Heparin-protamine balance after neonatal cardiopulmonary bypass surgery.

Essentials Heparin-protamine balance (HPB) modulates bleeding after neonatal cardiopulmonary bypass (CPB). HPB was examined in 44 neonates undergoing CPB. Post-operative bleeding occurred in 36% and heparin rebound in 73%. Thrombin-initiated fibrin clot kinetic assay and partial thromboplastin time best assessed HPB. SUMMARY: Background Neonates undergoing cardiopulmonary bypass (CPB) are at risk of excessive bleeding. Blood is anticoagulated with heparin during CPB. Heparin activity is reversed with protamine at the end of CPB. Paradoxically, protamine also inhibits blood coagulation when it is dosed in excess of heparin. Objectives To evaluate heparin-protamine balance in neonates undergoing CPB by using research and clinical assays, and to determine its association with postoperative bleeding. Patients/Methods Neonates undergoing CPB in the first 30 days of life were studied. Blood samples were obtained during and after surgery. Heparin-protamine balance was assessed with calibrated automated thrombography, thrombin-initiated fibrin clot kinetic assay (TFCK), activated partial thromboplastin time (APTT), anti-FXa activity, and thromboelastometry. Excessive postoperative bleeding was determined by measurement of chest tube output or the development of cardiac tamponade. Results and Conclusions Of 44 neonates enrolled, 16 (36%) had excessive postoperative bleeding. The TFCK value was increased. By heparin in neonatal blood samples, but was only minimally altered by excess protamine. Therefore, it reliably measured heparin in samples containing a wide range of heparin and protamine concentrations. The APTT most closely correlated with TFCK results, whereas anti-FXa and thromboelastometry assays were less correlative. The TFCK and APTT assay also consistently detected postoperative heparin rebound, providing an important continued role for these long-established coagulation tests in the management of postoperative bleeding in neonates requiring cardiac surgical repair. None of the coagulation tests predicted the neonates who experienced postoperative bleeding, reflecting the multifactorial causes of bleeding in this population.

Brain stimulation reward is altered by affecting dopamine-glutamate interactions in the central extended amygdala.

This work compares the effects on brain stimulation reward (BSR) when combining D2 dopamine receptor and AMPA glutamate receptor manipulations in the sublenticular central extended amygdala (SLEAc) and the nucleus accumbens shell (NAc shell). Thirty-seven male Long Evans rats received medial forebrain bundle (MFB) stimulation electrodes and bilateral injection guide cannulae aimed at either the SLEAc or the NAc shell. The rate-frequency paradigm was used to assess drug-induced changes in stimulation reward effectiveness and in response rate following 0.5 µl infusions of 0.50 µg of 1,2,3,4-tetrahydro-6-nitro-2,3-dioxo-benzo[f]quinoxaline-7-sulfonamide (NBQX) (AMPA receptor antagonist), 10.0 µg of quinpirole (D2 receptor agonist), 0.25 µg of AMPA (AMPA receptor agonist), 3.0 µg of eticlopride (D2 receptor antagonist), 0.50 µg of NBQX with 10.0 µg of quinpirole, and 0.25 µg of AMPA with 3.0 µg of eticlopride. The drugs were injected both ipsi- and contralateral to the stimulation site. AMPA blockade and D2 stimulation synergized to reduce BSR's reward efficacy when directed at the SLEAc contralateral to the stimulation site whereas changes in reward efficacy were primarily D2-dependent following injections into the ipsilateral SLEAc. When injected into the NAc shell the drugs had only one significant effect on the frequency required to maintain half-maximal responding: injections of NBQX with quinpirole ipsilateral to the stimulation site increased required frequency significantly more than did injections of saline. Contrary to expectations, stimulating AMPA receptors with and without co-blockade of D2 receptors also decreased the stimulation's reward efficacy, although these effects may reflect general behavioral disruption more than effects on reward per se. These results indicate a role for the SLEAc in BSR and also suggest that SLEAc neurons ipsi- and contralateral to the stimulated MFB play their roles in BSR through different mechanisms.