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  • Title: Heparinase thromboelastography compared with activated coagulation time for protamine titration after cardiopulmonary bypass.
    Author: Levin AI, Heine AM, Coetzee JF, Coetzee A.
    Journal: J Cardiothorac Vasc Anesth; 2014 Apr; 28(2):224-9. PubMed ID: 24461364.
    Abstract:
    OBJECTIVE: The present study is a comparison of two point-of-care (POC) tests as endpoints of protamine titration after CPB. The authors hypothesized that using the heparinase-kaolin thromboelastography (TEG-HK) R-time difference would more readily identify residual heparin necessitating additional protamine than when using activated coagulation time (ACT). The primary endpoint was the between-group difference in protamine dose. Whether this approach would lessen postoperative bleeding and sequelae also was investigated. DESIGN: Single center, blinded, prospective, randomized study. SETTING: University teaching hospital. PARTICIPANTS: Eighty-two adult patients for on-pump coronary artery bypass and/or valve surgery. INTERVENTIONS: Patients were randomized. In the ACT group, protamine was titrated until ACT did not exceed baseline by more than 10%. In the TEG group, a TEG-HK R-time difference less than 20% was targeted. Protamine was repeated to achieve the endpoints. Clinicians in the ACT group were blinded to TEG data and vice versa. MEASUREMENTS AND MAIN RESULTS: There was no between-group difference in total protamine dose (3.9 ± 0.6 and 4.2 ± 0.7; 95% CI of the difference between means: -0.544 to 0.008 mg/kg; p = 0.057) or protamine:heparin ratios (1.3:1 and 1.4:1; 95% CI of the difference between means: -0.05 to 0.03 mg/mg; p = 0.653). In the ACT group, 17% of patients required a second protamine dose, and in the TEG group, 24% of patients required a second protamine dose. No between-group differences in the postoperative transfusion requirements or intensive care unit length of stay were demonstrated. CONCLUSION: No difference was identified in protamine dosing using either ACT or TEG-HK R-time difference as endpoints. Heparinase TEG may be useful for monitoring heparin reversal.
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