Adequate Anticoagulation During Cardiopulmonary Bypass Determined by Activated Clotting Time and the Appearance of Fibrin Monomer

Young, J. A.; Kisker, C. Thomas; Doty, Donald B.

doi:10.1016/s0003-4975(10)63676-4

Cited by 239 publications

(83 citation statements)

References 22 publications

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“…Perhaps the relatively low ACT target contributed to the lack of identification of heparin-resistant patients. Historically, CPB has been initiated with higher ACTs to give a margin of safety 28 and in many studies, a large number of patients diagnosed as heparin resistant had target ACTs >400 seconds. [5][6][7][8]13,14 Definitions of heparin resistance based on a dose of heparin to achieve a specific target ACT such as requiring >500 IU/kg to achieve a target ACT of 480 seconds assume linearity of the HDR.…”

Section: Discussionmentioning

confidence: 99%

Heparin Dose Response Is Independent of Preoperative Antithrombin Activity in Patients Undergoing Coronary Artery Bypass Graft Surgery Using Low Heparin Concentrations

&NA;

2011

Survey of Anesthesiology

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Section: Discussionmentioning

confidence: 99%

Heparin Dose Response Is Independent of Preoperative Antithrombin Activity in Patients Undergoing Coronary Artery Bypass Graft Surgery Using Low Heparin Concentrations

&NA;

2011

Survey of Anesthesiology

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“…In patients receiving aprotinin a target of 750 sec or more should be used. Reinterpretation of the results from Young et al 15 suggests that a safer threshold of more than 750 sec should, probably, be used in the majority of patients.…”

Section: S90mentioning

confidence: 97%

“…The 400-sec target is supported by an animal study demonstrating that fibrin monomers were produced when the Hemochron® celite ACT was less than 400 sec. 15 Of note, preservation of fibrinogen and platelets at the end of CPB was improved significantly in animals with an ACT > 750 sec. A target value of 400-480 sec has been proposed only for the Hemochron®-based instrument.…”

Section: S90mentioning

confidence: 97%

Antithrombotic therapy in cardiac surgery

Vincentelli

Jude

Bélisle

2006

Can J Anesth/J Can Anesth

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Purpose: To review the perioperative management of antithrombotic therapy in cardiac surgery, including the management of cardiopulmonary bypass (CPB) and off-pump surgery.Methods: A review of the relevant English literature over the period was undertaken, in addition to a review of international practices in antithrombotic therapy in cardiac surgery. Principal findings:Cardiopulmonary bypass is required in most procedures and makes anticoagulation mandatory. Anticoagulation is, usually, achieved with unfractionnated heparin (UFH). Unfractionated heparin is monitored by point-ofcare (POC) testing, such as the activated clotting time or the determination of heparin concentration. The target values of both tests remain empirical, with no clearly validated thresholds. The target value needs to be adjusted according to the POC test, given significant variations between devices and activators. After CABG, the need for antiplatelet therapy is well demonstrated, in order to limit the risk of postoperative death or ischemic events, and improve venous graft patency. Immediately after valvular surgery, antithrombotic therapy should take into account the specific risk carried by each patient and by each prosthetic device. The risk of venous thromboembolism, though poorly defined, is also present in the postoperative period and may require additional attention. Given the frequent exposure to UFH, occurrence of heparininduced thrombocytopenia is not infrequent in these patients and requires careful individual management. Conclusions:Antithrombotic therapy is an essential component of cardiac surgery. Yet, with the exception of antiplatelet agents in CABG patients, antithrombotic therapy is often based on the clinical experience of medical teams more than on an evidence-based assessment of the literature. Objectif Constatations principales : La circulation extracorporelle est nécessaire pour la majorité des opérations et rend l'anticoagulation obligatoire. L'anticoagulation est, habituellement, réalisée avec de l'héparine non fractionnée (HNF). L'HNF est contrôlée par des tests faits au chevet du malade comme le temps de coagulation activée ou la détermination de la concentration d'héparine. Les valeurs cible des deux tests demeurent empiriques, sans valeurs seuil clairement validées. La valeur cible doit être ajustée en fonction de chaque test de chevet à cause des variations significatives entre les instruments et les activateurs. Après le pontage aortocoronarien (PAC), la nécessité d'un traitement antiplaquettaire a été bien démontrée, qui vise à limiter les décès postopératoires ou les incidents ischémiques et à améliorer la

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“…In an initial group of 18 patients (13 with coronary grafts and five with valve replacement), blood samples were obtained during the period of extracorporeal circulation, usually early (first 30 minutes) and again later during bypass. Survey of these patients served as a pilot study and, as detailed below, led to examination of a second group of 13 patients who had frequent blood samples obtained serially, with particular attention to the time of collection during bypass.…”

Section: Cardiopulmonary Bypass Patientsmentioning

confidence: 99%

Elevated plasma fibrinopeptide A and thromboxane B2 levels during cardiopulmonary bypass.

1980

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SUMMARY Patients who underwent operations in which cardiopulmonary bypass was used had elevations of plasma fibrinopeptide A which did not return to normal during bypass despite conventional heparin anticoagulation, suggesting inadequate heparin dosage and continued thrombin activity during the operation. Patients who underwent aortocoronary artery grafting had high plasma thromboxane B2 levels and a rapid fall in platelet count at the onset of extracorporeal circulation. Thromboxane elevations were less marked in patients who underwent valve replacement. Platelet aggregation and coronary artery constriction secondary to thromboxane production may contribute to the morbidity of cardiopulmonary bypass.CARDIOPULMONARY BYPASS is attended by risks of thromboembolism, hemorrhage and myocardial ischemia during surgery and in the immediate postoperative period, and many of its complications appear to result from interaction of blood components with the extracorporeal circuit.' We studied the effect of cardiopulmonary bypass on coagulation and platelet activation and consumption by measuring plasma levels of fibrinopeptide A (FpA) and thromboxane B2 (TxB2).FpA is a 16-amino-acid peptide cleaved from the Aa chains of fibrinogen by thrombin.2 Radioimmunoassay of FpA in plasma provides a sensitive index of in vivo thrombin activity.3 FpA is physiologically active, leading in experimental animals to changes in pulmonary blood flow, heart rate, stroke volume,4 and vascular permeability.5 Cardiopulmonary changes during respiratory distress syndrome, thromboembolism, septicemia, endotoxic shock and cardiopulmonary bypass4 have been attributed to FpA.TxA2, a product of platelet arachidonic acid metabolism, is the most potent known stimulant of platelet aggregation. In experimental animals TxA, causes profound coronary vasoconstriction, myocardial ischemia and infarction and death.6 7 TxA2 production, with resulting microembolization and vasospasm, could lead to myocardial ischemia during cardiopulmonary bypass. The substance is highly unstable, with a half-life of only 30 seconds,8 but it has a stable metabolite, thromboxane B2 (TxB2), for which a radioimmunoassay is available.9From the

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Adequate Anticoagulation During Cardiopulmonary Bypass Determined by Activated Clotting Time and the Appearance of Fibrin Monomer

Cited by 239 publications

References 22 publications

Heparin Dose Response Is Independent of Preoperative Antithrombin Activity in Patients Undergoing Coronary Artery Bypass Graft Surgery Using Low Heparin Concentrations

Heparin Dose Response Is Independent of Preoperative Antithrombin Activity in Patients Undergoing Coronary Artery Bypass Graft Surgery Using Low Heparin Concentrations

Antithrombotic therapy in cardiac surgery

Elevated plasma fibrinopeptide A and thromboxane B2 levels during cardiopulmonary bypass.

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