Antithrombin III

The other day we had a patient come in for a CABG. Aside for some coronary artery disease, hypertension, and chronic kidney disease, the patient was pretty healthy. They were not on anticoagulation prior to the procedure.

After I gave full dose heparin for going on bypass (41,000U in this case), the ACT only came up to 422. An additional 10,000U of heparin was given with a repeat ACT of 457. Still, our surgeon was not quite comfortable with that number and requested an additional 10,000U heparin. The ACT came to 477.

If the ACT stayed in the low 400s, would you go on bypass? What if the ACT had not responded to the repeated heparin dosings?

Management of coagulation during cardiopulmonary bypass. Continuing Education in Anaesthesia Critical Care & Pain, Volume 7, Issue 6, 1 December 2007, Pages 195–198, https://doi.org/10.1093/bjaceaccp/mkm036.

Antithrombin III concentrate to treat heparin resistance in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2002 Feb;123(2):213-7.

Would you give antithrombin III or plasma?

Treating Heparin Resistance With Antithrombin or Fresh Frozen Plasma. The Annals of Thoracic Surgery. June 2008Volume 85, Issue 6, Pages 2153–2160.

Is there evidence that fresh frozen plasma is superior to antithrombin administration to treat heparin resistance in cardiac surgery? Interact Cardiovasc Thorac Surg. 2014 Jan; 18(1): 117–120.

We ultimately decided to go on bypass. Repeat ACTs on bypass were in the 500s. No antithrombin was given. After separation from cardiopulmonary bypass and administration of protamine, repeat ACT was 111. Protamine was dosed accordingly to heparin administration and ACTs while on bypass.

Recommendations for the use of antithrombin concentrates and prothrombin complex concentrates. Blood Transfus. 2009 Oct; 7(4): 325–334.

Thrombate (antithrombin III) package insert

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