Version August 2025
| Initial protamine dosing strategies |
| POC heparin-protamine titration assays: Dosing based on Hepcon/HMS, Hemochron RxDx to determine the residual circulating heparin level |
| POC viscoelastic testing: Dosing based on TEG reaction time or ROTEM clotting time to titrate protamine administration |
| Empiric (fixed dose) strategy: Calculating protamine dose based on the amount of heparin administered (eg, 0.6 to 1.0 mg of protamine for every 100 units of heparin administered) |
| Pharmacokinetic dosing: Dosing algorithms based on pharmacokinetics of heparin that consider all heparin doses and timing to calculate a protamine dose |
| Dosing for continued bleeding after initial protamine administration |
| For persistent microvascular bleeding after CPB, a small additional dose of protamine is administered (25 to 50 mg) or an infusion is initiated (at 25 mg/hour), particularly if residual heparin is documented on a heparin-protamine titration assay, or suspected due to higher-than-baseline ACT values) |
| Additional doses of protamine are ideally calculated using a heparin-protamine titration assay |
| Avoiding heparin rebound |
| A protamine infusion is typically administered at 25 mg/hour, beginning after initial reversal of heparin anticoagulation and normalization of the ACT, and extending into the postoperative period over approximately 4 hours |
