonstrate significant differences in either coagulation or platelet function in patients anticoagulated with a high or standard dose of heparin during cardiac surgery. Therefore, although the higher dose of heparin was as safe as the lower dose, regarding POC measurements, it does not seem to offer any benefit.
Conflict of Interest
None.
References (32)
- et al.
Clinical practice guidelines—anticoagulation during cardiopulmonary bypass
Ann Thorac Surg
(2018) - et al.
The impact of heparin concentration and activated clotting time monitoring on blood conservation
J Thorac Cardiovasc Surg
(1995) - et al.
Heparin-induced thrombocytopenia: New evidence for the dynamic binding of purified anti-PF4–heparin antibodies to platelets and the resultant platelet activation
Blood
(2000) - et al.
Platelet factor 4 is a negative autocrine in vivo regulator of megakaryopoiesis: Clinical and therapeutic implications
Blood
(2007) - et al.
Heparin causes platelet dysfunction and induces fibrinolysis before cardiopulmonary bypass
Ann Thoracic Surg
(1995) - et al.
Influence of different anticoagulation regimens on platelet function during cardiac surgery
Br J Anaesth
(1994) - et al.
Prediction of excessive bleeding after coronary artery bypass graft surgery: The influence of timing and heparinise on thromboelastography
J Cardiothorac Vasc Anesth
(2002) - et al.
Correlation of perioperative platelet function and coagulation tests with bleeding after cardiopulmonary bypass surgery
J Lab Clin Med
(2006) - et al.
Thrombin in myocardial ischemia-reperfusion during cardiac surgery
Ann Thorac Surg
(2009) - et al.
Hydroxyethylstarch and gelatin solutions impair blood coagulation after cardiac surgery: A prospective randomized trial
Br J Anaesth
(2010)
Are the point-of-care diagnostics MULTIPLATE and ROTEM valid in the setting of high concentrations of heparin and its reversal with protamine?
J Cardiothorac Vasc Anesth
At high heparin concentrations, protamine concentrations which reverse heparin anticoagulant effects are insufficient to reverse heparin anti-platelet effects
Thromb Res
The platelet function defect of cardiopulmonary bypass
Blood
Low dose protamine based on heparin-protamine titration method reduces platelet dysfunction after cardiopulmonary bypass
J Thorac Cardiovasc Surg
Hematologic changes during and after cardiopulmonary bypass and their relationship to the bleeding time and nonsurgical blood loss
J Thorac Cardiovasc Surg
Coagulation and fibrinolysis system in aortic surgery under deep hypothermic arrest with aprotinin: The importance of adequate heparinization
Circulation
Cited by (8)
Anticoagulation for cardiopulmonary bypass: part one
2023, BJA EducationPoint-of-Care Platelet Function Monitoring: Implications for Patients With Platelet Inhibitors in Cardiac Surgery
2021, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :Similar changes have been described for the collagen receptor. These findings suggeststhat platelet reactivity becomes depressed during CPB but seems to quickly recover thereafter.64,68,82,85,86 Within different test assays, it seems that tests evaluating the thrombin-receptor pathway are most suitable to monitor basal platelet function and could be used as a reference.
Toward Optimal Anticoagulation Monitoring During Cardiopulmonary Bypass: It Is Still A Tough “ACT”
2020, Journal of Cardiothoracic and Vascular AnesthesiaAssessing the impact of different heparin dosing regimens for cardiopulmonary bypass on anticoagulation: the HepDOSE pilot study
2024, Canadian Journal of AnesthesiaA meta-analysis of the effect of heparin dose on postoperative bleeding in patients undergoing cardiopulmonary bypass
2023, Chinese Journal of Thoracic and Cardiovascular Surgery
This work was supported by research funding from the Finnish Ministry of Social Affairs and Health.