Dietrich W, Spannagl M, Schramm W, Vogt W, Barankay A, Richter J A
Institute for Anesthesiology, German Heart Center, Munich.
J Thorac Cardiovasc Surg. 1991 Oct;102(4):505-14.
The effect of preoperative anticoagulant therapy on intraoperative heparin response in patients undergoing cardiac operations was examined in a prospective study. The study included 45 patients with different preoperative anticoagulant treatments: 10 patients received treatment with phenprocoumon (a warfarin analogue) (group M), 12 patients received treatment with intravenous heparin (group Hiv), and 13 patients received treatment with subcutaneous heparin (group Hsc). The control group consisted of 10 patients who did not receive anticoagulant therapy before operation (group C). Preoperative antithrombin III activity was highest in group M (85% +/- 6%) and lowest in group Hiv (70% +/- 15%, p less than 0.05). The activated clotting time, determined 10 minutes after bolus injection of 250 IU (group M) or 375 IU heparin (all other groups), was 529 +/- 109 seconds in group C, greater than 1000 seconds in group M, 483 +/- 99 seconds in group Hsc, and 406 +/- 63 seconds in group Hiv (p less than 0.05). Heparin consumption during cardiopulmonary bypass varied between 4.6 +/- 1.4 IU/kg.min (group Hiv) and 2.6 +/- 0.9 IU/kg.min (group M) (p less than 0.05). Despite this increased heparin consumption, the patients who had received heparin before operation demonstrated increased activation of coagulation at the end of cardiopulmonary bypass (thrombin-antithrombin III complex, 19 +/- 4.1 ng/ml in group M and 61 +/- 7 ng/ml in group Hsc, p less than 0.05; cross-linked fibrin fragments, 257 +/- 92 ng/ml in group M and 875 +/- 152 ng/ml in group Hiv, p less than 0.05). Increased platelet activation was also found in patients with preoperative heparin therapy (beta-thromboglobulin at the end of cardiopulmonary bypass was 585 +/- 88 ng/ml in group M versus 1341 +/- 190 ng/ml in group Hsc, p less than 0.05). Drainage from the chest tube 24 hours after operation was 815 +/- 305 ml in group C, 644 +/- 238 ml in group M, 1133 +/- 503 ml in group Hsc, and 950 +/- 505 ml in group Hiv (p less than 0.05 for group M versus group Hsc). This study suggests that patients who receive heparin therapy before operation face a high risk of insufficient anticoagulation during cardiopulmonary bypass if standard heparin doses are used. Therefore, for patients who receive preoperative heparin therapy, a larger (500 IU/kg) initial bolus of heparin is recommended before cardiopulmonary bypass. On the other hand, patients who undergo preoperative treatment with phenprocoumon receive sufficient anticoagulative effect with a heparin bolus of 250 IU/kg.(ABSTRACT TRUNCATED AT 400 WORDS)
一项前瞻性研究探讨了术前抗凝治疗对接受心脏手术患者术中肝素反应的影响。该研究纳入了45例接受不同术前抗凝治疗的患者：10例接受苯丙香豆素（一种华法林类似物）治疗（M组），12例接受静脉肝素治疗（Hiv组），13例接受皮下肝素治疗（Hsc组）。对照组由10例术前未接受抗凝治疗的患者组成（C组）。术前抗凝血酶III活性在M组最高（85%±6%），在Hiv组最低（70%±15%，p<0.05）。在静脉推注250IU肝素（M组）或375IU肝素（其他所有组）10分钟后测定的活化凝血时间，C组为529±109秒，M组大于1000秒，Hsc组为483±99秒，Hiv组为406±63秒（p<0.05）。体外循环期间肝素消耗量在4.6±1.4IU/kg·min（Hiv组）至2.6±0.9IU/kg·min（M组）之间变化（p<0.05）。尽管肝素消耗量增加，但术前接受肝素治疗的患者在体外循环结束时凝血激活增加（凝血酶-抗凝血酶III复合物，M组为19±4.1ng/ml，Hsc组为61±7ng/ml，p<0.05；交联纤维蛋白片段，M组为257±92ng/ml，Hiv组为875±152ng/ml，p<0.05）。术前接受肝素治疗的患者还出现血小板活化增加（体外循环结束时β-血小板球蛋白，M组为585±88ng/ml，Hsc组为1341±190ng/ml，p<0.05）。术后24小时胸腔引流液量，C组为815±305ml，M组为644±238ml，Hsc组为1133±503ml，Hiv组为950±505ml（M组与Hsc组相比，p<0.05）。本研究表明，如果使用标准肝素剂量，术前接受肝素治疗的患者在体外循环期间面临抗凝不足的高风险。因此，对于术前接受肝素治疗的患者，建议在体外循环前给予较大剂量（500IU/kg）的初始肝素推注。另一方面，术前接受苯丙香豆素治疗的患者给予250IU/kg的肝素推注可获得足够的抗凝效果。（摘要截短至400字）
