The use of alternatives to heparin in terms of managing anicoagulation doesn’t come up often. So many of us get a bit rusty when it comes to using exotic agents such as Ancrod (Hirudin), Angiomax and similar agents.
So here is a brief refresher, and as always- a disclaimer here: Use this information with due prejudice, and verify through your own research and due diligence prior to implementing.
Angiomax Perfusion Considerations
- Reconstitute Angiomax in OR- 250 mg in powder with 5 cc NSS= 50 mg per ml.
- No heparin coated surfaces (circuit, CDI, Swann Ganz– etc)
- Angiomax ½ life = 25 minutes
- Will precipitate if blood is allowed to pool
- Observed clot in the pericardium (after Angiomax is bolused) is Normal- remove with cell saver suction- Not pump suckers!
- Angiomax is excreted via kidneys- Diurese postoperatively to get ACT back to baseline.
- Vancomycin may inhibit function of Angiomax. Uses dedicated infusion pump to avoid contact with vancomycin.
- Target ACT is 500 seconds
- 1 mg per kg for initial dose (off pump)
- Maintenance Dose: 1.75 mg/kg/hr (increase in 0.15 to 0.45 mg/kg/hr increments)
Prime: Normal Add 50 mg Angiomax
Cardioplegia– Prefer Crystalloid only (if using blood- always recirculate Cardioplegia to Avoid Stasis!
Arterial Venous Bridge at field to recirculate after CPB
Remove CDI (Heparin issue)
Use Hemoconcentrator Only when rewarming- remove 300 cc and test act.
Continue with that algorithm- not allowing ACT to fall below 300 on CPB.
Cooling Potentiates Action of Angiomax- and Warming accelerates excretion.
Rewarming and maintaining core temp at 37 Celsius is key- for Angiomax reversal!
Put 50 mg Angiomax in Pump after coming off bypass.