medalphabetМедицинский алфавитMedical alphabet2078-56312949-2807ООО «Альфмед»medalphabet-921Research ArticleСтатьиФакторы увеличения периоперационной кровопотери в кардиохирургииFactors of increasing perioperative blood loss in cardiac surgeryГусеваН. В.GusevaN. V.noemail@neicon.ruАкуленкоМ. С.AkulenkoM. S.noemail@neicon.ruТихоновА. В.TikhonovA. V.noemail@neicon.ruДворядкинА. А.DvoryadkinA. A.noemail@neicon.ruПлемянниковаЕ. А.PlemyannikovaE. A.noemail@neicon.ruКричевскийЛ. А.KrichevskyL. A.noemail@neicon.ruГБУЗ г. Москвы «Городская клиническая больница имени С. С. Юдина» Департамента здравоохранения г. МосквыРоссияCity Clinical Hospital n.a. S. S. YudinRussian Federation201809122018438Неотложная медицина2225Copyright © Гусева Н.В., Акуленко М.С., Тихонов А.В., Дворядкин А.А., Племянникова Е.А., Кричевский Л.А., 20182018Гусева Н.В., Акуленко М.С., Тихонов А.В., Дворядкин А.А., Племянникова Е.А., Кричевский Л.А.Guseva N.V., Akulenko M.S., Tikhonov A.V., Dvoryadkin A.A., Plemyannikova E.A., Krichevsky L.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-alphabet.com/jour/article/view/921

Были обследованы 73 больных, перенесших операцию коронарного шунтирования в условиях искусственного кровообращения. У 33 больных (группа 1) была отмечена периоперационная кровопотеря 10 и более мл/кг, в остальных случаях (n = 40, группа 2) - менее 10 мл/кг. В группе 1 по сравнению с группой 2 оказались значимо (р < 0,05) выше дезагрегантный эффект аспирина, измеренный методом оптической трансмиссионной агрегометрии (570 ± 77; 620 ± 55 ARU; р = 0,0009), суммарные дозировки гепарина (594 ± 110; 520 ± 54 ЕД/ кг; р = 0,002) и протамина сульфата (4,7 ± 1,0; 3,9 ± 0,5 мг/кг; р = 0,0005). Таким образом, антиагрегантный эффект аспирина, назначенного до операции, и суммарная доза использованного во время операции гепарина, несмотря на расчетную нейтрализацию протамина сульфатом, являются достоверными факторами риска увеличения периоперационной кровопотери при коронарном шунтировании.

Seventy three patients who underwent on-pump CABG surgery were examined. in 33 patients (group 1), perioperative blood loss of 10 or more ml/kg was noted, in other cases (n = 40, group 2) it was less than 10 ml/kg. in group 1, compared with group 2, the antiplatelet effect of aspirin measured by optical transmission aggregometry (570 ± 77; 620 ± 55 ARU; p = 0.0009), the total dosages of heparin (594 ± 110; 520 ± 54 U/ kg; p = 0.002) and protamine sulfate (4.7 ± 1.0; 3.9 ± 0.5 mg/ kg; p = 0.0005). Thus, the antiplatelet effect of aspirin administered before the operation, and the total dose of heparin, despite the calculated neutralization with protamine sulfate, are significant risk factors for an increase in perioperative blood loss during CABG-surgery.

аспиринискусственное кровообращениекоронарное шунтированиекровопотерягепаринпротаминVerifyNowAspirinVerifyNowcardio-pulmonary bypassCABGblood lossheparinprotamineReferencesDespotis G, Avidan M, Eby C. Prediction and management of bleeding in cardiac surgery. JThromb Haemost. 2009, vol. 7Suppl. 1, p. 111-117Despotis G, Avidan M, Eby C. Prediction and management of bleeding in cardiac surgery. JThromb Haemost. 2009, vol. 7Suppl. 1, p. 111-117Jabagi H, Boodhwani M, Tran DT, et al. The effect of preoperative anemia on patients undergoing cardiac surgery: a propensity-matched analysis. Semin Thorac Cardiovasc Surg. 2018, vol. 28, S 1043-0679.Jabagi H, Boodhwani M, Tran DT, et al. The effect of preoperative anemia on patients undergoing cardiac surgery: a propensity-matched analysis. Semin Thorac Cardiovasc Surg. 2018, vol. 28, S 1043-0679.Shehata N, Whitlock R, Fergusson DA, et al. Transfusion requirements in cardiac surgery III (TRICS III): Study design of a randomized controlled trial. J Cardiothorac Vasc Anesth, 2018, vol. 32, p. 121-129.Shehata N, Whitlock R, Fergusson DA, et al. Transfusion requirements in cardiac surgery III (TRICS III): Study design of a randomized controlled trial. J Cardiothorac Vasc Anesth, 2018, vol. 32, p. 121-129.Hung M, Ortmann E, Besser M, et al. A prospective observational cohort study to identify the causes of anaemia and association with outcome in cardiac surgical patients. Heart, 2015, vol. 101, p. 107-112.Hung M, Ortmann E, Besser M, et al. A prospective observational cohort study to identify the causes of anaemia and association with outcome in cardiac surgical patients. Heart, 2015, vol. 101, p. 107-112.Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/ American Heart Association task force on practice guidelines. Circulation, 2011, vol. 124, p. 2610-42.Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/ American Heart Association task force on practice guidelines. Circulation, 2011, vol. 124, p. 2610-42.Kolh P, Windecker S, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). European journal of cardio-thoracic surgery. Official J EACTS, 2014, vol. 46, p. 517-592.Kolh P, Windecker S, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). European journal of cardio-thoracic surgery. Official J EACTS, 2014, vol. 46, p. 517-592.Mangano DT, Tudor IC, Dietzel C. Multicenter study of perioperative ischemia research group; ischemia research and education foundation. The risk associated with aprotinin in cardiac surgery. N Engl J Med, 2006, vol. 26, p. 353-65.Mangano DT, Tudor IC, Dietzel C. Multicenter study of perioperative ischemia research group; ischemia research and education foundation. The risk associated with aprotinin in cardiac surgery. N Engl J Med, 2006, vol. 26, p. 353-65.Mangano DT, Miao Y, Vuylsteke A, et al. Investigators of the multicenter study of perioperative ischemia research group; Ischemia research and education foundation. Mortality associated with aprotinin during 5 years following coronary artery bypass graft surgery. J Am Med Ass, 2007, vol. 7, p. 471-479.Mangano DT, Miao Y, Vuylsteke A, et al. Investigators of the multicenter study of perioperative ischemia research group; Ischemia research and education foundation. Mortality associated with aprotinin during 5 years following coronary artery bypass graft surgery. J Am Med Ass, 2007, vol. 7, p. 471-479.Schneeweiss S, Seeger JD, Landon J, Walker AM. Aprotinin during coronary-artery bypass grafting and risk of death. N Engl J Med, 2008, vol. 21, p. 771-783.Schneeweiss S, Seeger JD, Landon J, Walker AM. Aprotinin during coronary-artery bypass grafting and risk of death. N Engl J Med, 2008, vol. 21, p. 771-783.Baumann Kreuziger L, Karkouti K, Tweddell J, Massicotte MP. Antithrombotic therapy management of adult and pediatric cardiac surgery patients. J Thromb Haemost, 2018, vol. 16, p. 2133-2146.Baumann Kreuziger L, Karkouti K, Tweddell J, Massicotte MP. Antithrombotic therapy management of adult and pediatric cardiac surgery patients. J Thromb Haemost, 2018, vol. 16, p. 2133-2146.Sirvinskas E, Veikutiene A, Grybauskas P, et al. Influence of aspirin or heparin on platelet function and postoperative blood loss after coronary artery bypass surgery. Perfusion, 2006, vol. 21, p. 61-66.Sirvinskas E, Veikutiene A, Grybauskas P, et al. Influence of aspirin or heparin on platelet function and postoperative blood loss after coronary artery bypass surgery. Perfusion, 2006, vol. 21, p. 61-66.Mahla E, Tantry US, Prüller F, Gurbel PA. Is there a role for preoperative platelet function testing in patients undergoing cardiac surgery during antiplatelet therapy? Circulation, 2018, vol. 138, p. 2145-2159.Mahla E, Tantry US, Prüller F, Gurbel PA. Is there a role for preoperative platelet function testing in patients undergoing cardiac surgery during antiplatelet therapy? Circulation, 2018, vol. 138, p. 2145-2159.Gorog DA, Jeong Y-H. Platelet function tests: Why they fail to guide personalized antithrombotic medication. J Am Heart Assoc, 2015, vol. 4, e002094.Gorog DA, Jeong Y-H. Platelet function tests: Why they fail to guide personalized antithrombotic medication. J Am Heart Assoc, 2015, vol. 4, e002094.Vlot EA, Willemsen LM, Van Dongen EPA, et al. Perioperative point of care platelet function testing and postoperative blood loss in high-risk cardiac surgery patients. Platelets, 2018, vol. 9, p. 1-7.Vlot EA, Willemsen LM, Van Dongen EPA, et al. Perioperative point of care platelet function testing and postoperative blood loss in high-risk cardiac surgery patients. Platelets, 2018, vol. 9, p. 1-7.Van Hout FM, Hogervorst EK, Rosseel PM, et al. Does a platelet transfusion independently affect bleeding and adverse outcomes in cardiac surgery? Anesthesiology, 2017, vol. 126, p. 441-449.Van Hout FM, Hogervorst EK, Rosseel PM, et al. Does a platelet transfusion independently affect bleeding and adverse outcomes in cardiac surgery? Anesthesiology, 2017, vol. 126, p. 441-449.Aubron C, Flint AW, Bailey M, Pilcher D, et al. Is platelet transfusion associated with hospital-acquired infections in critically ill patients? Crit Care, 2017, vol. 21, 2-9.Aubron C, Flint AW, Bailey M, Pilcher D, et al. Is platelet transfusion associated with hospital-acquired infections in critically ill patients? Crit Care, 2017, vol. 21, 2-9.Wademan BH, Galvin SD. Desmopressin for reducing postoperative blood loss and transfusion requirements following cardiac surgery in adults. Interactive CardioVasc Thorac Surg, 2013, vol. 18, p. 360-370.Wademan BH, Galvin SD. Desmopressin for reducing postoperative blood loss and transfusion requirements following cardiac surgery in adults. Interactive CardioVasc Thorac Surg, 2013, vol. 18, p. 360-370.Дементьева И. И., Чарная М. А., Морозов Ю. А. Патология системы гемостаза. Руководство для врачей. 2013, ГЭОТАР-Медиа, с. 288.Дементьева И. И., Чарная М. А., Морозов Ю. А. Патология системы гемостаза. Руководство для врачей. 2013, ГЭОТАР-Медиа, с. 288.Chan T, Chih Hwang N, Hee Lim C. A statistical analysis of factors predisposing patients to heparin resistance. Perfusion, 20(06, vol. 21, p. 99-103.Chan T, Chih Hwang N, Hee Lim C. A statistical analysis of factors predisposing patients to heparin resistance. Perfusion, 20(06, vol. 21, p. 99-103.Grieshaber P, Bakchoul T, Wilhelm J, et al. Platelet-activating protamine-heparin-anti-bodies lead to higher protamine demand in patients undergoing cardiac surgery J Thorac Cardiovasc Surg, 2015, vol. 150, p. 967-973.Grieshaber P, Bakchoul T, Wilhelm J, et al. Platelet-activating protamine-heparin-anti-bodies lead to higher protamine demand in patients undergoing cardiac surgery J Thorac Cardiovasc Surg, 2015, vol. 150, p. 967-973.Ainle N, Preston RJ, Jenkins PV, et al. Protamine sulfate down-regulates thrombin generation by inhibiting factor V activation. Blood, 2009, vol. 20, p. 1658-1665.Ainle N, Preston RJ, Jenkins PV, et al. Protamine sulfate down-regulates thrombin generation by inhibiting factor V activation. Blood, 2009, vol. 20, p. 1658-1665.Чарная М.А., Морозов Ю.А., Клыпа Т. В. и др. Влияние протамина сульфата на систему гемостаза после операций в условиях искусственного кровообращения. Хирургия, 2007, № 8, с. 17-20.Чарная М.А., Морозов Ю.А., Клыпа Т. В. и др. Влияние протамина сульфата на систему гемостаза после операций в условиях искусственного кровообращения. Хирургия, 2007, № 8, с. 17-20.Bolliger D, Szlam F, Azran M, et al. The anticoagulant effect of protamine sulfate is attenuated in the presence of platelets or elevated factor VIII concentrations. Anesth Analg, 2010, vol. 111, p. 601-608.Bolliger D, Szlam F, Azran M, et al. The anticoagulant effect of protamine sulfate is attenuated in the presence of platelets or elevated factor VIII concentrations. Anesth Analg, 2010, vol. 111, p. 601-608.Meesters MI, Veerhoek D, de Lange F., et al. Effect of high or low protamine dosing on postoperative bleeding following heparin anticoagulation in cardiac surgery. Thrombosis and Haemostasis, 2016, vol. 116, p. 251-261.Meesters MI, Veerhoek D, de Lange F., et al. Effect of high or low protamine dosing on postoperative bleeding following heparin anticoagulation in cardiac surgery. Thrombosis and Haemostasis, 2016, vol. 116, p. 251-261.Zhang Y, Liu K, Li W, et al. An adjusted calculation model of reduced heparin doses in cardiopulmonary bypass surgery in a Chinese population. J Cardiothorac Vasc Anesth, 2016, vol. 30, p. 1179-1183.Zhang Y, Liu K, Li W, et al. An adjusted calculation model of reduced heparin doses in cardiopulmonary bypass surgery in a Chinese population. J Cardiothorac Vasc Anesth, 2016, vol. 30, p. 1179-1183.Kjellberg G, Holm M, Fux T, et al, Calculation Algorithm Reduces Protamine Doses Without Increasing Blood Loss or the Transfusion Rate in Cardiac Surgery: Results of a RCT. J Cardiothorac Vasc Anesth, 2018, in press (doi. org/10.1053/j.jvca.2018.07.044).Kjellberg G, Holm M, Fux T, et al, Calculation Algorithm Reduces Protamine Doses Without Increasing Blood Loss or the Transfusion Rate in Cardiac Surgery: Results of a RCT. J Cardiothorac Vasc Anesth, 2018, in press (doi. org/10.1053/j.jvca.2018.07.044).

The authors declare that there are no conflicts of interest present.