Impact of protamine dose on activated clotting time and thromboelastography in infants and small children undergoing cardiopulmonary bypass

Nischal K. Gautam, Michael L. Schmitz, Dale Harrison, Luis M. Zabala, Pamela Killebrew, Ryan H. Belcher, Parthak Prodhan, Wesley McKamie, Daniel C. Norvell

Research output: Contribution to journalArticle

13 Citations (Scopus)

Abstract

Objectives: To study the effect of two protamine-dosing strategies on activated clotting time (ACT) and thromboelastography (TEG). Background Protamine dosage based on neutralizing heparin present in the combined estimated blood volumes (EBVs) of the patient and cardiopulmonary bypass (CPB) pump may result in excess protamine and contributes toward a coagulopathy that can be detected by ACT and TEG in pediatric patients. Methods: A total of 100 pediatric patients 1 month to ≤5 years of age undergoing CPB were included in this retrospective before/after design study. Combined-EBV group consisted of 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the combined EBVs of the patient and the pump. Pt-EBV group consisted of the next 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the patient's EBV. Results: Baseline and postprotamine ACTs were similar between groups. Postprotamine heparin assay (Hepcon) showed the absence of residual heparin in both groups. Postprotamine kaolin-heparinase TEG showed that R was prolonged by 7.5 min in the Combined-EBV group compared with the Pt-EBV group (mean R of 20.17 vs 12.4 min, respectively, P < 0.001). Increasing doses of protamine were associated with a corresponding, but nonlinear increase in R. There was no significant difference in the changes for K, alpha, and MA between the groups. Conclusion: Automated protamine titration with a protamine dosage based on Pt-EBV can adequately neutralize heparin as assessed by ACT while minimizing prolonging clot initiation time as measured by TEG.

Original languageEnglish (US)
Pages (from-to)233-241
Number of pages9
JournalPaediatric Anaesthesia
Volume23
Issue number3
DOIs
StatePublished - Mar 2013

Fingerprint

Thrombelastography
Protamines
Blood Volume
Cardiopulmonary Bypass
Heparin
Blood Group Antigens
Heparin Lyase
Pediatrics
Kaolin

Keywords

  • cardiac surgery
  • cardiopulmonary bypass
  • congenital heart disease
  • heparin
  • pediatrics
  • protamine

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine
  • Pediatrics, Perinatology, and Child Health

Cite this

Impact of protamine dose on activated clotting time and thromboelastography in infants and small children undergoing cardiopulmonary bypass. / Gautam, Nischal K.; Schmitz, Michael L.; Harrison, Dale; Zabala, Luis M.; Killebrew, Pamela; Belcher, Ryan H.; Prodhan, Parthak; McKamie, Wesley; Norvell, Daniel C.

In: Paediatric Anaesthesia, Vol. 23, No. 3, 03.2013, p. 233-241.

Research output: Contribution to journalArticle

Gautam, NK, Schmitz, ML, Harrison, D, Zabala, LM, Killebrew, P, Belcher, RH, Prodhan, P, McKamie, W & Norvell, DC 2013, 'Impact of protamine dose on activated clotting time and thromboelastography in infants and small children undergoing cardiopulmonary bypass', Paediatric Anaesthesia, vol. 23, no. 3, pp. 233-241. https://doi.org/10.1111/pan.12109
Gautam, Nischal K. ; Schmitz, Michael L. ; Harrison, Dale ; Zabala, Luis M. ; Killebrew, Pamela ; Belcher, Ryan H. ; Prodhan, Parthak ; McKamie, Wesley ; Norvell, Daniel C. / Impact of protamine dose on activated clotting time and thromboelastography in infants and small children undergoing cardiopulmonary bypass. In: Paediatric Anaesthesia. 2013 ; Vol. 23, No. 3. pp. 233-241.
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abstract = "Objectives: To study the effect of two protamine-dosing strategies on activated clotting time (ACT) and thromboelastography (TEG). Background Protamine dosage based on neutralizing heparin present in the combined estimated blood volumes (EBVs) of the patient and cardiopulmonary bypass (CPB) pump may result in excess protamine and contributes toward a coagulopathy that can be detected by ACT and TEG in pediatric patients. Methods: A total of 100 pediatric patients 1 month to ≤5 years of age undergoing CPB were included in this retrospective before/after design study. Combined-EBV group consisted of 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the combined EBVs of the patient and the pump. Pt-EBV group consisted of the next 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the patient's EBV. Results: Baseline and postprotamine ACTs were similar between groups. Postprotamine heparin assay (Hepcon) showed the absence of residual heparin in both groups. Postprotamine kaolin-heparinase TEG showed that R was prolonged by 7.5 min in the Combined-EBV group compared with the Pt-EBV group (mean R of 20.17 vs 12.4 min, respectively, P < 0.001). Increasing doses of protamine were associated with a corresponding, but nonlinear increase in R. There was no significant difference in the changes for K, alpha, and MA between the groups. Conclusion: Automated protamine titration with a protamine dosage based on Pt-EBV can adequately neutralize heparin as assessed by ACT while minimizing prolonging clot initiation time as measured by TEG.",
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T1 - Impact of protamine dose on activated clotting time and thromboelastography in infants and small children undergoing cardiopulmonary bypass

AU - Gautam, Nischal K.

AU - Schmitz, Michael L.

AU - Harrison, Dale

AU - Zabala, Luis M.

AU - Killebrew, Pamela

AU - Belcher, Ryan H.

AU - Prodhan, Parthak

AU - McKamie, Wesley

AU - Norvell, Daniel C.

PY - 2013/3

Y1 - 2013/3

N2 - Objectives: To study the effect of two protamine-dosing strategies on activated clotting time (ACT) and thromboelastography (TEG). Background Protamine dosage based on neutralizing heparin present in the combined estimated blood volumes (EBVs) of the patient and cardiopulmonary bypass (CPB) pump may result in excess protamine and contributes toward a coagulopathy that can be detected by ACT and TEG in pediatric patients. Methods: A total of 100 pediatric patients 1 month to ≤5 years of age undergoing CPB were included in this retrospective before/after design study. Combined-EBV group consisted of 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the combined EBVs of the patient and the pump. Pt-EBV group consisted of the next 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the patient's EBV. Results: Baseline and postprotamine ACTs were similar between groups. Postprotamine heparin assay (Hepcon) showed the absence of residual heparin in both groups. Postprotamine kaolin-heparinase TEG showed that R was prolonged by 7.5 min in the Combined-EBV group compared with the Pt-EBV group (mean R of 20.17 vs 12.4 min, respectively, P < 0.001). Increasing doses of protamine were associated with a corresponding, but nonlinear increase in R. There was no significant difference in the changes for K, alpha, and MA between the groups. Conclusion: Automated protamine titration with a protamine dosage based on Pt-EBV can adequately neutralize heparin as assessed by ACT while minimizing prolonging clot initiation time as measured by TEG.

AB - Objectives: To study the effect of two protamine-dosing strategies on activated clotting time (ACT) and thromboelastography (TEG). Background Protamine dosage based on neutralizing heparin present in the combined estimated blood volumes (EBVs) of the patient and cardiopulmonary bypass (CPB) pump may result in excess protamine and contributes toward a coagulopathy that can be detected by ACT and TEG in pediatric patients. Methods: A total of 100 pediatric patients 1 month to ≤5 years of age undergoing CPB were included in this retrospective before/after design study. Combined-EBV group consisted of 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the combined EBVs of the patient and the pump. Pt-EBV group consisted of the next 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the patient's EBV. Results: Baseline and postprotamine ACTs were similar between groups. Postprotamine heparin assay (Hepcon) showed the absence of residual heparin in both groups. Postprotamine kaolin-heparinase TEG showed that R was prolonged by 7.5 min in the Combined-EBV group compared with the Pt-EBV group (mean R of 20.17 vs 12.4 min, respectively, P < 0.001). Increasing doses of protamine were associated with a corresponding, but nonlinear increase in R. There was no significant difference in the changes for K, alpha, and MA between the groups. Conclusion: Automated protamine titration with a protamine dosage based on Pt-EBV can adequately neutralize heparin as assessed by ACT while minimizing prolonging clot initiation time as measured by TEG.

KW - cardiac surgery

KW - cardiopulmonary bypass

KW - congenital heart disease

KW - heparin

KW - pediatrics

KW - protamine

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