Angiomax: Use and Dosing Regimen

Editor’s Note:

The use of alternatives to heparin in terms of managing anicoagulation doesn’t come up often.  So many of us get a bit rusty when it comes to using exotic agents such as Ancrod (Hirudin), Angiomax and similar agents.

So here is a brief refresher, and as always- a disclaimer here:  Use this information with due prejudice, and verify through your own research and due diligence prior to implementing.

Angiomax Perfusion Considerations

• Reconstitute Angiomax in OR- 250 mg in powder with 5 cc NSS=  50 mg per ml.
• No heparin coated surfaces (circuit, CDI, Swann Ganz– etc)
• Angiomax ½ life = 25 minutes
• Will precipitate if blood is allowed to pool
• Observed clot in the pericardium (after Angiomax is bolused)  is Normal- remove with cell saver suction- Not pump suckers!

• Angiomax is excreted via kidneys- Diurese postoperatively to get ACT back to baseline.
• Vancomycin may inhibit function of Angiomax.  Uses dedicated infusion pump to avoid contact with vancomycin.

 

Dosing

• Target ACT is 500 seconds
• 1 mg per kg for initial dose (off pump)
• Maintenance Dose:  1.75 mg/kg/hr (increase in 0.15 to 0.45 mg/kg/hr  increments)

 

Perfusion Circuit:

Prime: Normal  Add 50 mg Angiomax

Cardioplegia–  Prefer Crystalloid only (if using blood- always recirculate Cardioplegia to Avoid Stasis!

Arterial Venous Bridge at field to recirculate after CPB

Remove CDI (Heparin issue)

Use Hemoconcentrator Only when rewarming- remove 300 cc and test act.

Continue with that algorithm- not allowing ACT to fall below 300 on CPB.

 

Other Considerations

Cooling Potentiates Action of Angiomax- and Warming accelerates excretion.

Rewarming and maintaining core temp at 37 Celsius is key- for Angiomax reversal!

Put 50 mg Angiomax in Pump after coming off bypass.