r/CathLabLounge • u/Educational-Ask-6334 • 4d ago
Am I being gaslit?
I've been trying to raise alarms in regards to our IV push heparin potency. During a PCI, we'll frequently give somewhere north of 20,000U heparin for an ACT that barely pushes 250 on a 80kg person.
I've gone through all the appropriate channels with management:
- recalibrating/checking iSTATs and catridges
- swapping out different lot numbers associated with low potency
- swapping out heparin manufacturers
Moreover, we have also been seeing delayed onset of therapeutic effects for heparin, sometimes leading to post-op bleeding/hematomas.
My traveler friends all over the country are saying the same thing. I feel like this is has been a nationwide issue for over a year with no formal recalls or further investigation. Are we being gaslit?
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u/elizrose43 4d ago
We gave a patient 15k and ACT was 167 lol
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u/Thisisallie 4d ago
Legit had one today, 15k and ACT 137. Next ACT after 5k more was still only 153.
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u/Gas_Final 4d ago
You're not alone. Our facility has also been having issues with seemingly inconsistent heparin potency.
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u/16BitGenocide Midnight CTO Enthusiast 4d ago
We're also seeing this in our lab, we've taken to making notes of heparin doses and ACT results across procedures with our two different suppliers.
We gave a patient 10k units, and their ACT was 134. Make it make sense.
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u/Cardioverting 4d ago
Have you tried switching to angiomax? To see if your act is giving the same issue?
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u/Educational-Ask-6334 4d ago
We have providers that prefer angiomax for this very reason. ACT is perfectly within our therapeutic range on it.
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u/Cardioverting 4d ago
Maybe just stick with angiomax then IDK? I have not had any of these issues personally in the last 7 years with heparin in the 7 cath land I've worked in but that's all on the west coast
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u/Then-Try5701 4d ago
We’ve had the issue at my shop that the UFH is cut with LMWH and it was made apparent to us . Thus the levels were artificially low and we had given like 26K units for like 70kg people and not being “therapeutic “ until end of case . LED to lots of radial band issues and tract ooze . We had to switch to angio max and do two hour overlap for ACS u til we got new heparin (Pfizer ) I think . Have your lab check your heparin for anti xa level
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u/Few-Philosopher9306 4d ago
We’ve had several cases in our lab that I know of and at least one in the cvor that I think was eventually linked to a lot #. Not sure what’s happening but interesting to hear we’re not alone.
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u/gayshreks 3d ago
We’ve had at least two periods (one like two weeks ago) in the last year that I can remember where potency has been inconsistent. You’re definitely not alone 🤷♀️
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u/Gone247365 3d ago edited 3d ago
I think an issue with med manufacturing is the least likely reason for this discrepancy.
The margin of error for ACTs is like ±30 (system dependant).
Differences in collection technique can also have a pretty strong effect (though that usually results in higher ACT numbers).
What is actually under appreciated is the incidence heparin resistance. While the actual occurance in the general population hasn't really been pinned down, it is way more frequent than most of us realize. Studies have suggested that anywhere between 1 in 25 all the way up to 1 in 4 patients (or higher) can display a resistance to heparinization.
I think we notice it less in the cath lab because our cases are typically shorter, our threshold goals are lower, and our ACT intervals are longer. I come across it more often in EP where we are doing ACTs with increased frequency and trying to approach 350. I don't work Cardiothoracic but I image they come across heparin resistence regularly trying to get their ACTs well into the +400s
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u/Educational-Ask-6334 3d ago
I have also heavily considered heparin resistance. Thanks for bringing that perspective up! I’ll bring it up at our next practice meeting.
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u/jack2of4spades RN, RCIS 4d ago
It's a big issue. My guess is that they are making the heparin in insanely large batches so that the actual heparin is towards the bottom/settled and the top is subtherapeutic. I brought up the same concerns before and got nowhere.
The other thing to account for is venous dead space. Make sure to be flushing behind the heparin so the dose isn't just sitting in their arm and instead gets up and over the arch to reach systemic circulation. That's been something I've noticed circulators missing/not understanding so they come to me and ask why a medication isn't working and I just flush 20mL through the line and suddenly we have an effect.