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Heparin Concentration–Based Anticoagulation for Cardiac Surgery Fails to Reliably Predict Heparin Bolus Dose Requirements

Sean Garvin, MD^*, Daniel C. FitzGerald, CCP, George Despotis, MD^,,||, Prem Shekar, MD, and Simon C. Body, MBChB, MPH^*

From the *Department of Anesthesiology, Perioperative and Pain Medicine, and Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and Departments of Pathology, Immunology, and ||Anesthesiology, Washington University School of Medicine, St. Louis, Missouri.

Address correspondence and reprint requests to Simon C. Body, MBChB, MPH, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02215. Address e-mail to body{at}zeus.bwh.harvard.edu.

Abstract

Background: Hemostasis management has evolved to include sophisticated point-of-care systems that provide individualized dosing through heparin concentration–based anticoagulation. The Hepcon HMS Plus system (Medtronic, Minneapolis, MN) estimates heparin dose, activated clotting time (ACT), and heparin dose response (HDR). However, the accuracy of this test has not been systematically evaluated in large cohorts.

Methods: We examined institutional databases for all patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) at our institution from February 2005 to July 2008. During this period, the Hepcon HMS Plus was used exclusively for assessment of heparin dosing and coagulation monitoring. Detailed demographic, surgical, laboratory, and heparin dosing data were recorded. ACT, calculated and measured HDR, and heparin concentrations were recorded. Performance of the Hepcon HMS Plus was assessed by comparison of actual and target ACT values and calculated and measured HDR.

Results: In 3880 patients undergoing cardiac surgery, heparin bolus dosing to a target ACT resulted in wide variation in the postheparin ACT (r² = 0.03). The postheparin ACT did not reach the target ACT threshold in 7.4% (i.e., when target ACT was 300 s) and 16.9% (i.e., when target ACT was 350 s) of patients. Similarly, the target heparin level calculated from the HDR did not correlate with the postbolus heparin level, with 18.5% of samples differing by more than 2 levels of the assay. Calculated and measured HDR were not linearly related at any heparin level.

Conclusions: The Hepcon HMS Plus system poorly estimates heparin bolus requirements in the pre-CPB period. Further prospective studies are needed to elucidate what constitutes adequate anticoagulation for CPB and how clinicians can reliably and practically assess anticoagulation in the operating room.