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The Journal of Thoracic and Cardiovascular Surgery, Vol 99, 518-527, Copyright © 1990 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
GP Gravlee, WS Haddon, HK Rothberger, SA Mills, AT Rogers, VE Bean, DH Buss, DS Prough and AR Cordell
Subclinical plasma coagulation during cardiopulmonary bypass has been
associated with marked platelet and clotting factor consumption in monkeys.
To better define subclinical coagulation in man, we measured plasma
fibrinopeptide A concentrations before, during, and after cardiopulmonary
bypass. Patients were assigned to one of three groups of heparin
management: group 1 (n = 10)--initial heparin dose 300 IU/kg, with
supplemental heparin if the activated coagulation time fell below 400
seconds; group 2 (n = 6)--initial heparin dose 250 IU/kg, with supplemental
heparin if activated coagulation time was less than 400 seconds; and group
3 (n = 5)--initial heparin dose 350 to 400 IU/kg, with supplemental heparin
if whole blood heparin concentration was less than or equal to 4.1 IU/ml.
Activated coagulation time and heparin concentration were measured every 30
minutes during cardiopulmonary bypass, and fibrinopeptide A was measured at
hypothermia, normothermia, and whenever activated coagulation time was less
than 400 seconds. Quantitative and qualitative blood clotting competence
was assessed after cardiopulmonary bypass, including mediastinal drainage
for the first 24 hours. Fibrinopeptide A values were markedly elevated
during cardiopulmonary bypass but were well below the levels present before
and after cardiopulmonary bypass. Fibrinopeptide A correlated inversely
with heparin concentration during cardiopulmonary bypass (r = -0.46, p =
0.03), but higher fibrinopeptide A levels during cardiopulmonary bypass did
not correlate with post- cardiopulmonary bypass coagulopathy. Group 3
patients received the highest heparin doses (p less than 0.05) and had the
greatest postoperative blood loss (p less than 0.05). Protamine dose and
heparin concentration during cardiopulmonary bypass correlated best with
postoperative mediastinal drainage. Our findings support the following
conclusions: (1) compensated subclinical plasma coagulation activity occurs
during cardiopulmonary bypass despite activated coagulation time greater
than 400 seconds or heparin concentration greater than or equal to 4.1
IU/ml; (2) post-cardiopulmonary bypass mediastinal drainage correlates
strongly with increased heparin concentration during cardiopulmonary bypass
(p less than 0.05) and protamine dose (p less than 0.05); and (3) during
cardiopulmonary bypass at both normothermia and hypothermia, activated
coagulation times greater than 350 seconds result in acceptable
fibrinopeptide A levels and post-cardiopulmonary bypass blood clotting.
ARTICLES
Heparin dosing and monitoring for cardiopulmonary bypass. A comparison of techniques with measurement of subclinical plasma coagulation
Wake Forest University, Department of Anesthesia, Bowman Gray School of Medicine, Winston-Salem, NC 27103.
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L. H. Edmunds Jr Surface-bound heparin--Panacea or peril? Ann. Thorac. Surg., August 1, 1994; 58(2): 285 - 286. [PDF]
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L. K. v. Segesser, B. M. Weiss, M. Pasic, E. Garcia, and M. I. Turina Risk and benefit of low systemic heparinization during open heart operations Ann. Thorac. Surg., August 1, 1994; 58(2): 391 - 398. [Abstract] [PDF]
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C. Prentice, M. Orchard, and C. Goodchild Haemostatic dysfunction and cardiopulmonary bypass: mechanisms and therapeutic choices Perfusion, May 1, 1993; 8(1_suppl): 28 - 35. [Abstract] [PDF]
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A. G Hill, R. C Groom, B. F Akl, E. A Lefrak, and M. Kurusz Current paediatric perfusion practice in North America Perfusion, January 1, 1993; 8(1): 27 - 38. [PDF]
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