9. Reverse the heparin gently. Remember you don't have a bypass circuit ready to bail you out. Moreover, the dose of protamine may be reduced because of the lack of damage to the platelets. Check the ACT 1/3 and 2/3 of the way through the protamine to avoid overdosing.
10. Consider anticoagulation post reversal of protamine. CABG surgery benefits from prolonged damage to the coagulation system. When was the last time you saw a post CABG pulmonary embolus? When do they start anticoagulating after a valve? In a Off Pump-CABG where the coagulation system was not exposed to an extracorporeal circulation circuit the coagulation system is normal. All of the problems with pulmonary embolus, graft closure, graft clotting that the vascular surgeons have will now occur with cardiac surgery. If graft closure causes a cold leg and a mid-night trip to the OR to remove the clot for vascular surgeons. Off Pump CABG graft closure causes an MI and possibly a cold blue patient and a trip to the morgue. Be very, very, very careful about post operative MI's. Remember the anastamosis was done in less than optimal circumstances (movement, bleeding, limited positioning). The coagulation system is fully functional. We are trying dextran infusions to try to have some prolonged anti-coagulant effect without bleeding. The jury is still out though.
We have had thirty years to figure out all the tricks for normal CABG's. The Off Pump-CABG is still in its childhood.
Good Luck: You should enjoy your month at the VA. You will get a reasonable experience with adult cardiac surgery. If there are any comments, changes, additions, errors in this text, I, Art Wallace, M.D, Ph.D., am responsible. Please e-mail me with suggestions.
by Art Wallace, M.D., Ph.D.
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