1
|
Bailly A, Gaillard C, Cadiet J, Fortuit C, Roux F, Morin H, Desanlis E, LE Teurnier Y, Miguet B, Robert D, Silleran J, Rigal JC, LE Thuaut A, Pere M, Roussel JC, Rozec B. Evaluation of the impact of HMS Plus on postoperative blood loss compared with ACT Plus in cardiac surgery. Minerva Anestesiol 2021; 87:1191-1199. [PMID: 34102807 DOI: 10.23736/s0375-9393.21.15482-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The standardized management of anticoagulation during the cardiopulmonary bypass seems inaccurate because of patients and surgeries variability. This study evaluates if an individualized management of heparin and protamine guided by the HMS Plus system during cardiopulmonary bypass could reduce postoperative blood loss. METHODS We conducted a prospective, controlled, unblinded, single-center study. 188 patients operated for cardiac surgery were included. Patients were divided in ACT Plus group (standardized approach) and HMS Plus group (individualized approach). The primary outcome was blood-loss volume during the first 24 postoperative hours. The main secondary outcomes were the need for allogeneic blood transfusions and the final protamine/heparin ratio. RESULTS There was no difference between the two groups for baseline characteristics. Medium bloodloss volume (±DS) in the ACT Plus group was 522 mL ±260 mL vs. 527 mL ±255 mL in the HMS Plus group (P = 0.58). The final protamine/heparin ratio (±DS) in the ACT Plus group was 0.94 ±0.1 vs. 0.58 ± 0.1 in the HMS Plus group (P < 0.0001). The transfusion rate during surgery in the ACT Plus group was 25% vs. 14% in the HMS Plus group (P = 0.09). CONCLUSIONS HMS Plus did not reduce the mean blood-loss volume during the first 24 postoperative hours compared with ACT Plus. Its utility for potential transfusion rate reduction remains to be proven.
Collapse
Affiliation(s)
- Arthur Bailly
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France -
| | - Côme Gaillard
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Julien Cadiet
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Camille Fortuit
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - François Roux
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Hélène Morin
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Enguerrand Desanlis
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Yann LE Teurnier
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Bertrand Miguet
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - David Robert
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Jacqueline Silleran
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Jean-Christophe Rigal
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Aurélie LE Thuaut
- Department of Methodology and Biostatistics, University Hospital of Nantes, Nantes, France
| | - Morgane Pere
- Department of Methodology and Biostatistics, University Hospital of Nantes, Nantes, France
| | - Jean-Christian Roussel
- Department of Thoracic and Cardiovascular Surgery, Université de Nantes, CHU Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - Bertrand Rozec
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France.,Université de Nantes, CHU Nantes, Nantes, France
| |
Collapse
|
2
|
Meesters MI, Veerhoek D, de Lange F, de Vries JW, de Jong JR, Romijn JWA, Kelchtermans H, Huskens D, van der Steeg R, Thomas PWA, Burtman DTM, van Barneveld LJM, Vonk ABA, Boer C. Effect of high or low protamine dosing on postoperative bleeding following heparin anticoagulation in cardiac surgery. Thromb Haemost 2018; 116:251-61. [DOI: 10.1160/th16-02-0117] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 05/06/2016] [Indexed: 11/05/2022]
Abstract
SummaryWhile experimental data state that protamine exerts intrinsic anticoagulation effects, protamine is still frequently overdosed for heparin neutralisation during cardiac surgery with cardiopulmonary bypass (CPB). Since comparative studies are lacking, we assessed the influence of two protamine-to-heparin dosing ratios on perioperative haemostasis and bleeding, and hypothesised that protamine overdosing impairs the coagulation status following cardiac surgery. In this open-label, multicentre, single-blinded, randomised controlled trial, patients undergoing on-pump coronary artery bypass graft surgery were assigned to a low (0.8; n=49) or high (1.3; n=47) protamine-to-heparin dosing group. The primary outcome was 24-hour blood loss. Patient haemostasis was monitored using rotational thromboelastometry and a thrombin generation assay. The low protamine-to-heparin dosing ratio group received less protamine (329 ± 95 vs 539 ± 117 mg; p<0.001), while post-protamine activated clotting times were similar among groups. The high dosing group revealed increased intrinsic clotting times (236 ± 74 vs 196 ± 64 s; p=0.006) and the maximum post-protamine thrombin generation was less suppressed in the low dosing group (38 ± 40% vs 6 ± 9%; p=0.001). Postoperative blood loss was increased in the high dosing ratio group (615 ml; 95% CI 500–830 ml vs 470 ml; 95% CI 420–530 ml; p=0.021) when compared to the low dosing group, respectively. More patients in the high dosing group received fresh frozen plasma (11% vs 0%; p=0.02) and platelet concentrate (21% vs 6%; p=0.04) compared to the low dosing group. Our study confirms in vitro data that abundant protamine dosing is associated with increased postoperative blood loss and higher transfusion rates in cardiac surgery.
Collapse
|
6
|
Noui N, Zogheib E, Walczak K, Werbrouck A, Amar AB, Dupont H, Caus T, Remadi JP. Anticoagulation monitoring during extracorporeal circulation with the Hepcon/HMS device. Perfusion 2012; 27:214-20. [DOI: 10.1177/0267659112436632] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective: The objective of our study was to compare the standard protocol of anticoagulation to the Hepcon/HMS. Method: This study included forty-four patients who underwent coronary bypass grafting surgery (CABG), or biological aortic valve replacement (AVR). Unfractionated heparin (UH) was used for patients who underwent operations in the control group (n = 22) (300U/Kg of UH with a goal of an ACT of 400s). The heparin was antagonized dose/dose by protamine. For the patients who underwent operations in the HMS group (n = 22), the heparin and protamine doses were assessed by the Hepcon/HMS device. Results: The sex ratio amounted to 1.93 (29 men and 15 women) and the mean age was 70 ± 11 years. The patients in the HMS group had a chest closure time that was significantly shorter than patients in the control group. The times were, respectively, 42 ± 15 minutes and 68 ± 27 minutes (p = 0.001). The protamine/heparin ratio was significantly lower in the HMS group (0.62 ± 0.13 vs. 1 ± 0.11) (p = 0.0001). The postoperative bleeding amounted to 804 ± 729 ml in the HMS group versus 1416 ± 1103 in the control group (p = 0.016). In multivariate linear regression analysis, only two independent factors were significantly associated with bleeding: the Hepcon/HMS (OR = 0.1-p = 0.03) and the preoperative hemoglobin rate (OR = 1.4 - p = 0.05). Postoperatively, within 72 hours, the red blood cell transfusion was 1.04 ± 1.5 units for the HMS group and 2.1 ± 1.87 units for the control group (p = 0.05). Conclusion: During cardiac surgery under CPB, heparin and protamine titration with the Hepcon/HMS device could predict a lower protamine dose and lower postoperative bleeding without higher thromboembolic events, and lower perioperative red blood cell transfusion with a shorter chest closure time.
Collapse
Affiliation(s)
- N Noui
- Anesthesiology Unit, South Hospital, Amiens, France
| | - E Zogheib
- Anesthesiology Unit, South Hospital, Amiens, France
| | - K Walczak
- Anesthesiology Unit, South Hospital, Amiens, France
| | - A Werbrouck
- Anesthesiology Unit, South Hospital, Amiens, France
| | - A Ben Amar
- Cardio-vascular Surgery Unit, University Hospital, CHU Amiens, France
| | - H Dupont
- Anesthesiology Unit, South Hospital, Amiens, France
| | - T Caus
- Cardio-vascular Surgery Unit, University Hospital, CHU Amiens, France
| | - JP Remadi
- Cardio-vascular Surgery Unit, University Hospital, CHU Amiens, France
| |
Collapse
|
7
|
Ranucci M, Aronson S, Dietrich W, Dyke CM, Hofmann A, Karkouti K, Levi M, Murphy GJ, Sellke FW, Shore-Lesserson L, von Heymann C. Patient blood management during cardiac surgery: Do we have enough evidence for clinical practice? J Thorac Cardiovasc Surg 2011; 142:249.e1-32. [DOI: 10.1016/j.jtcvs.2011.04.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 02/09/2011] [Accepted: 04/08/2011] [Indexed: 12/13/2022]
|
8
|
Dunning J, Versteegh M, Fabbri A, Pavie A, Kolh P, Lockowandt U, Nashef SAM. Guideline on antiplatelet and anticoagulation management in cardiac surgery. Eur J Cardiothorac Surg 2008; 34:73-92. [PMID: 18375137 DOI: 10.1016/j.ejcts.2008.02.024] [Citation(s) in RCA: 246] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 02/15/2008] [Accepted: 02/19/2008] [Indexed: 01/17/2023] Open
Abstract
This document presents a professional view of evidence-based recommendations around the issues of antiplatelet and anticoagulation management in cardiac surgery. It was prepared by the Audit and Guidelines Committee of the European Association for Cardio-Thoracic Surgery (EACTS). We review the following topics: evidence for aspirin, clopidogrel and warfarin cessation prior to cardiac surgery; perioperative interventions to reduce bleeding including the use of aprotinin and tranexamic acid; the use of thromboelastography to guide blood product usage; protamine reversal of heparin; the use of factor VIIa to control severe bleeding; anticoagulation after mechanical, tissue valve replacement and mitral valve repair; the use of antiplatelets and clopidogrel after cardiac surgery to improve graft patency and reduce thromboembolic complications and thromboprophylaxis in the postoperative period. This guideline is subject to continuous informal review, and when new evidence becomes available. The formal review date will be at 5 years from publication (September 2013).
Collapse
Affiliation(s)
- Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | | | | | | | | | | | | |
Collapse
|