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Paediatr Anaesth. 2013 Mar;23(3):233-41. doi: 10.1111/pan.12109. Epub 2013 Jan 2.

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

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1
Division of Pediatric Anesthesiology and Pain Medicine, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA. nischal.gautam@gmail.com

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.

PMID:
23279140
DOI:
10.1111/pan.12109
[Indexed for MEDLINE]
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