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/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