We measured act 3 minutes after the initial administration of heparin and considered act values 400 seconds as appropriate for safe initiation of cpb. Indian j anaesth serial online 2017 cited 2020 may 15. Attenuation of hemostatic activation is a central goal during cpb. Management of coagulation during cardiopulmonary bypass. Failure to attain the target act raises concerns that the patient is not fully anticoagulated and initiating cardiopulmonary bypass may result in excessive activation of the. In patients with heparin induced thrombocytopenia hit, heparin resistance, or. Management of heparin resistance during cardiopulmonary bypass. Is the use of albumin in colloid prime solution of.
Emergency cardiac surgery and heparin resistance in a. Heparin resistance is defined as the need for more than 35 000 units in a 24hour period to prolong activated ptt in the therapeutic range. Hydroxyethyl starch versus ringer solution in cardiopulmonary. A treatment strategy of a difficult and unusual problem is presented. Impaired heparin responsiveness or heparin resistance is often the result of patientspeci. A 66yearold man with thrombocytosis was brought to our hospital to undergo removal of a left ventricular thrombus. Blood tests on admission revealed his platelet count to be 124. Heparin resistance occurs in up to 22% of patients undergoing cardiopulmonary bypass, and 65% of these cases are secondary to atiii deficiency. Basics of cardiopulmonary bypass sarkar m, prabhu v indian. We are reporting a case of a patient who had a documented allergy to heparin and required cardiac surgery for an asd closure. The effects of etomidate and propofol induction on.
Antithrombin levels during pediatric cardiopulmonary. In our study we compared the ringer solution, which is the standard prime solution of our department, with the hes hydroxyethyl starch 0. Patients with heparininduced thrombocytopenia are at high risk for thromboembolic complications. Challenges encountered with argatroban anticoagulation during cardiopulmonary bypass. Ppt cardiopulmonary bypass powerpoint presentation free. Optimal heparin dosing regimens for cardiopulmonary bypass heparin dosing the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. This blood has the advantage of not having undergone clotting factor destruction or platelet activation on cardiopulmonary bypass 52. The xaxisshows the value for target act before instituting cpb, and the yaxis shows the percentage of sites reporting that. History the first operation performed using cardiopulmonary bypass and open cardiotomy was on april 5, 1951 by dr. Monitoring heparin in patients with a lupus anticoagulant. Target activated clotting time act before instituting cardiopulmonary bypass cpb. Complications from heparininduced thrombocytopenia in. Management of heparin resistance during cardiopulmonary.
Ppt cardiopulmonary bypass powerpoint presentation. We surveyed society of cardiovascular anesthesiologists members regarding anticoagulation practices for cardiopulmonary bypass and attitudes on heparin. One exception is the situation of antithrombin iii deficiency, a state of heparin resistance. Heparin infusion may cause heparin resistance and may affect monitoring by. Management of coagulation during cardiopulmonary bypass bja. Depending on the specific definition used, the reported incidence of heparin resistance during cardiac surgery ranges from 4% to 26% table 1. The present investigation was performed to assess different strategies of managing patients with heparin resistance during cpb. This was following four years of experiments with dogs. Determination of risk factors for heparin resistance. Heparin pretreatment does not alter heparin requirements during. In addition, there is exposure of blood to air and tf in the wound and recirculation of this blood via cardiotomy suction. An accurate perfusion record must be maintained according to an established protocol. During cardiopulmonary bypass procedures, systemic anticoagulation to prevent thrombosis in the patient as well as the circuit is utilized.
Antithrombin iii levels in the children were the most predictive r 0. After approval from the institute ethics committee hundred american society of anesthesiologists asa grade ii or iii patients undergoing scheduled coronary artery bypass surgery on. Heparin in the dose of 04 mgkg was administered prior to initiation of cpb. The urgent removal operation was performed under general anesthesia. Treating heparin resistance with antithrombin or fresh. Resistance to heparin was determined to be present when greater than 600 ukg body weight of heparin failed to prolong the kaolinactivated clotting time to more than 600 seconds. Introduction cardiopulmonary bypass cpb is a form of extracorporeal circulation in which the patients blood is diverted from the heart and lungs and rerouted outside of the body. Decreased heparin responsiveness, frequently termed heparin resistance, is an area that lacks consensus in either diagnosis or treatment.
However, this poses a problem in patients insensitive to heparin. Understanding heparin resistance in cardiac surgery full. The diminished activated clotting time response to heparin, in patients receiving preoperative heparin therapy, poses difficulties when attempting to provide adequate anticoagulation for cardiopulmonary bypass. Heparin resistance during cardiopulmonary bypass the journal of. Guidelines for using bivalirudin during cardiopulmonary. Heparin resistance occurs in up to 22% of patients under going cardiac surgery requiring cardiopulmonary bypass and it is associated with decreased levels of antithrombin.
Antithrombin iii concentrate to treat heparin resistance in. Heparin resistance during cardiopulmonary bypass request pdf. Group 3 patients received an initial heparin dose of 400 ukg and additional heparin whenever the whole blood heparin concentration was below 4. Heparin clearance heparinbinding proteins factor viii. Because approximately one quarter of the patients exhibited heparin resistance without prior heparin therapy, larger studies will also be necessary to delineate the effect of the authors therapy. September 26, 1996 essentials and guidelines for perfusion practice of the american society of extracorporeal circulation essential i. He had developed cerebral infarction 6 days before presenting to the hospital and suffered from right incomplete hemiparalysis. Resistance to heparin was determined to be present when greater than 600 ukg body weight of heparin failed to prolong the. Current data suggest that heparin resistance is not observed when highdose thrombin time is used to monitor anticoagulation and that a.
Heparin resistance during cardiopulmonary bypass sciencedirect. Despite heparin anticoagulation, some activation of coagulation still occurs and increases with the duration of cpb. May 15, 2012 understanding heparin resistance in cardiac surgery the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Using the proposed formula, administered heparin dose was 241 27 iukg and target act was achieved in 86. List the complications and their likely underlying mechanisms specifically related to cardiopulmonary bypass that may be seen in the intensive care unit following cardiac surgery. Treatment options for heparin resistance include adminis tration of antithrombin or fresh frozen plasma. The answer offered by the college lists the complications according to the systems they have. Resistance to heparin therapy during cardiopulmonary bypass cpr is an infrequent yet potentially catastrophic occurrence. Anticoagulation for cardiac surgery in patients receiving pr. The effect of five different anticoagulation strategies on hemostatic activation. Heparin resistance and anticoagulation failure in a. Use of heparin during cardiopulmonary bypass in patients. Heparin dose for accurate anticoagulation in cardiac surgery. P mar 25, 2019 cardiopulmonary bypass cpb replaces the function of the heart and lungs while the heart is arrested to provide a bloodless, stable surgical field.
This report indicates that rhirudin provides effective anticoagulation, however unless ect is monitoring, post. Antiinflammatory effects of heparin and its derivatives. Cardiopulmonary bypass cpb is a technique in which a machine temporarily takes over the function of the heart and lungs during surgery, maintaining the circulation of blood and the oxygen content of the patients body. Additional doses of heparin during cardiopulmonary bypass should be determined by.
Optimal heparin dosing regimens for cardiopulmonary bypass. Anticoagulation for cardiac surgery in patients receiving. The condition has been defined as the failure to achieve the desired activated clotting time act. The act is used to monitor heparin levels during cardiopulmonary bypass, with the aim of achieving an act time 480 s 5, which is normally achieved with a 300 400 iu kg1 loading dose of ufh. The technique allows the surgical team to oxygenate and circulate the patients blood, thus allowing the surgeon to operate on the heart. Evaluation of a new formula for calculating heparin dose for. The availability of heparinbonded extracorporeal circuits has engendered clinical management controversies that test the clinicians knowledge and judgement. Heart c3a and endothelin cause coronary constriction. Treating heparin resistance with antithrombin or fresh frozen. The mean time from initial exposure to heparin to time of cardiopulmonary bypass was 4. Anticoagulation management and heparin resistance during. Atiii deficiency may be either inherited or acquired table 2. Average resistance during cardiopulmonary bypass of the study groups in the normothermia and hypothermia periods.
Volatile anesthetics versus total intravenous anesthesia for cardiac surgery. Lepirudin as an alternative to heparin allergy during. Heparin clearance heparin binding proteins factor viii levels. Up to 20% of the patients undergoing cardiothoracic surgery with cardiopulmonary bypass using unfractionated heparin ufh for anticoagulation experience heparin resistance.
Learn vocabulary, terms, and more with flashcards, games, and other study tools. There has been a little bit of confusion over how to define heparin resistanceor alterations to heparin dose responsivenessbut the standard definition is an act of less than 480 seconds after 500 ukg of heparin. To observe the protective effect of heparincoated circuits hcc on the platelet function during cardiopulmonary bypass cpb. The incidence of heparin resistance during adult cardiac surgery with cardiopulmonary bypass has been reported at 15%20%. While the use of this machine during the surgery has been beneficial in stopping the. The purpose of this report is to describe the clinical use of antithrombin iii concentrate in 53 patients who were found, in the operating room before cardiopulmonary bypass, to be heparin resistant. Evaluation of a new formula for calculating heparin dose. Guidelines for using bivalirudin during cardiopulmonary bypass surgery during cardiopulmonary bypass procedures, systemic anticoagulation to prevent thrombosis in the patient as well as the circuit is utilized. Antithrombin levels during pediatric cardiopulmonary bypass. Understanding heparin resistance in cardiac surgery. This may be due to atiii deficiency or increased protein binding of heparin. As discussed, antithrombin is depleted with heparin, and it has been measured at as low as 20% to 30% during cpb. Two or three times the usual dose of heparin may be required to produce.
Altered heparin response with failure to achieve target act may be seen in some patients, with response to additional doses of heparin ultimately achieving the target act. The effects of cardiopulmonary bypass on coagulation. Heparin, used clinically as an anticoagulant, also has antiinflammatory properties. Contact activation occurs on foreign surfaces within the bypass circuit. Hemostasis and cardiopulmonary bypass springerlink. Protein binding is variable and increases in acute illness. Heparin resistance occurs in up to 22% of patients undergoing cardiac surgery requiring cardiopulmonary bypass and it is associated with decreased levels of antithrombin. Example of oxygenator resistance monitored in patient 1a by the operating room data integration system. The anticoagulation regime used during cardiopulmonary bypass was lepirudin based. Heparin resistance can be defined as a need for higher than usual doses of heparin to achieve adequate anticoagulation.
Heparininduced thrombocytopenia is caused by heparinrelated and plateletactivatin. In many operations, such as coronary artery bypass grafting cabg, the heart is arrested i. Typically, blood is gravity drained from the heart and lungs to a reservoir via venous cannulation and tubing, and returned oxy. Basics of cardiopulmonary bypass sarkar m, prabhu v. Heparin resistance patients requiring large amounts of heparin to achieve a therapeutic aptt 35,000 units daily cardiopulmonary bypass surgery. This relates to question 1 from the second paper of 2011, and the identical question 2 from the first paper of 2015. Pdf heparin levels and cardiopulmonary bypass researchgate. Lung complement increases pulmonary capillary permeability. Understanding heparin resistance in cardiac surgery the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. The adverse effects of the cardiopulmonary bypass machine. Heparin resistance during cardiac surgery is defined as the inability of an adequate heparin dose to increase the activated clotting time act to the desired level. Cardio pulmonary bypass circulatory system atrium heart. Cardio pulmonary bypass free download as powerpoint presentation.
Antithrombin iii concentrate to treat heparin resistance. Heparin resistance is failure to achieve target act despite high doses of heparin 800. Treatment options for heparin resistance include administration of antithrombin or fresh frozen plasma. This report indicates that rhirudin provides effective anticoagulation, however unless ect is monitoring. Anticoagulation management and heparin resistance during car.
Patients in groups 1 and 2 received an initial heparin dose of 200 or 300 ukg and additional heparin during cardiopulmonary bypass whenever the activated clotting time was below 400 seconds. Although the formula assumes activated clotting time act to be within normal range, baseline act varies in each patient. Management during cardiopulmonary bypass heparin resistance during cardiac surgery is defined as the inability of an adequate heparin dose to. Alternatively, heparin resistance can be better defined by a decreased heparin dose response hdr curve. The normal physiologic functions of the heart and lungs, including circulation of blood, oxygenation, and ventilation, are temporarily taken over by the cpb machine. Challenges with heparinbased anticoagulation during. The system heparin dose was 3 mgkg in the control group n15 and heparincoated circuits in the hcc group n8. Heparin resistance is failure to achieve target act despite high doses of heparin 800 ukg. The use of heparin preoperatively 2448 hours is commonly thought to contribute to heparin resistance. Cardiopulmonary bypass is commonly used in operations involving the heart. The hemostatic system is activated during cardiopulmonary bypass cpb procedures, and the use of heparin attenuates the coagulation.
It incorporates an extracorporeal circuit to provide physiological support. Listing a study does not mean it has been evaluated by the u. Jul 12, 2008 in our study we compared the ringer solution, which is the standard prime solution of our department, with the hes hydroxyethyl starch 0. The reported incidence during cpb use ranges from 4% to 26% 4 and is highly dependent on the initial bolus dose of heparin and the desired activated clotting time target for cpb initiation. Heparin is the most common agent used, but in selective circumstances, alternate form of anticoagulation may be considered. However, heparin resistance occurs in between 4 and 22% of patients undergoing cardiac surgery, and the preoperative use of heparin is usually responsible for this. Predictors of heparin resistance before cardiovascular operations. Although hematocrit is not allowed to recover prior to surgery and heparin is administered when the blood is returned, this strategy may be a good. Anticoagulation management during cardiopulmonary bypass. Jan 07, 2008 optimal heparin dosing regimens for cardiopulmonary bypass heparin dosing the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Anticoagulation, argatroban, cardiopulmonary bypass, heparin induced thrombocytopenia, heparin alternative how to cite this article. Heparin resistance was sometimes or always treated with.
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