Heparin Management Protocols?
Submitted by Maggie Savelberg on Wed, 06/30/2010 - 12:10.
Hi Everyone,
I was wondering if anyone students or perfusionists from various hospitals could share their heparin management protocols? I am doing a project on heparin pathologies (heparin allergy, heparin resistance and heparin rebound) for one of my master's courses and was wondering if anyone had any protocols or general guidelines they could share with me and the students? I will post some of the answers I have received from Perflist so far, but I am curious to know in addition to the dosing questions what you do for heparin rebound and resistance? When do you deem the patient resistant? (In my clinical rotations - I found the rule was if you have to give greater than 600 IU/kg and still are not above the target ACT, others say anything above what they would normally expect)
Here were the other questions I asked - if you guys can answer these I'd appreciate any feedback you could give me :)
Here was my question:
Anticoagulation is used during cardiac surgery to prevent overt thrombosis of the extracorporeal circuit and to limit cellular, platelet and coagulation factor activation during cardiopulmonary bypass. In a recent survey of 54 American and Canadian institutions (Lobato, 2010) a large variation was found to still exist in the target ACT used for instituting CPB, the amount of heparin (IU/kg) given to achieve target ACT, as well as when and how heparin resistance is treated.
Given there is no single “best” ACT level or standard that can be agreed upon from available literature according to Ferraris et al., 2007;
i) What does your hospital use for a heparin dosing protocol? Who calculates and decides upon the heparin bolus dose value?
ii) What is your target ACT/heparin concentration for initiating CPB? What POC testing device do you use?
iii) Who determines when to administer more heparin, what is your guiding value?
iv) Finally, for those using heparin-coated circuits do you also follow low dose systemic heparinization as safely proposed by Mirow et al., 2008? What are your target ACTs/heparin concentrations if so?
I was able to get 7 replies using Perflist, along with some literature information from a recent study (Lobato, 2010) which surveyed cardiac centers across the US and Canada about their heparin management "protocols".. I have used a combination of that material to get an idea of what different centers are doing. My group then developed a Standard Operating Protocol to address the lack of standardized heparin protocols. I have posted this in the Presentations section of the education forum.
Here is the reference and brief summary for those that are interested.
Robert L. Lobato, George J. Despotis, Jerrold H. Levy, Linda J. Shore-Lesserson, Melvin O. Carlson, Elliott Bennett-Guerrero. (2010) Anticoagulation management during cardiopulmonary bypass: A survey of 54 North American institutions. J Thorac Cardiovasc Surg. Jun;139(6):1665-6
This article discusses a survey conducted throughout North America to deduce anticoagulation management schemes carried out during cardiopulmonary bypass in cardiac surgical centers. This 18 question survey was sent out to 162 centers across Canada and the United States and with a 33% response rate (7.9% from Canada, and 25.1% from the US) the following was determined; i) that wide variability exists in the target ACT required for initiation of CPB (350-500 sec), with the majority of Canadian institutions using a value between 400-480 sec. With 57% of US and 77% of Canadian centers using a value of 500 IU/kg as a marker for using additional therapies to promote and assist with anticoagulation. 85% of US and Canadian sites treated heparin resistance with FFP, whereas 46% of US sites and 8% of Canadian sites used antithrombin concentrate to treat heparin resistance. In 95% of US sites e-amniocaproic acid (EACA) is used during cardiac surgery requiring CPB, vs no Canadian site usage, and only 17% of American sites used tranexamic acid in contrast to 100% of Canadian sites.