College Answer

Consistent with heparin

b) List 3 complications  of the agent commonly used to correct the above coagulation abnormality.

Anaphylaxis Pulm HT Hypotension Bleeding Bradycardia

Discussion

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.

• Thrombocytopenia (the circuit ate my platelets)
• Platelet antagonists
• Factor deficiencies (the circuit ate my clotting factors)
• Low fibrinogen, DIC etc
• Hemodilution
• Hypothermia (the patient returns from theatre with a core temperature of 33.0°C)
• Lupus anticoagulant

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:

• Anaphylaxis
• Urticaria
• Bronchospasm
• Pulmonary hypertension
• Hypotension
• Bradycardia
• Decreased cardiac output
• Paradoxical anticoagulation.

It also has antibacterial properties, mainly hitting the Gram-positives.