Heparin titration protocol with tranexamic acid in cardiac surgery: a pilot study

Year 2021, Volume: 5 Issue: 3, 282 - 288, 31.12.2021

Başak Soran Türkcan , Ertekin Utku Ünal , Erman Kiriş Bahadır Aytekin , Bekir Akkaya Z.aslı Demir , Aslıhan Aykut Ayşen Aksöyek Levent Bırıncıoğlu

https://doi.org/10.30565/medalanya.956769

Abstract

Aim: Postoperative bleeding related to cardiac surgery is a clinically important condition. Consequently, re-exploration and increased blood utilization lead to adverse outcomes. The aim of this pilot study was to assess the effect of a newly adapted blood conservation strategy, including heparin titration protocol along with antifibrinolytics, regarding to mediastinal bleeding, re-exploration for bleeding and blood and blood products utilization.

Methods: This study included 100 patients undergoing cardiac surgery with higher risk for bleeding, such as mitral valve replacement, aortic valve replacement, ascending / arcus aortic surgery, between January 2015 and August 2016. The study group consisted of consecutive patients who underwent new protocol (heparin titration protocol + tranexamic acid). The control group consisted of patients who were administered standard dose heparin(4 mg/kg). Fifty patients in each group (with the new protocol and the standard protocol) were compared by means of amount of heparin applied, blood utilization, mediastinal drainage and rate of re-exploration.

Results: Twenty-eight of the 50 study group patients (56%) received a red blood cell (RBC) transfusion for the first 24 hours. RBC transfusion ≥ 3 units was lower in the study group (34% vs 54%; p=0.044). Moreover, mediastinal drainage and blood utilization was found to be lower at the study group, however re-exploration rates remained similar.

Conclusion: Based on our study results, the suggested heparin titration protocol seemed to be beneficial for reducing postoperative bleeding and blood product usage. We consider that blood utilization protocols like our heparin titration protocol should be established to reduce the need for blood transfusion in cardiac surgery.

Keywords

Cardiac Surgery, heparin titration, tranexamic acid, blood transfusion,, drainage,

Kalp Cerrahisinde Traneksamik Asit ile Beraber Heparin Titrasyon Protokolü Kullanımına Yönelik Bir Pilot Çalışma

Abstract

Amaç: Kalp cerrahisi ile ilişkili postoperatif kanama klinik olarak önemli bir durumdur. Sonuç olarak, reeksplorasyon ve artan kan kullanımı olumsuz sonuçlara yol açar. Bu pilot çalışmanın amacı, mediastinal kanama, kanama sebepli reeksplorasyon ve kan-kan ürünü kullanımına ilişkin antifibrinolitikler ile birlikte heparin titrasyon protokolünü içeren yeni uyarlanmış bir kan koruma stratejisinin etkisini değerlendirmektir.

Yöntemler: Bu çalışmaya Ocak 2015 ile Ağustos 2016 tarihleri arasında mitral kapak replasmanı, aort kapak replasmanı, asendan/arkus aort cerrahisi gibi kanama riski daha yüksek kalp cerrahisi geçiren 100 hasta dahil edilmiştir. Çalışma grubu yeni protokol uygulanan ardışık hastalardan oluşmaktadır.(heparin titrasyon protokolü+traneksamik asit) Kontrol grubu ise standart doz heparin (4 mg/kg) uygulanan hastalardan oluşmaktadır.Her gruptaki 50 hasta (yeni protokol ve standart protokol) uygulanan heparin miktarı, kan-kan ürünü kullanımı, mediastinal drenaj ve reeksplorasyon açısından karşılaştırıldı.

Bulgular: Çalışma grubundaki 50 hastanın 28’i (%56) ilk 24 saat boyunca kırmızı kan hücresi (RBC) transfüzyonu aldı. 3 üniteden fazla RBC transfüzyonu alan hasta sayısı çalışma grubunda daha düşüktü. (%34’e karşı %54; p=0.044). Ayrıca reeksplorasyon oranları benzer olarak bulundu.

Sonuç: Sonuç olarak, çalışma sonuçlarımıza göre önerilen heparin titrasyon protokolünün postoperative kanama ve kan ürünü kullanımını azaltmada faydalı olduğu görülmektedir. Kalp cerrahisinde kan transfüzyonu ihtiyacını azaltmak için heparin titrasyon protokolü gibi kan kullanım protokollerinin oluşturulması gerektiğini düşünüyoruz. 

Keywords

kalp cerrahisi, traneksamik asit, heparin titrasyonu, drenaj,, kan transfüzyonu,

References

• 1. Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011;91(3):944-82. PMID: 21353044.
• 2. Sapiano MRP, Savinkina AA, Ellingson KD, Haass KA, Baker ML, Henry RA et al. Supplemental findings from the National Blood Collection and Utilization Surveys, 2013 and 2015. Transfusion. 2017;57(Suppl 2):1599-1624. PMID: 28591471.
• 3. D'Agostino RS, Jacobs JP, Badhwar V, Paone G, Rankin JS, Han JM et al. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2016 Update on Outcomes and Quality. Ann Thorac Surg. 2016;101(1):24-32. PMID: 26616408.
• 4. Fassl J, Matt P, Eckstein F, Filipovic M, Gregor M, Zenklusen U et al. Transfusion of allogeneic blood products in proximal aortic surgery with hypothermic circulatory arrest: effect of thromboelastometry-guided transfusion management. J Cardiothorac Vasc Anesth. 2013;27(6):1181-8. PMID: 23962459.
• 5. Vivacqua A, Koch CG, Yousuf AM, Nowicki ER, Houghtaling PL, Blackstone EH, et al. Morbidity of bleeding after cardiac surgery: is it blood transfusion, reoperation for bleeding, or both? Ann Thorac Surg. 2011;91(6):1780-90. PMID: 21619974.
• 6. Shander A, Javidroozi M, Ozawa S, Hare GM. What is really dangerous: anaemia or transfusion? Br J Anaesth. 2011;107(1):41-59. PMID: 22156270.
• 7. Engoren M, Habib RH, Hadaway J, Zacharias A, Schwann TA, Riordan CJ, et al. The effect on long-term survival of erythrocyte transfusion given for cardiac valve operations. Ann Thorac Surg. 2009;88(1):95-100. PMID: 19559202.
• 8. Karkouti K, Wijeysundera DN, Yau TM, Beattie WS, Abdelnaem E, McCluskey SA, et al. The independent association of massive blood loss with mortality in cardiac surgery. Transfusion. 2004;44(10):1453-62. PMID: 15383018.
• 9. Hodgson S, Larvin JT, Dearman C. What dose of tranexamic acid is most effective and safe for adult patients undergoing cardiac surgery? Interact Cardiovasc Thorac Surg. 2015;21(3):384-8. PMID: 26015509.
• 10. Fergusson DA, Hébert PC, Mazer CD, Fremes S, MacAdams C, Murkin JM et al. BART Investigators. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med. 2008;358(22):2319-31. PMID: 18480196.
• 11. DeSantis SM, Toole JM, Kratz JM, Uber WE, Wheat MJ, Stroud MR et al. Early postoperative outcomes and blood product utilization in adult cardiac surgery: the post-aprotinin era. Circulation. 2011;124(11 Suppl):S62-9. PMID: 21911820.
• 12. Munoz JJ, Birkmeyer NJ, Dacey LJ, Birkmeyer JD, Charlesworth DC, Johnson ER et al. Trends in rates of reexploration for hemorrhage after coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg. 1999;68(4):1321-5. PMID: 10543500.
• 13. Choong CK, Gerrard C, Goldsmith KA, Dunningham H, Vuylsteke A. Delayed re-exploration for bleeding after coronary artery bypass surgery results in adverse outcomes. Eur J Cardiothorac Surg. 2007;31(5):834-8. PMID: 17360191.
• 14. Koch CG, Li L, Duncan AI, Mihaljevic T, Loop FD, Starr NJ et al. Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. Ann Thorac Surg. 2006;81(5):1650-7. PMID: 16631651.
• 15. Koch CG, Li L, Duncan AI, Mihaljevic T, Cosgrove DM, Loop FD et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med. 2006;34(6):1608-16. PMID: 16607235.
• 16. Engoren MC, Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ. Effect of blood transfusion on long-term survival after cardiac operation. Ann Thorac Surg. 2002;74(4):1180-6. PMID: 12400765.
• 17. Barton JC. Nonhemolytic, noninfectious transfusion reactions. Semin Hematol. 1981;18(2):95-121. PMID: 6164098.
• 18. Banbury MK, Brizzio ME, Rajeswaran J, Lytle BW, Blackstone EH. Transfusion increases the risk of postoperative infection after cardiovascular surgery. J Am Coll Surg. 2006;202(1):131-8. PMID: 16377506.
• 19. Despotis GJ, Joist JH, Hogue CW Jr, Alsoufiev A, Kater K, Goodnough LT et al. The impact of heparin concentration and activated clotting time monitoring on blood conservation. A prospective, randomized evaluation in patients undergoing cardiac operation. J Thorac Cardiovasc Surg. 1995;110(1):46-54. PMID: 7609568.
• 20. Jobes DR, Aitken GL, Shaffer GW. Increased accuracy and precision of heparin and protamine dosing reduces blood loss and transfusion in patients undergoing primary cardiac operations. J Thorac Cardiovasc Surg. 1995;110(1):36-45. PMID: 7609566.
• 21. Jobes DR, Schwartz AJ, Ellison N, Andrews R, Ruffini RA, Ruffini JJ. Monitoring heparin anticoagulation and its neutralization. Ann Thorac Surg. 1981;31(2):161-6. PMID: 6970019.
• 22. Mirow N, Brinkmann T, Minami K, Tenderich G, Kleesiek K, Körfer R. Heparin-coated extracorporeal circulation with full and low dose heparinization: comparison of thrombin related coagulatory effects. Artif Organs. 2001;25(6):480-5. PMID: 11453879.
• 23. Garvin S, FitzGerald DC, Despotis G, Shekar P, Body SC. Heparin concentration-based anticoagulation for cardiac surgery fails to reliably predict heparin bolus dose requirements. Anesth Analg. 2010;111(4):849-55. PMID: 19861367.
• 24. Aykut A, Sabuncu Ü, Demir ZA, Balcı E, Soran Türkcan B, Ünal U et al. Heparin dose calculated according to lean body weight during on-pump heart surgery. Turk Gogus Kalp Damar Cerrahisi Derg. 2018;26(4):528-35. PMID: 32082793.
• 25. Boer C, Meesters MI, Veerhoek D, Vonk ABA. Anticoagulant and side-effects of protamine in cardiac surgery: a narrative review. Br J Anaesth. 2018;120(5):914-27. PMID: 29661409.