intraoperative protamine reactions rebecca tisdale, t4

Intraoperative Protamine ReactionsRebecca Tisdale, T4

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

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

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

Risk factors: Insulin use Vasectomy Fish allergy Previous exposure Rapid rate of infusion


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


Treatment(cont) May need to reheparinize and return to

CPB Inotropic support: epinephrine,

milrinone, isoproterenol Nebulized albuterol if bronchospasm,

elevated airway pressure


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


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 rebecca tisdale, t4

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