Heparin-protamine management: a comparison study of three different heparin-protamine management protocols

Abstract

In a prospective randomized open study, 180 patients underwent open-heart surgery using cardiopulmonary bypass (CPB) and were divided into three different heparin-protamine management protocols. Each group consisted of 60 patients. Patients were treated according to: (A) their dose-response curve using the Hemochron 800 system (International Technidyne Corporation): (B) their dose-response curve, but the heparin-protamine management was based on titrations using the Hepcon system 4 (Hemotec Inc.); or (C) the regular protocol in our hospital. The three groups were compared according to age, gender, weight, perfusion time and operation type. Fibrinogen levels and activated partial thrombin time (APTT) were measured before and after CPB¹: during CPB, activated clotting time (ACT) was monitored. ^2-4 At the onset of CPB an ACT value of at least 480 seconds was standard.4 Blood for ACT evaluation was drawn every 30 minutes during CPB. A significant difference in the heparin dose given to the different groups was noted, but there also was a significant difference in bodyweight. As calculated per kilogram bodyweight, group B's heparin dose was significantly lower than group A's and also significantly lower than group C's. Group C was given a significantly higher dose of protamine/kg than group A and group B, and Group B's dose was significantly higher than group A's. Hence, protamine/heparin ratios of 0.61 for group A, 0.74 for group B and 0.82 for group C resulted. There was no significant difference in blood loss for the three groups and there was also no significant difference in the use of bank blood for these three groups. APTT values, measured after protamine administration, were significantly higher in group A than in group C. This study suggests that a higher dose of protamine does not result in a decrease of blood loss postoperatively. Reduction in the amount of heparin and in the protamine/heparin ratio is possible by guiding the Hepcon or Hemochron measurements. This reduction, however, will not directly decrease postoperative blood loss. Accurate doses of heparin and protamine can be achieved with an individual patient-related protocol. Thus, an unnecessary excess of heparin and/or protamine can be eliminated.

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References

Schriever HG , Epstein SE , Mintz MD Statistical correlation and heparin sensitivity of activated partial thromboplastin time, whole blood coagulation time and an automated coagulation time. Am J Clin Pathol 1973;78:95-102.

Bull BS , Korpman RA , Huse WM , Briggs BD Heparin therapy during extracorporeal circulation I: problems inherent in existing heparin protocols. J Thorac Cardiovsc Surg 1975; 69: 674-84.

Bull BS , Korpman RA , Huse WM , Briggs BD Heparin therapy during extracorporeal circulation II: problems inherent in existing heparin protocols. J Thorac Cardiovasc Surg 1975; 69: 685-89.

Hattersly PG Activated coagulation time of whole blood. JAMA 1966; 196: 436-40.

Kaul TK , Craw MJ , Rajah SM , Deverall PB , Watson DA Heparin administration during extracorporeal circulation: heparin rebound and postoperative bleeding. J Thorac Cardiovasc Surg 1979; 78: 95-102.

Ellison N. , Edmonds LH , Coeman RW Platelet aggregation following heparin and protamine administration. Anaesthesiology 1976; 67: 117-20.

Schmid ER , Von Segesser LK , Hossli G. , Turina M. Akzidentelle hypothermie: Wiedererwärmung mit extrakorporaler Zirkulation . Anaesthesist 1989; 38: 120-24.

Bennet J. , Hill J. , Long W. et al. Biocompatible circuits: an adjunct to non-cardiac extracorporeal cardiopulmonary support. J Extracorporeal Technol 1992;24:6-11.

Von Segesser LK , Lachat M. , Turina M. , Gallino A. , Van Felten A. , Pei P. Cardiopulmonary bypass with low systemic heparinization: an experimental study. Perfusion 1990; 5: 267-76.

10.

Von Segesser LK , Weiss BM , Colman E. et al. Coagulation patterns in perfusion with low systemic heparinization. J Extracorporeal Technol 1992; 23: 80-85.

11.

Bindslew L. , Eklund J. , Norlander D. et al. Treatment of acute respiratory failure by extracorporeal carbon dioxide elimination performed with a surface heparinized artificial lung. Anaesthesiology 1987; 67: 117-20.

12.

Arén C. Heparin and protamine during cardiac surgery. Perfusion 1989; 4: 171-81.

13.

Shanberge JN , Murato M. , Quattrociocchi-Longe T. , Van Neste L. Heparin-protamine complexes in the production of heparin rebound and other complications of extra-corporeal bypass procedures. Am J Clin Pathol 1987; 2: 210-16.

14.

Horrow JC Protamine allergy. J Cardiothorac Surg 1988 ; 2: 225-42.

15.

Shapira N. , Schaff HV , Piehler JM , White RD , Sill JC , Pluth JR Cardiovascular effects of protamine sulfate in man. J Cardiovasc Surg 1982; 84: 505-14.

16.

Just-Viera JD , Fischer CR , Gago O. , Mooris JD Acute reaction to protamine. Am Surg 1984; 50: 52-60.

17.

Young JA , Kisker CT , Doty DB Adequate anticoagulants during cardiopulmonary bypass determined by activated clotting time and the appearance of fibrin monomer. Ann Thorac Surg 1978; 26: 231-40 .

18.

Tanaka K. , Takao M. , Yada I. et al. Alterations in coagulation and fibrinolysis associated with cardiopulmonary bypass during open heart surgery. J Cardiothorac Anesth 1989; 3: 181-88.

19.

Pearson DT Bleeding following open-heart surgery. Perfusion 1990; 5 (suppl): 53-56.

20.

Harloff M. , Taraskiewicz J. , Fotouhi C. Comparison study of the Hepcon system four and the hemostasis management system . J Extracorporeal Technol 1992; 23: 43-46.