intraoperative protamine reactions rebecca tisdale, t4
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Intraoperative Protamine ReactionsRebecca Tisdale, T4
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Intraoperative protamine reactions Protamine
Nitrogenous alkaline protein from salmon sperm
2/3’s arginine(++++), complexes with sulfate groups of heparin
2 active sites: one neutralizes heparin, 1 exerts mild anticoagulatory effect
Uses: antidote for heparin overdose, during CPB, NPH insulin
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Intraoperative protamine reactions Protamine dosing(varies widely)
Protamine titration tests at end of CPB to determine amount of heparin still remaining
1 mg/100 units of heparin separated into 2 doses: initial dose(75% total) after CPB and second dose(25% total) after reinfusion of blood from bypass circuit
***give over 5 minutes or longer
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Adverse reactions(0.06%-10.7%) Peripheral cardiovascular changes
Systemic hypotension Increased pulmonary artery pressure
Pulmonary changes: Bronchospasm
Thrombocytopenia Cutaneous:
Severe angioedema, erythema, pruitis, flushing
Other: Chills, fever, nausea, vomiting, chest pain
Intraoperative protamine reactions
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Risk factors: Insulin use Vasectomy Fish allergy Previous exposure Rapid rate of infusion
Intraoperative protamine reactions
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Treatment If patient at risk, consider non-heparin
based CPB, OPCPB, heparinase, foregoing heparin reversal
Mild hypotension is often improved by slowing/stopping protamine infusion and increasing IVF’s
Consider phenylephrine, ephedrine
Intraoperative protamine reactions
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Treatment(cont) May need to reheparinize and return to
CPB Inotropic support: epinephrine,
milrinone, isoproterenol Nebulized albuterol if bronchospasm,
elevated airway pressure
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Alternatives to protamine Hexadimethrine(Polybrene)
synthetic polycation 1.1-2 times more potent Systemic hypotension when adminstered
rapidly Renal toxicity
Heparinase Bonded to exit filter Systemic administration
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References Kaplan, Joel A. . Kaplan: Essentials of Cardiac Anesthesia, 1st
ed.. 1. Philadelphia: Saunders, 2008. Miller, Ronald D. . Miller's Anesthesia. 7th ed. New York :
Churchill Livingstone, 2009. 1902-1904. Porsche, Renate, and Zara Brenner. "Allergy to protamine
sulfate." Heart and Lung. 28.6 (1999): 418-428.
Intraoperative protamine reactions