Anaes SAQs · Cardiac anaesthesia
Heparin, protamine, and coagulopathy on CPB
Final-examination SAQ for protamine-heparin-coagulopathy-cpb.
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Model answer
Core facts. Reproduce exact heparin/ACT/protamine numbers (weight-based bolus with 400–500 IU/kg most reported; ACT ≥480 s most-reported target and HARD STOP; protamine ~1 mg/100 IU heparin given slowly) and quote institutional CPB flow and MAP targets.
[3] [4]Topic structure. Cover preoperative risk, intraoperative heparin-to-protamine sequence, TOE role in excluding tamponade and ventricular failure, viscoelastic-guided bleeding management, and the canonical crisis: catastrophic pulmonary hypertension and systemic hypotension during protamine.[2][3][5]
Transfusion. TRICS III supports a restrictive red-cell strategy (7.5 g/dL threshold non-inferior to liberal) when not actively exsanguinating.[1]
Close. Disposition, ICU plan (including heparin-rebound vigilance), and common traps.[3]
References5ShowHide
- [1]Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery. N Engl J Med, 2017.PMID 29130845
- [2]Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr, 2013.PMID 23998692
- [3]Levy JH, Ghadimi K, Kizhakkedathu JN, et al. What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives. J Thromb Haemost, 2023.PMID 37062523
- [4]Levy JH, Sniecinski RM, Maier CL, et al. Finding a common definition of heparin resistance in adult cardiac surgery: communication from the ISTH SSC subcommittee on perioperative and critical care thrombosis and hemostasis. J Thromb Haemost, 2024.PMID 38215912
- [5]Agarwal S, Abdelmotieleb M Viscoelastic testing in cardiac surgery. Transfusion, 2020.PMID 32955756