CASE REPORT
The plight of protamine for heparin reversal in sensitized individuals
,
 
,
 
 
 
More details
Hide details
1
Department of Anesthesiology, Emory University, Atlanta, GA, USA
 
 
Submission date: 2016-07-27
 
 
Acceptance date: 2017-02-21
 
 
Online publication date: 2017-07-03
 
 
Publication date: 2020-03-22
 
 
Corresponding author
Vinita Singh   

Department of Anesthesiology, Emory University, 1365 Clifton Rd., Atlanta 30322, GA, USA. Fax: +1 404 686 4475.
 
 
Pol. Ann. Med. 2017;24(2):264-267
 
KEYWORDS
ABSTRACT
Introduction:
Anaphylaxis to protamine is a rare and potentially fatal complication. Risk factors for protamine reaction may include history of prior cardiac surgery (with intraoperative protamine exposure), true fish allergy (as protamine is commonly derived from salmon sperm), history of vasectomy (due to formation of anti-sperm antibodies), insulindependent diabetes (due to exposure to neutral protamine Hagedorn (NPH) and other protamine containing forms of insulin), as well as excessively rapid administration of protamine.

Aim:
To report a case of anaphylaxis to protamine, increase awareness of protamine anaphylaxis and its treatments.

Case study:
Our patient had several risk factors not identified preoperatively and experienced a type 1 allergic reaction with anaphylaxis upon protamine administration. The patient was appropriately treated and made a full recovery from this potentially catastrophic event.

Results and discussion:
We present this case of a known drug reaction to remind our colleagues of the importance of screening for risk factors for protamine reaction, which include: shellfish allergy, insulin-dependent diabetes, prior protamine exposure, and vasectomy. The patient presented in this case had risk factors for allergic reaction to protamine including prior protamine exposure and vasectomy. The risks and benefits of protamine administration in a patient with multiple risk factors for protamine reaction are discussed, as is the controversy surrounding the clinical utility (or lack thereof) for protamine administration in elective peripheral vascular procedures.

Conclusions:
Identification of patient risk factors prior to protamine administration could result in (1) avoidance of protamine administration or (2) improved preparation for potential anaphylaxis.

REFERENCES (19)
1.
Weiler JM, Gellhaus MA, Carter JG, et al. A prospective study of the risk of an immediate adverse reaction to protamine sulfate during cardiopulmonary bypass surgery. J Allergy Clin Immunol. 1990;85(4):713–719.
 
2.
Levy JH, Zaidan JR, Faraj B. Prospective evaluation of risk of protamine reactions in patients with NPH insulindependent diabetes. Anesth Analg. 1986;65(7):739–742.
 
3.
Kimmel SE, Sekeres MA, Berlin JA, Ellison N, DiSesa VJ, Strom BL. Risk factors for clinically important adverse events after protamine administration following cardiopulmonary bypass. J Am Coll Cardiol. 1998;32(7):1916–1922.
 
4.
Freundlich RE, Duggal NM, Housey M, Tremper TT, Engoren MC, Kheterpal S. Intraoperative medications associated with hemodynamically significant anaphylaxis. J Clin Anesth. 2016;35:415–423.
 
5.
Vezina D, Sheridan P, Blain R, Roberts KD, Bleau G. Safety of protamine sulfate administration in vasectomized men. Contraception. 1990;[28TD$DIF]41(6):605–616.
 
6.
Adourian U, Shampaine EL, Hirshman CA, Fuchs E, Adkinson Jr NF. High-titer protamine-specific IgG antibody associated with anaphylaxis: report of a case and quantitative analysis of antibody in vasectomized men. Anesthesiology. 1993;78(2):368–372.
 
7.
Finkelman FD, Rothenberg ME, Brandt EB, Morris SC, Strait RT. Molecular mechanisms of anaphylaxis: lessons from studies with murine models. J Allergy Clin Immunol. 2005;115(3):449–457. quiz 458.
 
8.
Simons KJ, Simons FE. Epinephrine and its use in anaphylaxis: current issues. Curr Opin Allergy Clin Immunol. 2010;10(4):354–361.
 
9.
Vadas P, Perelman B. Effect of epinephrine on plateletactivating factor-stimulated human vascular smooth muscle cells. J Allergy Clin Immunol. 2012;129(5):1329–1333.
 
10.
Westfall TC, Westfall WD. In: Brunton LL, Chabner BA, Knollmann BC, eds. Goodman & Gilman's: The Pharmacological Basis of Therapeutics. McGraw Hill; 2011.
 
11.
Campbell RL, Bellolio MF, Knutson BD, et al. Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine. J Allergy Clin Immunol Pract. 2015;3(1):76–80.
 
12.
Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 suppl 3):S640–S656.
 
13.
Khoueiry G, Abi Rafeh N, Azab B, et al. Reverse Takotsubo cardiomyopathy in the setting of anaphylaxis treated with high-dose intravenous epinephrine. J Emerg Med. 2013;44(1):96–99.
 
14.
Lieberman P, Simons FE. Anaphylaxis and cardiovascular disease: therapeutic dilemmas. Clin Exp Allergy. 2015;45(8):1288–1295.
 
15.
Levy JH, Yegin A. Anaphylaxis. What is monitored to make a diagnosis? How is therapy monitored? Anesthesiol Clin North Am. 2001;19(4):705–715.
 
16.
Hepner DL, Castells MC. Anaphylaxis during the perioperative period. Anesth Analg. 2003;97(5):1381–1395.
 
17.
Cohen JA, Kaplan FEJ. Plasma heparin activity and antagonism during cardiopulmonary bypass with hypothermia. Anesth Analg. 1977;56:564–569.
 
18.
Dorman BH, Elliott BM, Spinale FG, et al. Protamine use during peripheral vascular surgery: a prospective randomized trial. J Vasc Surg. 1995;22(3):248–255. discussion, 256.
 
19.
Roelofse JA, van der Bijl P. An anaphylactic reaction to protamine sulfate. Anesth Prog. 1991;38(3):99–100.
 
Journals System - logo
Scroll to top