Anticoagulation management during multivessel coronary artery bypass grafting: a randomized trial comparing individualized heparin management and conventional hemostasis management

作者：Hoenicka M; Rupp P; Mueller Eising K; Deininger S; Kunert A; Liebold A; Gorki H^*

来源：Journal of Thrombosis and Haemostasis, 2015, 13(7): 1196-1206.

DOI：10.1111/jth.12999

• coronary artery bypass grafting
• heparin
• postoperative hemorrhage
• protamine sulfate
• thromboelastography

BackgroundIndividualized heparin management (IHM) uses heparin dose-response curves to improve hemostasis management during cardiac surgery as compared with activated clotting time-based methods.
ObjectivesIHM was compared with conventional hemostasis management (CHM) in a randomized, prospective study (ID DRKS00007580).
MethodsOne-hundred and twenty patients undergoing multivessel coronary artery bypass grafting (CABG) were enrolled. Heparin and protamine consumption, blood losses, blood transfusions and administration of hemostatic agents were recorded. Time courses of platelet counts and of coagulation parameters were determined. Coagulation was analyzed at intensive care unit (ICU) arrival by thromboelastometry.
ResultsIHM patients received significantly lower initial heparin doses (289.3IUkg(-1) [interquartile range (IQR)221.5-376.2IUkg(-1)] versus 350.5IUkg(-1) [IQR346.8-353.7IUkg(-1)], P<0.0001) but similar total heparin doses (418.5IUkg(-1) [IQR346.9-590.5 IUkg(-1)] versus 435.8IUkg(-1) [IQR411.7-505.1IUkg(-1)]). IHM patients received significantly less protamine, resulting in protamine/total heparin ratios of 0.546 [IQR0.469-0.597] versus 0.854 [IQR0.760-0.911] in CHM patients (P<0.0001). Activated partial thromboplastin time (50.5s [IQR40.0-60.0s] versus 37.0s [IQR33.0-40.0s], P<0.0001), activated clotting time (136s [IQR129.0-150.5s] versus 126.5s [IQR120.3-134.0s], P=0.0002) and INTEM clotting times (215s [IQR192-237] versus 201s [IQR191-216s], P=0.0397) were significantly longer in IHM patients than in CHM patients at ICU arrival, with no difference in prothrombin time (P=0.538). IHM patients lost significantly more blood within 12h postoperatively (420mL [IQR337.5-605.0mL] versus 345mL [IQR230.0-482.5mL], P=0.0041), and required significantly more hemostatic agents to control bleeding. Red blood cell transfusion requirements and time courses of platelet counts did not differ between groups.
ConclusionsMultivessel CABG patients did not benefit from IHM in comparison with our established protocol based on activated clotting time.

• 出版日期2015-7