Keywords
thromboelastometry
pediatric cardiac surgery
How to Cite
Abstract
Introduction: Correct management of heparinization, hemostasisand signs of coagulopathy are challenging in neonates undergoing cardiovascular surgery (CVS). Aim: To evaluate hemostasis and heparinization monitoring of neonatal patients weighing <5 kg undergoing CVS with viscoelastic (VT) and conventional laboratory (CL) tests. Methodology: Single center retrospective study that included consecutive neonates undergoing CVS (October-2020 to September-2021) were included. Surgery stages: basal (B), extracorporeal circulation (ECC) and post protamine (PostProt). VT: ROTEM® delta thromboelastometry (Instrumentation Laboratory, IL). CL: PT % activity (PT%), APTT, fibrinogen, thrombin time (TT), platelet count (PLT), antithrombin (AT) and antifactor Xa activity (AntiXa) analyzed immediately post heparinization (PostHep), in ECC and PostProt. CL measurement in ACL TOP coagulometer with Werfen reagents. PLT: HemoCell DXH800 (Beckman Coulter). ACT: performed by using ACT Plus (Medtronic) in the operating room to guide heparinization. Results were expressed as median (interquartile range, IQR). Statistics: SPSS 23 software. Results: Patients: 32 (24 men). Age: 19(6-25) days; weight: 3380 (3082-3785) grams. CT (clotting time) and CFT (clot formation time) of EXTEM, INTEM, FIBTEM and HEPTEM were significantly prolonged and A5, A10, MCF (firmness) were lower in ECC compared to B and Post- Prot (p<0.001). PT% were lower and APTT higher in PostProt compared to B. ECC presented the lowest PLT. AT in B: 0.56 (IQR: 0.46-0.68) IU/mL, no patient received AT supplements. Median AntiXa was 6.8 (5.4-7.9) and 5.3 (4.1-6.9) in PostHep and ECC, respectively. PostProt antiXa 0.1(0.03-0.33), 9/32 >0.2U/mL. AntiXa correlated significantly with EXTEM CT and ACT in ECC, with AntiXa >6 U/mL being found in 10/32 patients, but only with TT in PostProt. However, PostProt ACT correlated with PT%, APTT, INTEM and HEPTEM CT and the HEPTEMCT/ INTEMCT ratio. The median of postoperative bleeding at 12 hours was 50 (28-91) mL, significantly correlating only with antiXa, and TT in PostProt, and additionally with the total heparin infused. Conclusions The control of antiXa would allow a better heparinization during surgery and estimation of residual heparin in PostProt, which correlated with increased bleeding, not detected by PC (except for moderate prolongations of TT), CT of PV or ACT. This strategy could be useful to avoid excesses in the amount of heparin infused that would be associated with increased bleeding.
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