Heparinase thromboelastography compared with activated coagulation time for protamine titration after cardiopulmonary bypass.
OBJECTIVE
The present study is a comparison of two point-of-care (POC) tests as endpoints of protamine titration after CPB. The authors hypothesized that using the heparinase-kaolin thromboelastography (TEG-HK) R-time difference would more readily identify residual heparin necessitating additional protamine than when using activated coagulation time (ACT). The primary endpoint was the between-group difference in protamine dose. Whether this approach would lessen postoperative bleeding and sequelae also was investigated.


METHODS
Single center, blinded, prospective, randomized study.


METHODS
University teaching hospital.


METHODS
Eighty-two adult patients for on-pump coronary artery bypass and/or valve surgery.


METHODS
Patients were randomized. In the ACT group, protamine was titrated until ACT did not exceed baseline by more than 10%. In the TEG group, a TEG-HK R-time difference less than 20% was targeted. Protamine was repeated to achieve the endpoints. Clinicians in the ACT group were blinded to TEG data and vice versa.


RESULTS
There was no between-group difference in total protamine dose (3.9 ± 0.6 and 4.2 ± 0.7; 95% CI of the difference between means: -0.544 to 0.008 mg/kg; p = 0.057) or protamine:heparin ratios (1.3:1 and 1.4:1; 95% CI of the difference between means: -0.05 to 0.03 mg/mg; p = 0.653). In the ACT group, 17% of patients required a second protamine dose, and in the TEG group, 24% of patients required a second protamine dose. No between-group differences in the postoperative transfusion requirements or intensive care unit length of stay were demonstrated.


CONCLUSIONS
No difference was identified in protamine dosing using either ACT or TEG-HK R-time difference as endpoints. Heparinase TEG may be useful for monitoring heparin reversal.
Department of Anesthesiology and Critical Care, Faculty of Health Sciences, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa. Electronic address: ail@sun.ac.za.
Andrew Ian
AI
Levin
Private practice, Cape Town, South Africa.
Adriaan Martin
AM
Heine
Department of Anesthesiology and Critical Care, Faculty of Health Sciences, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa.
Johan Francois
JF
Coetzee
Department of Anesthesiology and Critical Care, Faculty of Health Sciences, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa.
André
A
Coetzee
D000368:Aged; D001803:Blood Transfusion / Q000706:statistics & numerical data; D006348:Cardiac Surgical Procedures; D002315:Cardiopulmonary Bypass / Q000379:methods*; D003422:Critical Care; D023381:Endpoint Determination; D005260:Female; D006351:Heart Valves / Q000601:surgery; D006494:Heparin Antagonists / Q000008:administration & dosage* / Q000627:therapeutic use*; D019763:Heparin Lyase; D006801:Humans; D007616:Kaolin / Q000097:blood; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019095:Point-of-Care Systems; D019106:Postoperative Hemorrhage / Q000517:prevention & control; D011446:Prospective Studies; D011479:Protamines / Q000008:administration & dosage* / Q000627:therapeutic use*; D013916:Thrombelastography / Q000379:methods*; D014914:Whole Blood Coagulation Time / Q000379:methods*
D006494:Heparin Antagonists; D011479:Protamines; D007616:Kaolin; D019763:Heparin Lyase
activated coagulation time; cardiopulmonary bypass; heparin; heparinase; point-of-care test; postoperative bleeding; protamine; thromboelastography