The following blood results are obtained in a patient post cardiac surgery.
a) What is the most likely cause of the abnormal coagulation profile ?
PT |
13.9 seconds |
10.5 to 13.5 |
INR |
1.4 |
0.9 to 1.2 |
APTT |
85 sec |
24 to 39 |
ACT |
240 seconds |
<150 seconds |
b) List 3 complications of the agent commonly used to correct the above coagulation abnormality.
Consistent with heparin
b) List 3 complications of the agent commonly used to correct the above coagulation abnormality.
Anaphylaxis Pulm HT Hypotension Bleeding Bradycardia
The question "why does this post-bypass patient still have such a high ACT" is easily answered with "duh, heparin". However, the ACT could also be raised for a large number of reasons, and Practical-Haemostasis.com give a list of alternative possibilities, many of which could be relevant with this scenario.
Yes, perhaps too little protamine was given (the dose is usually 1mg per every 100 units of heparin).
However, protamine itself can have a potent anticoagulant effect in overdose.
Its other delightful side effects are discussed in (slightly) greater detail in the chapter on unfractionated heparin. briefly, they can be listed as follows:
It also has antibacterial properties, mainly hitting the Gram-positives.
The PI for protamine sulfate is illuminating.
Ellison, Norig, Alan J. Ominsky, and Harry Wollman. "Is Protamine a Clinically Important Anticoagulant?." Anesthesiology 35.6 (1971): 621-629.
Holland, C. L., et al. "Adverse reactions to protamine sulfate following cardiac surgery." Clinical cardiology 7.3 (1984): 157-162.
Johansen, Charlotte, T. Gill, and Lone Gram. "Antibacterial effect of protamine assayed by impedimetry." Journal of applied bacteriology 78.3 (1995): 297-303.
Jastrzebski, J., M. K. Sykes, and D. G. Woods. "Cardiorespiratory effects of protamine after cardiopulmonary bypass in man." Thorax 29.5 (1974): 534-538.
Hobbhahn, J., et al. "[Complications caused by protamine. 1: Pharmacology and pathophysiology]." Der Anaesthesist 40.7 (1991): 365-374.
Fadali, Moneim A., et al. "Mechanism responsible for the cardiovascular depressant effect of protamine sulfate." Annals of surgery 180.2 (1974): 232.