Approach to heparin resistance during anticoagulation for cardiac surgery with CPB

This algorithm addresses heparin resistance, a term used when the desired preset systemic anticoagulation target for CPB is not achieved after initial standard heparin dosing. Typically this target is an ACT value ≥400 seconds, although some institutions use ≥450 seconds or ≥480 seconds. Refer to UpToDate's content on anticoagulation during cardiac surgery with CPB.

ACT: activated whole blood clotting time; CPB: cardiopulmonary bypass; FFP: fresh frozen plasma; POC: point-of-care.

* Although institutional protocols for systemic anticoagulation with heparin vary, the total maximum dose of heparin is typically 500 units/kg to 600 units/kg. When such large doses of heparin are administered, accumulation in body tissues will occur. After termination of CPB and initial administration of protamine to neutralize heparin effect, administration of additional protamine (small bolus doses of 25 mg or via infusion at 25 mg/hour) may be necessary. Refer to to UpToDate's content on protamine administration during cardiovascular procedures.

¶ Antithrombin concentrate is preferred over FFP in this setting due to less risk of volume overload, infection transmission, and other complications of blood transfusion.

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Approach to heparin resistance during anticoagulation for cardiac surgery with CPB