Baykut D, Weichelt K, Wehrle J, Zerkowski H-R, Bernet F
Division of Cardio-Thoracic Surgery, University of Clinics Basel, Switzerland.
Eur J Med Res. 2003 Apr 30;8(4):161-4.
BACKGROUND/OBJECTIVE: In recent years, a remarcable increase in off-pump coronary bypass surgery (OPCAB) was observed. The identical anticoagulation treatment in cardiac surgery with cardiopulmonary bypass (CPB) and OPCAB makes the hemodynamic management in OPCAB procedures essential, since a perioperative compensation of blood loss is difficult and the hemodynamic stability has to be maintained by infusions. The aim of this study was to evaluate the circulating heparin concentration measurement in OPCAB patients by using the heparin/protamine titration method with Hepcon/HMSplus (HMS).
In 8 patients (3F/5M) undergoing elective OPCAB, the calculated heparin dose was administered and heparin concentration was registered together with activated clotting time (ACT) 5 min after administration. Measurements were carried out in 45 min periods and additional heparin was administered if the measured heparin concentration was lower than the calculated. The protamin dose was also automatically calculated by HMS.
The mean operation time was 155 +/- 36 min (80-210) with 2.3 bypass grafts per patient. There was a significant difference between the demand for heparin as determined by HMS and the conventionally calculated value (p<0.05). Similarly, the calculated and measured concentration of heparin diverged significantly from each other (p<0.05), independent of ACT. In spite of an initially higher administration of heparin as calculated by HMS, the concentration of circulating heparin was below the estimated value in 7 patients which made a further administration of heparin necessary. The 24 h postoperative blood loss was 550 +/- 176 mL (300-850). No rethoracotomy for bleeding was necessary.
HMS could be a useful method for appropriate anticoagulative treatment in OPCAB procedures, if there is a sufficient hemodynamic management with restrictive administration of infusions guaranted during surgery.
背景/目的：近年来，非体外循环冠状动脉搭桥手术（OPCAB）的数量显著增加。由于在非体外循环心脏手术中围手术期失血的补偿困难且必须通过输液维持血流动力学稳定，因此在体外循环（CPB）心脏手术和OPCAB中采用相同的抗凝治疗使得OPCAB手术中的血流动力学管理至关重要。本研究的目的是通过使用Hepcon/HMSplus（HMS）肝素/鱼精蛋白滴定法评估OPCAB患者循环肝素浓度的测量。
8例（3例女性/5例男性）接受择期OPCAB的患者，给予计算出的肝素剂量，并在给药后5分钟记录肝素浓度及活化凝血时间（ACT）。每45分钟进行一次测量，如果测得的肝素浓度低于计算值，则追加肝素。鱼精蛋白剂量也由HMS自动计算。
平均手术时间为155±36分钟（80 - 210分钟），每位患者平均进行2.3次搭桥。HMS测定的肝素需求量与传统计算值之间存在显著差异（p<0.05）。同样，肝素的计算浓度和测量浓度彼此也有显著差异（p<0.05），与ACT无关。尽管最初按照HMS计算给予了较高剂量的肝素，但7例患者的循环肝素浓度低于估计值，因此需要进一步给予肝素。术后24小时失血量为550±176毫升（300 - 850毫升）。无需因出血进行再次开胸手术。
如果在手术期间能保证通过限制输液进行充分的血流动力学管理，HMS可能是OPCAB手术中进行适当抗凝治疗的有用方法。
