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Title: The effect of protamine dosing variation on bleeding and transfusion after heparinisation for cardiopulmonary bypass.
Austin Authors: Kunz, Stephen A ;Miles, Lachlan F ;Ianno, Damian J ;Mirowska-Allen, Kelly L;Matalanis, George ;Bellomo, Rinaldo ;Seevanayagam, Siven 
Affiliation: Department of Cardiac Surgery, Austin Health, Heidelberg, Victoria, Australia
School of Medicine, The University of Melbourne, Parkville, Victoria, Australia
Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
Issue Date: Sep-2018 2018-03-15
Publication information: Perfusion 2018; 33(6): 445-452
Abstract: Accurate dosing of protamine reversal following on-pump cardiac surgical procedures is challenging, with both excessive and inadequate administration recognised to increase bleeding risk. We aimed to examine the relationship between three ratios for heparin reversal and markers of haemostasis. A retrospective analysis of a prospectively collected database was undertaken at a single tertiary cardiac unit, reviewing all cases of on-pump coronary artery bypass grafts and single valve replacements from 01/01/2011 to 31/12/2015. The ratio between total intra-operative heparin and protamine was stratified to three groups (low: ≤0.6 mg per 100 IU of heparin, moderate: 0.6-1.0 and high: >1.0) and related to the primary outcome of red blood cell (RBC) transfusion, with secondary outcomes being the number of units transfused, the haemoglobin differential and mediastinal drain output at 4 hours. Of the 803 patients identified, 338 received a blood transfusion, with 1035 units being used. Eighteen percent of individuals (145) received a low ratio, 50% (404) received a moderate ratio and 32% (254) a high ratio. Using the moderate group as a reference, the low dose group was 56.5% less likely to have received a RBC transfusion (OR 0.435; 95% CI 0.270:0.703 p=0.001) while the high dose group carried a 241% increased association with transfusion (OR 3.412; 95% CI 2.399:4.853 p<0.001). For those transfused, a lower protamine:heparin ratio was associated with a lower number of units transfused, lesser haemoglobin differential and less mediastinal drain output. Higher doses of intra-operative protamine relative to heparin are associated with greater risk of transfusion and post-operative bleeding.
DOI: 10.1177/0267659118763043
ORCID: 0000-0001-7424-9472
PubMed URL: 29544405
Type: Journal Article
Subjects: bleeding
Appears in Collections:Journal articles

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