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Thromb Haemost 1996; 76(06): 0902-0908
DOI: 10.1055/s-0038-1650684
Original Article
Schattauer GmbH Stuttgart

More Effective Suppression of Hemostatic System Activation in Patients Undergoing Cardiac Surgery by Heparin Dosing Based on Heparin Blood Concentrations rather than ACT

George J Despotis
The Departments of Anesthesiology, Internal Medicine, Pathology, Washington University School of Medicine, St. Louis
,
J Heinrich Joist
2   Departments of Internal Medicine and Pathology, St. Louis University School of Medicine, St. Louis
,
Charles W Hogue Jr
The Departments of Anesthesiology, Internal Medicine, Pathology, Washington University School of Medicine, St. Louis
,
Alexander Alsoufiev
The Departments of Anesthesiology, Internal Medicine, Pathology, Washington University School of Medicine, St. Louis
,
D Joiner-Maier
2   Departments of Internal Medicine and Pathology, St. Louis University School of Medicine, St. Louis
,
Samuel A Santoro
The Departments of Anesthesiology, Internal Medicine, Pathology, Washington University School of Medicine, St. Louis
,
Edward Spitznagel
3   Department of Mathematics, Washington University, St. Louis, MO, USA
,
Jeffrey I Weitz
4   Department of Medicine, McMaster University & Hamilton Civic Hospitals Research Center, Hamilton, Ontario, Canada
,
Lawrence T Goodnough
The Departments of Anesthesiology, Internal Medicine, Pathology, Washington University School of Medicine, St. Louis
› Author Affiliations
Further Information

Publication History

Received 10 April 1996

Accepted after resubmission 19 August 1996

Publication Date:
11 July 2018 (online)

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Summary

This study was designed to determine whether the maintenance of higher than usual patient-specific heparin concentrations during cardiopulmonary bypass (CPB) was associated with more effective suppression of hemostasis system activation.

Thirty-one patients scheduled for repeat cardiac sugery or combined procedures (i.e., coronary revascularization + valve repair/replacement) were consented and enrolled in this study. All patients received porcine heparin and protamine and were randomly assigned to monitoring of anticoagulation by either celite ACT alone (Control, n = 16) or by kaolin ACT combined with on-site measurements of whole blood heparin concentration (Intervention, n = 15). Blood specimens collected before administration of heparin, before weaning from CPB and after administration of protamine were analyzed with a battery of coagulation assays.

Patients in the intervention cohort received appreciably greater heparin doses than control patients, resulting in higher anti-Xa heparin levels at the end of CPB. Fibrinopeptide A and D-dimer levels were higher in the control group before discontinuation of CPB. Percent decrease during CPB were greater in the control group for factors V and VIII, fibrinogen and antithrombin III. Percent decrease in complement 3 was greater in the control group after protamine and bleeding times measured in the Intensive Care Unit were significantly more prolonged in this group.

Maintenance of higher patient-specific heparin concentrations during CPB more effectively suppresses excessive hemostatic system activation than do standard heparin doses chosen based on measurement of ACT. These findings may explain, at least in part, the significant reduction in perioperative blood loss and blood product use when higher heparin concentrations are maintained.

 

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