Individualized heparin and protamine management in infants and children undergoing cardiac operations Massimiliano Codispoti, MD, Christopher A Ludlam,

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Individualized heparin and protamine management in infants and children undergoing cardiac operations Massimiliano Codispoti, MD, Christopher A Ludlam, PhD, David Simpson, Pankaj S Mankad, PhD The Annals of Thoracic Surgery Volume 71, Issue 3, Pages 922-927 (March 2001) DOI: 10.1016/S0003-4975(00)02586-8

Fig 1 The bell-shaped line represents a normal distribution curve built using the same mean and variance of the study population. It is evident that the distribution of heparin sensitivities in the study population is not normal (Shapiro-Wilk test of normality = 0.906; p = 0.03). Although the mean sensitivity (296 U/kg) corresponds almost exactly with the empiric dose of heparin commonly administered (300 U/kg), a significant proportion of patients has a lower or higher heparin requirement to achieve a “safe” activated coagulation time. (HDR = heparin dose-response: amount of heparin necessary to achieve activated coagulation time of 480 seconds; Std. Dev = standard deviation.) The Annals of Thoracic Surgery 2001 71, 922-927DOI: (10.1016/S0003-4975(00)02586-8)

Fig 2 The activated coagulation time (ACT) remained more than 1,500 seconds at all time points after the initial 30 minutes despite falling heparin concentrations in group C, underlying its inability to guide anticoagulation. On the contrary, in group HC, the administration of heparin was targeted to maintain the concentration indicated by the initial heparin dose-response (HDR), regardless of the activated coagulation time reading. This protocol resulted in significantly higher heparin concentrations in group HC as compared to group C at all time points after the initial 30 minutes on cardiopulmonary bypass (CPB). (∗p less than 0.001; #p = 0.02; open circles = ACT of group C; open squares = ACT of group HC; filled circles = heparin concentration of group C; filled squares = heparin concentration of group HC.) The Annals of Thoracic Surgery 2001 71, 922-927DOI: (10.1016/S0003-4975(00)02586-8)

Fig 3 Blood loss during the first 24 postoperative hours was significantly reduced in group HC. In addition, requirements for blood and blood products were also significantly lower in the intervention group. (FFP = fresh frozen plasma; RCC = red cell concentrate.) The Annals of Thoracic Surgery 2001 71, 922-927DOI: (10.1016/S0003-4975(00)02586-8)