Heparin v. Protamine

Calculating Heparin Dosing and Protamine Reversal:

Well it was one of those days when we had a TEG representative running TEGS on all of our patient’s for a few days, and I was having a discussion with our Lab manager regarding standards for heparin reversal.  We use the HepCon system, but had been dealing with an inordinate amount of postoperative bring backs for exploration.  We looked at the obvious things:

  • ECC
  • Total heparin
  • Timing of reversal
  • Protamine dosing
  • Antiplatelet Rx
  • Plavix
  • Heparin rebound
  • Factor administration
  • The kitchen sink….

A lot of head scratching, and I put together a brief list of things and studies we looked at that may or may not be helpful when you find yourself having this same discussion.

Any other links or points of view would be of great use, and very helpful to the community.

Thanks guys-

Frank

Good abstract on Heparin Rebound- and increased Rx with protamine administration

https://journals.lww.com/anesthesiology/Abstract/1992/03000/Heparin_Management_Protocol_for_Cardiopulmonary.12.aspx

Abstract on Low dose heparin versus heparin bonded circuits-  interesting note that reduced heparin does not translate to reduced bleeding.

https://ats.ctsnetjournals.org/cgi/content/full/60/6/1755

A very comprehensive chapter on heparin management for bypass.  Definitely review- the book is the standard for perfusionists.

https://www.wildcatanesthesia.com/Lippincott%20Interactive%20CD/text/gr/gr022.htm


Heparin Response curve and empiric protamine dosing

https://books.google.com/books?id=45DKiUj1hLUC&pg=PA322&lpg=PA322&dq=heparin+dosing+protocol+cardiopulmonary+bypass&source=bl&ots=UMDo1rCzIw&sig=1rrc45GDhZ1RHM2mJuRDcXbpTRY&hl=en&ei=-o8ZTOzHPIK8lQfl1en8Cw&sa=X&oi=book_result&ct=result&resnum=3&ved=0CBkQ6AEwAjgo#v=onepage&q=heparin%20dosing%20protocol%20cardiopulmonary%20bypass&f=false

Compilation of multiple studies comparing Hepcon to ACT monitoring-

https://www.bestbets.org/bets/bet.php?id=1151

Very good study- Conclusion supports protamine dosing of at least 1 mg per 100 units of heparin.  Also discusses potential effects of  TOO much protamine-

https://asianannals.ctsnetjournals.org/cgi/content/full/12/1/47