INTRAOPERATIVE ANTICOAGULATION MONITORIZATION IN VASCULAR SURGERY – DOES A BLIND DOSIS FITS ALL?
Autor(a) principal: | |
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Data de Publicação: | 2019 |
Outros Autores: | , , , , , , , , , , , , |
Tipo de documento: | Artigo |
Idioma: | eng |
Título da fonte: | Repositório Científico de Acesso Aberto de Portugal (Repositórios Cientìficos) |
Texto Completo: | https://doi.org/10.48750/acv.159 |
Resumo: | Introduction: Unfractionated heparin (UFH) has been used for decades to prevent thrombotic events during vascular surgery. Although it is known that UFH has a complex and nonlinear pharmacokinetics, with great individual variability, anticoagulation monitorization in vascular surgery is not routine and a standard empirical dose is often used. Activated clotting time (ACT) has been shown to be a simple, reliable and inexpensive way to monitor UFH anticoagulant effect, being routinely used during cardiac surgery. However, heparinisation remains a dilemma in vascular surgery and few studies emphasized the role of anticoagulation monitoring in this setting.Objectives: To investigate whether a fixed heparin dose of 5000 IU in arterial vascular surgery results in adequate and homogeneous heparinisation in all patients. Secondary endpoints: to identify preoperative factors for heparin response, intraoperative events and outcomes.Methods: This observational prospective pilot study included 30 consecutive patients undergoing arterial vascular surgery. ACT monitoring was performed before clamping and at 3, 30 and 60 minutes after 5000 IU UFH bolus. Preoperative and intraoperative data were also accessed. A target ACT of ≥ 200 s was set, taking in account of the lowest ACT value admitted by vascular surgery recommendations.Results: The average ACT value increased to 210.20 ± 28.82 s (1.61 ± 0.25 times vs baseline) 3 minutes after bolus, then declined to 191.60 ± 21.86 s and 173.4 ± 21.37 s after 30 and 60 minutes, respectively. Three minutes after UFH bolus, 53% patients had ACT ≥ 200 s, decreasing to one third and 7% at 30 and 60 minutes, respectively. Even when weight-based, a correlation between heparin dose per kilogram and ACT change was not found (r = 0.187; p = 0.322). There was also no correlation between ACT values and preoperative hemoglobin, platelet count, creatinine clearance or INR. There was a positive correlation between preoperative aPTT and intraoperative ACT measurements (r = 0.432; p = 0.017). There was no difference between ACT values and previous antithrombotic/anticoagulant therapy and between intraoperative ACT and intraoperative blood loss.Conclusions: This study confirms that administrating a fixed or even a weight-based heparinisation is insufficient to provide consistent anticoagulation levels in all patients. Perioperative anticoagulation should be monitored and ACT-based. Larger clinical RCT's are warranted. |
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INTRAOPERATIVE ANTICOAGULATION MONITORIZATION IN VASCULAR SURGERY – DOES A BLIND DOSIS FITS ALL?MONITORIZAÇÃO INTRAOPERATÓRIA DA ANTICOAGULAÇÃO EM CIRURGIA VASCULAR – UMA DOSE CEGA SERVE PARA TODOS?unfractionated heparinheparinization monitoringactivated clotting timeanticoagulation monitorizationvascular surgeryheparina não fracionadamonitorização intraoperatória da anticoagulaçãoactivated clotting timecirurgia vascularIntroduction: Unfractionated heparin (UFH) has been used for decades to prevent thrombotic events during vascular surgery. Although it is known that UFH has a complex and nonlinear pharmacokinetics, with great individual variability, anticoagulation monitorization in vascular surgery is not routine and a standard empirical dose is often used. Activated clotting time (ACT) has been shown to be a simple, reliable and inexpensive way to monitor UFH anticoagulant effect, being routinely used during cardiac surgery. However, heparinisation remains a dilemma in vascular surgery and few studies emphasized the role of anticoagulation monitoring in this setting.Objectives: To investigate whether a fixed heparin dose of 5000 IU in arterial vascular surgery results in adequate and homogeneous heparinisation in all patients. Secondary endpoints: to identify preoperative factors for heparin response, intraoperative events and outcomes.Methods: This observational prospective pilot study included 30 consecutive patients undergoing arterial vascular surgery. ACT monitoring was performed before clamping and at 3, 30 and 60 minutes after 5000 IU UFH bolus. Preoperative and intraoperative data were also accessed. A target ACT of ≥ 200 s was set, taking in account of the lowest ACT value admitted by vascular surgery recommendations.Results: The average ACT value increased to 210.20 ± 28.82 s (1.61 ± 0.25 times vs baseline) 3 minutes after bolus, then declined to 191.60 ± 21.86 s and 173.4 ± 21.37 s after 30 and 60 minutes, respectively. Three minutes after UFH bolus, 53% patients had ACT ≥ 200 s, decreasing to one third and 7% at 30 and 60 minutes, respectively. Even when weight-based, a correlation between heparin dose per kilogram and ACT change was not found (r = 0.187; p = 0.322). There was also no correlation between ACT values and preoperative hemoglobin, platelet count, creatinine clearance or INR. There was a positive correlation between preoperative aPTT and intraoperative ACT measurements (r = 0.432; p = 0.017). There was no difference between ACT values and previous antithrombotic/anticoagulant therapy and between intraoperative ACT and intraoperative blood loss.Conclusions: This study confirms that administrating a fixed or even a weight-based heparinisation is insufficient to provide consistent anticoagulation levels in all patients. Perioperative anticoagulation should be monitored and ACT-based. Larger clinical RCT's are warranted.Introdução: A heparina não fracionada (HNF) tem sido usada desde há décadas na Cirurgia Vascular como medida preventiva de fenómenos tromboembólicos. A sua farmacocinética complexa e não linear, associada a grande variabilidade individual, está amplamente documentada. Contudo, a monitorização da anticoagulação não é realizada por rotina em Cirurgia Vascular e uma dose standardé muitas vezes utilizada. O activated clotting time (ACT)tem mostrado ser uma forma simples, confiável e barata de monitorizar o efeito da HNF, sendo usado por rotina durante a cirurgia cardíaca. Contudo, a heparinização e a sua monitorização mantém-se um dilema em Cirurgia Vascular e são escassos os estudos que enfatizam a importância da monitorização. Objetivos: analisar se uma dose fixa de HNF (5000 UI) usada durante cirurgia vascular resulta numa heparinização adequada e homogénea em todos os doentes. Métodos: Este estudo observacional e prospetivo incluiu 30 doentes sujeitos a cirurgia arterial. A monitorização do efeito da HNF foi realizada através de medições consecutivas do ACT (antes da clampagem e 3, 30 e 60 minutos após o bólus de heparina). Dados pré-, intra-procedimento e pós-cirurgia foram também analisados. Dada a inexistência de guidelinesou recomendações concordantes quanto ao valor de ACT adequado para cirurgia arterial, foi tido em conta o menor valor referido nas diversas recomendações analisadas (ACT ³200 s). Resultados: Aos 3 minutos constatou-se um ACT médio de 210.20 ±28.82 s (1.61 ±0.05 vezes o ACT basal). Após esta medição verificou-se um declínio para os 191.60 ±21.86 s e 173.4 ±21.37 s após 30 e 60 minutos, respetivamente. Três minutos após o bólusde heparina, apenas 53% dos doentes atingiram o ACT alvo, diminuindo esta percentagem para um terço aos 30 e apenas 7% aos 60 minutos. Mesmo quando ajustada ao peso, não se verificou uma correlação estatisticamente significativa entre a dose de heparina (UI/Kg) e o ACT medido após o bólus(r= 0.187; p= 0.322). Também não se constatou uma correlação entre os valores de ACT obtidos e os valores pré-cirurgia de hemoglobina, plaquetas, clearance de creatinina e INR. Verificou-se uma correlação positiva entre o valor de aPTT pré-intervenção e os valores de ACT medidos. Não houve diferença entre os valores de ACT obtidos e a toma previa de antiagregantes e anticoagulantes bem como também não houve diferença entre os valores de ACT alcançados e as perdas sanguíneas intraoperatórias. Conclusão: Este estudo vem demonstrar que quer regime de heparinização baseado numa dose fixe, quer baseado no peso são insuficientes para proporcionar uma anticoagulação adequada a todos os doentes sugerindo que heparinização intraoperatória deve ser monitorizada e guiada de acordo com os valores de ACT obtidos. São necessários mais estudos para definer as reais implicações da monitorização, os seus benefícios e as ações requeridas quando confrontados com determinado valor de ACT.Sociedade Portuguesa de Angiologia e Cirurgia Vascular2019-05-15T00:00:00Zinfo:eu-repo/semantics/publishedVersioninfo:eu-repo/semantics/articleapplication/pdfhttps://doi.org/10.48750/acv.159oai:ojs.acvjournal.com:article/159Angiologia e Cirurgia Vascular; Vol. 14 No. 4 (2018): December; 301-306Angiologia e Cirurgia Vascular; Vol. 14 N.º 4 (2018): Dezembro; 301-3062183-00961646-706Xreponame:Repositório Científico de Acesso Aberto de Portugal (Repositórios Cientìficos)instname:Agência para a Sociedade do Conhecimento (UMIC) - FCT - Sociedade da Informaçãoinstacron:RCAAPenghttp://acvjournal.com/index.php/acv/article/view/159https://doi.org/10.48750/acv.159http://acvjournal.com/index.php/acv/article/view/159/116Copyright (c) 2019 Angiologia e Cirurgia Vascularinfo:eu-repo/semantics/openAccessCoelho, Nuno HenriquesLaranja Pontes, RaquelSilva, RitaMartins, VictorOliveira, CármenCampos, JacintaSousa, PedroCoelho, AndreiaAugusto, RitaSemião, CarolinaPinto, EveliseRibeiro, JoãoCanedo, AlexandraBentes, Carla2022-05-23T15:10:03Zoai:ojs.acvjournal.com:article/159Portal AgregadorONGhttps://www.rcaap.pt/oai/openaireopendoar:71602024-03-19T14:57:33.240796Repositório Científico de Acesso Aberto de Portugal (Repositórios Cientìficos) - Agência para a Sociedade do Conhecimento (UMIC) - FCT - Sociedade da Informaçãofalse |
dc.title.none.fl_str_mv |
INTRAOPERATIVE ANTICOAGULATION MONITORIZATION IN VASCULAR SURGERY – DOES A BLIND DOSIS FITS ALL? MONITORIZAÇÃO INTRAOPERATÓRIA DA ANTICOAGULAÇÃO EM CIRURGIA VASCULAR – UMA DOSE CEGA SERVE PARA TODOS? |
title |
INTRAOPERATIVE ANTICOAGULATION MONITORIZATION IN VASCULAR SURGERY – DOES A BLIND DOSIS FITS ALL? |
spellingShingle |
INTRAOPERATIVE ANTICOAGULATION MONITORIZATION IN VASCULAR SURGERY – DOES A BLIND DOSIS FITS ALL? Coelho, Nuno Henriques unfractionated heparin heparinization monitoring activated clotting time anticoagulation monitorization vascular surgery heparina não fracionada monitorização intraoperatória da anticoagulação activated clotting time cirurgia vascular |
title_short |
INTRAOPERATIVE ANTICOAGULATION MONITORIZATION IN VASCULAR SURGERY – DOES A BLIND DOSIS FITS ALL? |
title_full |
INTRAOPERATIVE ANTICOAGULATION MONITORIZATION IN VASCULAR SURGERY – DOES A BLIND DOSIS FITS ALL? |
title_fullStr |
INTRAOPERATIVE ANTICOAGULATION MONITORIZATION IN VASCULAR SURGERY – DOES A BLIND DOSIS FITS ALL? |
title_full_unstemmed |
INTRAOPERATIVE ANTICOAGULATION MONITORIZATION IN VASCULAR SURGERY – DOES A BLIND DOSIS FITS ALL? |
title_sort |
INTRAOPERATIVE ANTICOAGULATION MONITORIZATION IN VASCULAR SURGERY – DOES A BLIND DOSIS FITS ALL? |
author |
Coelho, Nuno Henriques |
author_facet |
Coelho, Nuno Henriques Laranja Pontes, Raquel Silva, Rita Martins, Victor Oliveira, Cármen Campos, Jacinta Sousa, Pedro Coelho, Andreia Augusto, Rita Semião, Carolina Pinto, Evelise Ribeiro, João Canedo, Alexandra Bentes, Carla |
author_role |
author |
author2 |
Laranja Pontes, Raquel Silva, Rita Martins, Victor Oliveira, Cármen Campos, Jacinta Sousa, Pedro Coelho, Andreia Augusto, Rita Semião, Carolina Pinto, Evelise Ribeiro, João Canedo, Alexandra Bentes, Carla |
author2_role |
author author author author author author author author author author author author author |
dc.contributor.author.fl_str_mv |
Coelho, Nuno Henriques Laranja Pontes, Raquel Silva, Rita Martins, Victor Oliveira, Cármen Campos, Jacinta Sousa, Pedro Coelho, Andreia Augusto, Rita Semião, Carolina Pinto, Evelise Ribeiro, João Canedo, Alexandra Bentes, Carla |
dc.subject.por.fl_str_mv |
unfractionated heparin heparinization monitoring activated clotting time anticoagulation monitorization vascular surgery heparina não fracionada monitorização intraoperatória da anticoagulação activated clotting time cirurgia vascular |
topic |
unfractionated heparin heparinization monitoring activated clotting time anticoagulation monitorization vascular surgery heparina não fracionada monitorização intraoperatória da anticoagulação activated clotting time cirurgia vascular |
description |
Introduction: Unfractionated heparin (UFH) has been used for decades to prevent thrombotic events during vascular surgery. Although it is known that UFH has a complex and nonlinear pharmacokinetics, with great individual variability, anticoagulation monitorization in vascular surgery is not routine and a standard empirical dose is often used. Activated clotting time (ACT) has been shown to be a simple, reliable and inexpensive way to monitor UFH anticoagulant effect, being routinely used during cardiac surgery. However, heparinisation remains a dilemma in vascular surgery and few studies emphasized the role of anticoagulation monitoring in this setting.Objectives: To investigate whether a fixed heparin dose of 5000 IU in arterial vascular surgery results in adequate and homogeneous heparinisation in all patients. Secondary endpoints: to identify preoperative factors for heparin response, intraoperative events and outcomes.Methods: This observational prospective pilot study included 30 consecutive patients undergoing arterial vascular surgery. ACT monitoring was performed before clamping and at 3, 30 and 60 minutes after 5000 IU UFH bolus. Preoperative and intraoperative data were also accessed. A target ACT of ≥ 200 s was set, taking in account of the lowest ACT value admitted by vascular surgery recommendations.Results: The average ACT value increased to 210.20 ± 28.82 s (1.61 ± 0.25 times vs baseline) 3 minutes after bolus, then declined to 191.60 ± 21.86 s and 173.4 ± 21.37 s after 30 and 60 minutes, respectively. Three minutes after UFH bolus, 53% patients had ACT ≥ 200 s, decreasing to one third and 7% at 30 and 60 minutes, respectively. Even when weight-based, a correlation between heparin dose per kilogram and ACT change was not found (r = 0.187; p = 0.322). There was also no correlation between ACT values and preoperative hemoglobin, platelet count, creatinine clearance or INR. There was a positive correlation between preoperative aPTT and intraoperative ACT measurements (r = 0.432; p = 0.017). There was no difference between ACT values and previous antithrombotic/anticoagulant therapy and between intraoperative ACT and intraoperative blood loss.Conclusions: This study confirms that administrating a fixed or even a weight-based heparinisation is insufficient to provide consistent anticoagulation levels in all patients. Perioperative anticoagulation should be monitored and ACT-based. Larger clinical RCT's are warranted. |
publishDate |
2019 |
dc.date.none.fl_str_mv |
2019-05-15T00:00:00Z |
dc.type.status.fl_str_mv |
info:eu-repo/semantics/publishedVersion |
dc.type.driver.fl_str_mv |
info:eu-repo/semantics/article |
format |
article |
status_str |
publishedVersion |
dc.identifier.uri.fl_str_mv |
https://doi.org/10.48750/acv.159 oai:ojs.acvjournal.com:article/159 |
url |
https://doi.org/10.48750/acv.159 |
identifier_str_mv |
oai:ojs.acvjournal.com:article/159 |
dc.language.iso.fl_str_mv |
eng |
language |
eng |
dc.relation.none.fl_str_mv |
http://acvjournal.com/index.php/acv/article/view/159 https://doi.org/10.48750/acv.159 http://acvjournal.com/index.php/acv/article/view/159/116 |
dc.rights.driver.fl_str_mv |
Copyright (c) 2019 Angiologia e Cirurgia Vascular info:eu-repo/semantics/openAccess |
rights_invalid_str_mv |
Copyright (c) 2019 Angiologia e Cirurgia Vascular |
eu_rights_str_mv |
openAccess |
dc.format.none.fl_str_mv |
application/pdf |
dc.publisher.none.fl_str_mv |
Sociedade Portuguesa de Angiologia e Cirurgia Vascular |
publisher.none.fl_str_mv |
Sociedade Portuguesa de Angiologia e Cirurgia Vascular |
dc.source.none.fl_str_mv |
Angiologia e Cirurgia Vascular; Vol. 14 No. 4 (2018): December; 301-306 Angiologia e Cirurgia Vascular; Vol. 14 N.º 4 (2018): Dezembro; 301-306 2183-0096 1646-706X reponame:Repositório Científico de Acesso Aberto de Portugal (Repositórios Cientìficos) instname:Agência para a Sociedade do Conhecimento (UMIC) - FCT - Sociedade da Informação instacron:RCAAP |
instname_str |
Agência para a Sociedade do Conhecimento (UMIC) - FCT - Sociedade da Informação |
instacron_str |
RCAAP |
institution |
RCAAP |
reponame_str |
Repositório Científico de Acesso Aberto de Portugal (Repositórios Cientìficos) |
collection |
Repositório Científico de Acesso Aberto de Portugal (Repositórios Cientìficos) |
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Repositório Científico de Acesso Aberto de Portugal (Repositórios Cientìficos) - Agência para a Sociedade do Conhecimento (UMIC) - FCT - Sociedade da Informação |
repository.mail.fl_str_mv |
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1799129848881348608 |