Pro: Activated Clotting Time Should Be Monitored During Heparinization For Vascular Surgery

Goldhammer, Jordan E.; Zimmerman, Darin

doi:10.1053/j.jvca.2017.04.047

Cited by 15 publications

(9 citation statements)

References 15 publications

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“…Evidence suggests that avoiding allogenic blood product transfusions reduces postoperative morbidity and mortality, which results in more conservative transfusion thresholds for hemoglobin (7 g/dL). In the absence of active bleeding and acute myocardial ischemia, or concern for spinal cord ischemia, a restrictive transfusion strategy to maintain hemoglobin at more than 7 g/dL is recommended [ 89 , 99 ].…”

Section: Hematologic Complicationsmentioning

confidence: 99%

Postoperative Intensive Care Management of Aortic Repair

Paulis

Arlotta

Calabrese

et al. 2022

JPM

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Vascular surgery patients have multiple comorbidities and are at high risk for perioperative complications. Aortic repair surgery has greatly evolved in recent years, with an increasing predominance of endovascular techniques (EVAR). The incidence of cardiac complications is significantly reduced with endovascular repair, but high-risk patients require postoperative ST-segment monitoring. Open aortic repair may portend a prohibitive risk of respiratory complications that could be a contraindication for surgery. This risk is greatly reduced in the case of an endovascular approach, and general anesthesia should be avoided whenever possible in the case of endovascular repair. Preoperative renal function and postoperative kidney injury are powerful determinants of short- and long-term outcome, so that preoperative risk stratification and secondary prevention are critical tasks. Intraoperative renal protection with selective renal and distal aortic perfusion is essential during open repair. EVAR has lower rates of postoperative renal failure compared to open repair, with approximately half the risk for acute kidney injury (AKI) and one-third of the risk of hemodialysis requirement. Spinal cord ischemia used to be the most distinctive and feared complication of aortic repair. The risk has significantly decreased since the beginning of aortic surgery, with advances in surgical technique and spinal protection protocols, and is lower with endovascular repair. Endovascular repair avoids extensive aortic dissection and aortic cross-clamping and is generally associated with reduced blood loss and less coagulopathy. The intensive care physician must be aware that aortic repair surgery has an impact on every organ system, and the importance of early recognition of organ failure cannot be overemphasized.

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Section: Hematologic Complicationsmentioning

confidence: 99%

Postoperative Intensive Care Management of Aortic Repair

Paulis

Arlotta

Calabrese

et al. 2022

JPM

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“…This ACT measurement could ensure the individual patient of safe, tailor-made periprocedural anticoagulation. (16)(17)(18)(19)(20)(21)(22)(23). This should lead to better results of procedures, with improved patient-related outcomes and less harm for the patient {6b}.…”

Section: Background {6a}mentioning

confidence: 99%

ACTION-1: study protocol for a randomised controlled trial on ACT guided heparinization during open abdominal aortic aneurysm repair {1}

Wiersema

Roosendaal

Koelemaij

et al. 2021

Preprint

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BackgroundHeparin is used worldwide for 70 years during all non-cardiac arterial procedures (NCAP) to reduce thrombo-embolic complications (TEC). But heparin also increases blood loss causing possible harm for the patient. Heparin has an unpredictable effect in the individual patient. The Activated Clotting Time (ACT) can measure the effect of heparin. Currently this ACT is not measured during NCAP as standard of care, contrary to during cardiac interventions, open and endovascular. A RCT will evaluate if ACT guided heparinization results in less TEC than the current standard: a single bolus of 5 000 IU of heparin and no measurements at all. A goal ACT of 200-220 seconds should be reached during ACT guided heparinization and this should decrease (mortality caused by) TEC, while not increasing major bleeding complications. This RCT will be executed during open abdominal aortic aneurysm (AAA) surgery, as this is a standardized procedure throughout Europe.MethodsSeven-hundred-fifty patients, who will undergo open AAA repair of an aneurysm originating below the superior mesenteric artery, will be randomised in 2 treatment arms: 5 000 IU of heparin and no ACT measurements and no additional doses of heparin, or a protocol of 100 IU/kg bolus of heparin and ACT measurements after 5 min., and then every 30 min. Goal ACT is 200-220 sec. If the ACT after 5 min. is < 180 sec. 60 IU/kg will be administered, if the ACT is between 180 and 200 sec. 30 IU/kg. If the ACT is > 220 sec. no extra heparin is given, and the ACT is measured after 30 minutes and then the same protocol is applied. The expected incidence for the combined endpoint of TEC and mortality is 19% for the 5 000 IU group and 11% for the ACT guided group.DiscussionThe ACTION-1 trial is an international RCT during open AAA surgery, designed to show superiority of ACT guided heparinization compared to the current standard of a single bolus of 5 000 IU of heparin. A significant reduction in TEC and mortality, without more major bleeding complications, must be proven with a relevant economic benefit.Trial registration {2a}NTR: NL8421Clinicaltrials.gov: NCT04061798. Date of registration: 20-08-2019. https://clinicaltrials.gov/ct2/show/NCT04061798?cond=NCT04061798&draw=2&rank=1 EudraCT: 2018-003393-27

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“…The activated clotting time (ACT) can be used to measure the anticoagulant effect of heparin in the individual patient. 13 Little clinical data is available defining the optimal peri-procedural ACT associated with the lowest number of ATEC and bleeding complications in NCAP. 1 Studies on interventions of the carotid artery recommend a target ACT of 200 -250 s during carotid endarterectomy (CEA) and a target ACT of 250 -300 s during carotid stenting.…”

Section: Introductionmentioning

confidence: 99%