• Antoine G Rochon, Sylvain Bélisle, Pierre Couture, Annik Fortier, Jean-Sébastien Lebon, and Alain Deschamps.
• Department of Anesthesia, Montreal Heart Institute, Montreal, Quebec, Canada. Electronic address: antoinerochon@me.com.
• J. Cardiothorac. Vasc. Anesth. 2020 Sep 1; 34 (9): 2369-2374.

ObjectiveIn vivo protamine titration (IVPT) is based on the observation of a plateau on the decay curve of the celite activated clotting times (ACTs) during protamine infusion for heparin reversal. The aim of the present study was to determine the optimal protamine/heparin ratio to reverse anticoagulation using IVPT curves.DesignProspective, randomized study.SettingTertiary care university hospital.ParticipantsThe study comprised 138 patients undergoing elective cardiac surgery requiring cardiopulmonary bypass.InterventionsThe control group was given a protamine infusion of 1.3 mg per 1 mg (100 U) of heparin over 21 minutes. ACT was measured every 3 minutes. In the test group, the protamine dose was prepared using the same ratio as for the control group, and ACT values were measured every 3 minutes until a plateau was reached (2 consecutive ACT values <160 s), at which time the protamine infusion was stopped. The protamine/heparin ratio, blood losses, transfusions, and heparin concentrations were recorded.ResultsThe protamine dose was lower in the test group (456.00 ± 105.66 mg [control group] v 295.25 ± 100.60 mg [test group]; p < 0.0001). The mean protamine/heparin ratios were 1.30 ± 0.10 (control group) and 0.81 ± 0.22 (test group) (p < 0.0001). Heparin concentrations were greater in the test group 15 minutes (0.10 [0-0.2] U/mL v 0 [0-0.1] U/mL; p = < 0.0001) and 3 hours (0 [0-0.1] U/mL v 0 [0-0] U/mL; p = 0.0002) after protamine infusion. There was no difference in the blood losses and transfusion requirements.ConclusionsIVPT is safe and efficient in this low-risk population.Copyright © 2020 Elsevier Inc. All rights reserved.

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