Increased accuracy in heparin and protamine administration decreases bleeding: a pilot study.
Three to 5 percent of the patients undergoing cardiac surgery are reoperated because of bleeding. When a surgical cause can be excluded, heparin/protamine mismatch may be considered. Insufficient reversal of heparin and overdosing of protamine may cause postoperative bleeding. The purpose of the study was to evaluate whether a heparin-protamine titration system, Hemochron RxDx, could reduce postoperative bleeding and blood transfusion. Fifty-three patients were included prospectively over a 6-month period. The test group (RxDx group; 28 patients) received heparin and protamine doses calculated using the Hemochron RxDx system, which performs a baseline activated clotting time (ACT) value together with a heparin response test. An accurate heparin dose was calculated based on the Bull dose/response curve. Protamine doses were calculated by the same method. In the control group (25 patients), heparin was administered based on weight (3.5 mg/kg) and monitored by ACT. Heparin was reversed with protamine (1 mg/l mg of total heparin). Postoperative bleeding was significantly lower in the RxDx group (375 mL; range, 125-700 mL) compared with the control group (600 mL; range, 250-1920 mL; p = .018). A reduced number of patients needed blood transfusions in the RxDx group, although this was not statistically significant (19% vs. 38%, respectively; p = .13). Initial heparin dose was significantly reduced in the RxDx group (250 mg; range, 100-375 mg) compared with the control group (300 mg; range, 200-350 mg; p = .04). The additional heparin during cardiopulmonary bypass (CPB) was significantly lower as well 62 (range, 0-185) vs. 100 mg (range, 0-350 mg); p = .04. Initial protamine dose was reduced in the RxDx group 200 (range, 75-340) vs. 350 mg (range, 200-500 mg); p = .0001. Satisfactory end ACT values were obtained in both groups. Using the Hemochron RxDx, we observed a significant reduction in postoperative blood loss, as well as the amount of heparin and initial doses of protamine used during CPB. Individual patient managed anticoagulation during cardiac surgery using dose/response curve techniques based on in vitro analysis of heparin and protamine seems to reduce bleeding.
Department of Clinical Perfusion, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark. marxrunge@rh.dk
Marx
M
Runge
Christian H
CH
Møller
Daniel A
DA
Steinbrüchel
D000368:Aged; D000369:Aged, 80 and over; D001803:Blood Transfusion; D002315:Cardiopulmonary Bypass / Q000009:adverse effects; D005260:Female; D006493:Heparin / Q000008:administration & dosage* / Q000009:adverse effects; D006494:Heparin Antagonists / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D010974:Platelet Aggregation; D019106:Postoperative Hemorrhage / Q000188:drug therapy*; D011446:Prospective Studies; D011479:Protamines / Q000008:administration & dosage* / Q000009:adverse effects; D013903:Thoracic Surgery; D014184:Transplantation, Homologous
D006494:Heparin Antagonists; D011479:Protamines; D006493:Heparin