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Arima T, Tatebayashi T, Noji S. Management of fulminating non-cardiogenic pulmonary edema following cardiac surgery. J Surg Case Rep 2023; 2023:rjac625. [PMID: 36636649 PMCID: PMC9831641 DOI: 10.1093/jscr/rjac625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 12/14/2022] [Indexed: 01/11/2023] Open
Abstract
A malignant form of non-cardiogenic pulmonary edema (NCPE) that develops soon after the termination of cardiopulmonary bypass support during cardiac surgery is rarely encountered. It sometimes requires immediate management, including venovenous extracorporeal membrane oxygenation (VV-ECMO). In the first case, a 78-year-old female patient experienced fulminating NCPE after mitral valve plasty, which caused severe respiratory failure and hemodynamic instability due to a huge amount of sputum. In the second case, a 47-year-old male patient presented with right-sided unilateral pulmonary edema with a substantial amount of sputum after minimally invasive cardiac surgery for mitral valve repair. In both cases, VV-ECMO and aggressive fluid replacement were promptly initiated. The NCPE resolved on post-operative day 2, resulting in the successful termination of VV-ECMO. NCPE leads to lethal respiratory failure with multifactorial causes during cardiac surgery. However, as NCPE is potentially transient, immediate treatment comprising VV-ECMO and aggressive fluid replacement can improve clinical outcomes.
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Affiliation(s)
- Takahiro Arima
- Correspondence address. Department of Surgery, Higashiyamato Hospital, 1-13-12, Nangai, Higashiyamato 207-0014, Tokyo. Tel: +81-42-562-1411; Fax: +81-42-562-1399; E-mail:
| | | | - Sakashi Noji
- Department of Surgery, Higashiyamato Hospital, Higashiyamato, Tokyo
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2
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Bailly A, Gaillard C, Cadiet J, Fortuit C, Roux F, Morin H, Desanlis E, LE Teurnier Y, Miguet B, Robert D, Silleran J, Rigal JC, LE Thuaut A, Pere M, Roussel JC, Rozec B. Evaluation of the impact of HMS Plus on postoperative blood loss compared with ACT Plus in cardiac surgery. Minerva Anestesiol 2021; 87:1191-1199. [PMID: 34102807 DOI: 10.23736/s0375-9393.21.15482-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The standardized management of anticoagulation during the cardiopulmonary bypass seems inaccurate because of patients and surgeries variability. This study evaluates if an individualized management of heparin and protamine guided by the HMS Plus system during cardiopulmonary bypass could reduce postoperative blood loss. METHODS We conducted a prospective, controlled, unblinded, single-center study. 188 patients operated for cardiac surgery were included. Patients were divided in ACT Plus group (standardized approach) and HMS Plus group (individualized approach). The primary outcome was blood-loss volume during the first 24 postoperative hours. The main secondary outcomes were the need for allogeneic blood transfusions and the final protamine/heparin ratio. RESULTS There was no difference between the two groups for baseline characteristics. Medium bloodloss volume (±DS) in the ACT Plus group was 522 mL ±260 mL vs. 527 mL ±255 mL in the HMS Plus group (P = 0.58). The final protamine/heparin ratio (±DS) in the ACT Plus group was 0.94 ±0.1 vs. 0.58 ± 0.1 in the HMS Plus group (P < 0.0001). The transfusion rate during surgery in the ACT Plus group was 25% vs. 14% in the HMS Plus group (P = 0.09). CONCLUSIONS HMS Plus did not reduce the mean blood-loss volume during the first 24 postoperative hours compared with ACT Plus. Its utility for potential transfusion rate reduction remains to be proven.
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Affiliation(s)
- Arthur Bailly
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France -
| | - Côme Gaillard
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Julien Cadiet
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Camille Fortuit
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - François Roux
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Hélène Morin
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Enguerrand Desanlis
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Yann LE Teurnier
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Bertrand Miguet
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - David Robert
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Jacqueline Silleran
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Jean-Christophe Rigal
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Aurélie LE Thuaut
- Department of Methodology and Biostatistics, University Hospital of Nantes, Nantes, France
| | - Morgane Pere
- Department of Methodology and Biostatistics, University Hospital of Nantes, Nantes, France
| | - Jean-Christian Roussel
- Department of Thoracic and Cardiovascular Surgery, Université de Nantes, CHU Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - Bertrand Rozec
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France.,Université de Nantes, CHU Nantes, Nantes, France
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3
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Kalaska B, Kamiński K, Miklosz J, Nakai K, Yusa SI, Pawlak D, Nowakowska M, Mogielnicki A, Szczubiałka K. Anticoagulant Properties of Poly(sodium 2-(acrylamido)-2-methylpropanesulfonate)-Based Di- and Triblock Polymers. Biomacromolecules 2018; 19:3104-3118. [DOI: 10.1021/acs.biomac.8b00691] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, Mickiewicza 2c, 15-089 Bialystok, Poland
| | - Kamil Kamiński
- Faculty of Chemistry, Jagiellonian University, Gronostajowa 2, 30-387 Kraków, Poland
| | - Joanna Miklosz
- Department of Pharmacodynamics, Medical University of Bialystok, Mickiewicza 2c, 15-089 Bialystok, Poland
| | - Keita Nakai
- Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, 2167 Shosha, Himeji, Hyogo 671-2280, Japan
| | - Shin-Ichi Yusa
- Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, 2167 Shosha, Himeji, Hyogo 671-2280, Japan
| | - Dariusz Pawlak
- Department of Pharmacodynamics, Medical University of Bialystok, Mickiewicza 2c, 15-089 Bialystok, Poland
| | - Maria Nowakowska
- Faculty of Chemistry, Jagiellonian University, Gronostajowa 2, 30-387 Kraków, Poland
| | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, Mickiewicza 2c, 15-089 Bialystok, Poland
| | - Krzysztof Szczubiałka
- Faculty of Chemistry, Jagiellonian University, Gronostajowa 2, 30-387 Kraków, Poland
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4
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Kunz SA, Miles LF, Ianno DJ, Mirowska-Allen KL, Matalanis G, Bellomo R, Seevanayagam S. The effect of protamine dosing variation on bleeding and transfusion after heparinisation for cardiopulmonary bypass. Perfusion 2018; 33:445-452. [PMID: 29544405 DOI: 10.1177/0267659118763043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Accurate dosing of protamine reversal following on-pump cardiac surgical procedures is challenging, with both excessive and inadequate administration recognised to increase bleeding risk. We aimed to examine the relationship between three ratios for heparin reversal and markers of haemostasis. METHODS A retrospective analysis of a prospectively collected database was undertaken at a single tertiary cardiac unit, reviewing all cases of on-pump coronary artery bypass grafts and single valve replacements from 01/01/2011 to 31/12/2015. The ratio between total intra-operative heparin and protamine was stratified to three groups (low: ≤0.6 mg per 100 IU of heparin, moderate: 0.6-1.0 and high: >1.0) and related to the primary outcome of red blood cell (RBC) transfusion, with secondary outcomes being the number of units transfused, the haemoglobin differential and mediastinal drain output at 4 hours. RESULTS Of the 803 patients identified, 338 received a blood transfusion, with 1035 units being used. Eighteen percent of individuals (145) received a low ratio, 50% (404) received a moderate ratio and 32% (254) a high ratio. Using the moderate group as a reference, the low dose group was 56.5% less likely to have received a RBC transfusion (OR 0.435; 95% CI 0.270:0.703 p=0.001) while the high dose group carried a 241% increased association with transfusion (OR 3.412; 95% CI 2.399:4.853 p<0.001). For those transfused, a lower protamine:heparin ratio was associated with a lower number of units transfused, lesser haemoglobin differential and less mediastinal drain output. CONCLUSION Higher doses of intra-operative protamine relative to heparin are associated with greater risk of transfusion and post-operative bleeding.
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Affiliation(s)
- Stephen A Kunz
- 1 Department of Cardiac Surgery, Austin Health, Heidelberg, Victoria, Australia.,2 School of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Lachlan F Miles
- 3 Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Damian J Ianno
- 2 School of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | | | - George Matalanis
- 1 Department of Cardiac Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Rinaldo Bellomo
- 2 School of Medicine, The University of Melbourne, Parkville, Victoria, Australia.,4 Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Siven Seevanayagam
- 1 Department of Cardiac Surgery, Austin Health, Heidelberg, Victoria, Australia
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5
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Sheu R, Berfield K, Jones S, Pal J, Mackensen GB. Intraoperative Acute Multivessel Coronary Vasospasm in Cardiac Allograft: A Case Report. ACTA ACUST UNITED AC 2017; 9:328-331. [PMID: 28727596 DOI: 10.1213/xaa.0000000000000608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present a patient who developed acute intraoperative cardiac failure requiring open cardiac message immediately after uncomplicated heart transplantation. After successful resuscitation and establishment of extracorporeal membrane oxygenation, coronary angiography showed diffuse multivessel coronary vasospasm, which responded to intracoronary and IV administration of vasodilators. Cardiac function gradually improved and the patient was discharged home after a prolonged hospital course. Cardiac allograft dysfunction associated with coronary vasospasm immediately after heart transplantation has not previously been reported.
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Affiliation(s)
- Richard Sheu
- From the Department of Anesthesiology & Pain Medicine and Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - Kathleen Berfield
- From the Department of Anesthesiology & Pain Medicine and Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - Stephanie Jones
- From the Department of Anesthesiology & Pain Medicine and Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - Jay Pal
- From the Department of Anesthesiology & Pain Medicine and Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - G Burkhard Mackensen
- From the Department of Anesthesiology & Pain Medicine and Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
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6
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Miles LF, Marchiori P, Falter F. Pilot validation of an individualised pharmacokinetic algorithm for protamine dosing after systemic heparinisation for cardiopulmonary bypass. Perfusion 2017; 32:481-488. [PMID: 28820026 DOI: 10.1177/0267659117695881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION This manuscript represents a pilot study assessing the feasibility of a single-compartment, individualised, pharmacokinetic algorithm for protamine dosing after cardiopulmonary bypass. METHODS A pilot cohort study in a specialist NHS cardiothoracic hospital targeting patients undergoing elective cardiac surgery using cardiopulmonary bypass. Patients received protamine doses according to a pharmacokinetic algorithm (n = 30) or using an empirical, fixed-dose model (n = 30). Categorical differences between the groups were evaluated using the Chi-squared test or Fisher's exact test. Continuous data was analysed using a paired Student's t-test for parametric data and the paired samples Wilcoxon test for non-parametric data. RESULTS Patients who had protamine dosing according to the algorithm demonstrated a lower protamine requirement post-bypass relative to empirical management as measured by absolute dose (243 ± 49mg vs. 305 ± 34.7mg; p<0.001) and the heparin to protamine ratio (0.79 ± 0.12 vs. 1.1 ± 0.15; p<0.001). There was no difference in the pre- to post-bypass activated clotting time (ACT) ratio (1.05 ± 0.12 vs. 1.02 ± 0.15; p=0.9). Patients who received protamine according to the algorithm had no significant difference in transfusion requirement (13.3% vs. 30.0%; p=0.21). CONCLUSIONS This study showed that an individualized pharmacokinetic algorithm for the reversal of heparin after cardiopulmonary bypass is feasible in comparison with a fixed dosing strategy and may reduce the protamine requirement following on-pump cardiac surgery.
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Affiliation(s)
- Lachlan F Miles
- 1 Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | | | - Florian Falter
- 3 Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, UK
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7
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Pezzella AT, Ascioti A, Ricardi P. Noncardiogenic pulmonary oedema following cardiopulmonary bypass: report of two cases and review of the literature. Perfusion 2016. [DOI: 10.1177/026765918800300104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Two cases of noncardiogenic pulmonary oedema following cardiopulmonary bypass are presented. The clinical manifestations, postulated pathogenesis and management are discussed. A recent review of the literature fails to yield a unified explanation of this rare but often disastrous entity.
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8
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Affiliation(s)
- Claes Arén
- Department of Thoracic and Cardiovascular Surgery, Sahlgrenska sjukhuset, Gothenburg
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9
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Abstract
We recently encountered a patient who had severe cardiovascular collapse following administration of protamine. This severe protamine reaction was resistant to all forms of pharmacological therapy except for heparinization. Heparinization resulted in immediate reversal of the cardiovascular collapse.
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10
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Sokolowska E, Kalaska B, Kaminski K, Lewandowska A, Blazejczyk A, Wietrzyk J, Kasacka I, Szczubialka K, Pawlak D, Nowakowska M, Mogielnicki A. The Toxicokinetic Profile of Dex40-GTMAC3-a Novel Polysaccharide Candidate for Reversal of Unfractionated Heparin. Front Pharmacol 2016; 7:60. [PMID: 27014072 PMCID: PMC4794501 DOI: 10.3389/fphar.2016.00060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/01/2016] [Indexed: 01/15/2023] Open
Abstract
Though protamine sulfate is the only approved antidote of unfractionated heparin (UFH), yet may produce life threatening side effects such as systemic hypotension, catastrophic pulmonary vasoconstriction or allergic reactions. We have described 40 kDa dextrans (Dex40) substituted with glycidyltrimethylammonium chloride (GTMAC) as effective, immunogenically and hemodynamically neutral inhibitors of UFH. The aim of the present study was to evaluate in mice and rats toxicokinetic profile of the most promising polymer—Dex40-GTMAC3. Polymer was rapidly eliminated with a half-time of 12.5 ± 3.0 min in Wistar rats, and was mainly distributed to the kidneys and liver in mice. The safety studies included the measurement of blood count and blood biochemistry, erythrocyte osmotic fragility and the evaluation of the histological alterations in kidneys, liver and lungs of mice and rats in acute and chronic experiments. We found that Dex40-GTMAC3 is not only effective but also very well tolerated. Additionally, we found that protamine may cause overt hemolysis with appearance of permanent changes in the liver and kidneys. In summary, fast renal clearance behavior and generally low tissue accumulation of Dex40-GTMAC3 is likely to contribute to its superior to protamine biocompatibility. Intravenous administration of therapeutic doses to living animals does not result in the immunogenic, hemodynamic, blood, and organ toxicity. Dex40-GTMAC3 seems to be a promising effective and safe candidate for further clinical development as new UFH reversal agent.
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Affiliation(s)
- Emilia Sokolowska
- Department of Pharmacodynamics, Medical University of Bialystok Bialystok, Poland
| | - Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok Bialystok, Poland
| | - Kamil Kaminski
- Faculty of Chemistry, Jagiellonian University Krakow, Poland
| | - Alicja Lewandowska
- Department of Histology and Cytophysiology, Medical University of Bialystok Bialystok, Poland
| | - Agnieszka Blazejczyk
- Department of Experimental Oncology, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences Wroclaw, Poland
| | - Joanna Wietrzyk
- Department of Experimental Oncology, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences Wroclaw, Poland
| | - Irena Kasacka
- Department of Histology and Cytophysiology, Medical University of Bialystok Bialystok, Poland
| | | | - Dariusz Pawlak
- Department of Pharmacodynamics, Medical University of Bialystok Bialystok, Poland
| | | | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok Bialystok, Poland
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11
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Imidazolium salts as small-molecule urinary bladder exfoliants in a murine model. Antimicrob Agents Chemother 2015; 59:5494-502. [PMID: 26124168 DOI: 10.1128/aac.00881-15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 06/19/2015] [Indexed: 01/19/2023] Open
Abstract
We present a novel family of small-molecule urinary bladder exfoliants that are expected to be of great value in preclinical studies of urologic conditions and have improved potential for translation compared with prior agents. There is broad urologic interest in the therapeutic potential of such exfoliating agents. The primary agent used in preclinical models, the cationic peptide protamine sulfate (PS), has limited translational potential due to concerns including systemic adverse reactions and bladder tissue injury. Intravesical application of a safe, systemically nontoxic exfoliant would have potential utility in the eradication of Escherichia coli and other uropathogens that reside in the bladder epithelium following cystitis, as well as in chronic bladder pain and bladder cancer. Here, we introduce a family of imidazolium salts with potent and focused exfoliating activity on the bladder epithelium. Synthesis and purification were straightforward and scalable, and the compounds exhibited prolonged stability in lyophilized form. Most members of the compound family were cytotoxic to cultured uroepithelial cells, with >10-fold differences in potency across the series. Upon topical (intravesical) administration of selected compounds to the murine bladder, complete epithelial exfoliation was achieved with physiologically relevant imidazolium concentrations and brief contact times. The exfoliative activity of these compounds was markedly improved in comparison to PS, as assessed by microscopy, immunofluorescence, and immunoblotting for uroplakins. Bladder uroepithelium regenerated within days to yield a histologically normal appearance, and no toxicity was observed. Finally, the chemical scaffold offers an opportunity for inclusion of antimicrobials or conjugation with chemotherapeutic or other moieties.
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12
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Pasalic L, Favaloro EJ. The new and the old of heparin-induced thrombocytopenia. ACTA ACUST UNITED AC 2015; 53:149-52. [DOI: 10.1515/cclm-2014-0983] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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13
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Bignami E, Frati E, Meroni R, Verzini A, Pozzoli A, Benussi S, Alfieri O. Extracorporeal Venovenous Membrane Oxygenation in the Treatment of Respiratory Insufficiency Following Cardiac Surgery. J Card Surg 2014; 29:270-3. [DOI: 10.1111/jocs.12278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Elena Bignami
- Department of Cardio-Thoracic and Vascular Anesthesia; San Raffaele Hospital; Milan Italy
| | - Elena Frati
- Department of Cardio-Thoracic and Vascular Anesthesia; San Raffaele Hospital; Milan Italy
| | - Roberta Meroni
- Department of Cardio-Thoracic and Vascular Anesthesia; San Raffaele Hospital; Milan Italy
| | | | - Alberto Pozzoli
- Department of Cardiac Surgery; San Raffaele Hospital; Milan Italy
| | - Stefano Benussi
- Department of Cardiac Surgery; San Raffaele Hospital; Milan Italy
| | - Ottavio Alfieri
- Department of Cardiac Surgery; San Raffaele Hospital; Milan Italy
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14
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Cationic derivative of dextran reverses anticoagulant activity of unfractionated heparin in animal models of arterial and venous thrombosis. Eur J Pharmacol 2012; 686:81-9. [DOI: 10.1016/j.ejphar.2012.04.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 04/13/2012] [Accepted: 04/21/2012] [Indexed: 11/21/2022]
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16
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Milot J, Perron J, Lacasse Y, Létourneau L, Cartier PC, Maltais F. Incidence and predictors of ARDS after cardiac surgery. Chest 2001; 119:884-8. [PMID: 11243972 DOI: 10.1378/chest.119.3.884] [Citation(s) in RCA: 121] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Severe pulmonary injury with the development of ARDS is a potential complication of cardiac surgery and cardiopulmonary bypass (CPB). STUDY OBJECTIVES This retrospective, case-control study was designed to determine the incidence and mortality of ARDS after cardiac surgery and CPB, as well as to identify preoperative and perioperative predisposing factors of this complication. METHODS Of 3,278 patients who underwent cardiac surgery and CPB between January 1995 and December 1998, 13 patients developed ARDS during the postoperative period. Each patient was matched with four or five control subjects who had the same type of surgery on the same day but did not develop postoperative respiratory complications. RESULTS The incidence of ARDS was 0.4%, with an ARDS mortality of 15%. In the ARDS group, 38% had previous cardiac surgery, as compared to 3.5% in the control group (p < 0.002). During the postoperative period, ARDS patients received more blood products (4 +/- 5 vs 2 +/- 3; p < 0.01) and developed shock more frequently (31% vs 5%; p < 0.02) than patients in the control group. Multivariate regression analysis identified previous cardiac surgery, shock, and the number of transfused blood products as significant independent predictors for ARDS, with odds ratios of 31.5 (p = 0.015), 10.8 (p = 0.03), and 1.6 (p = 0.03), respectively. CONCLUSIONS ARDS following cardiac surgery and CPB was a rare complication that carried a 15% mortality rate. Previous cardiac surgery, shock, and number of blood products received are important predicting factors for this complication.
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Affiliation(s)
- J Milot
- Centre de Recherche, Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l'Université Laval, Sainte-Foy, Québec, Canada
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17
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Urdaneta F, Lobato EB, Kirby RR, Horrow JC. Noncardiogenic pulmonary edema associated with protamine administration during coronary artery bypass graft surgery. J Clin Anesth 1999; 11:675-81. [PMID: 10680112 DOI: 10.1016/s0952-8180(99)00120-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Protamine sulfate is the only agent approved to reverse heparin-induced anticoagulation. As with any other drug, protamine has the potential to cause adverse effects that range from mild hypotension to potentially fatal events, such as noncardiogenic pulmonary edema (NCPE) and catastrophic pulmonary vasoconstriction. We report a case of NCPE after the administration of protamine to a patient undergoing coronary artery bypass graft surgery and discuss the diagnosis and management of this severe adverse event.
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Affiliation(s)
- F Urdaneta
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville 32610-0254, USA
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18
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Brooks JC. Noncardiogenic pulmonary edema immediately following rapid protamine administration. Ann Pharmacother 1999; 33:927-30. [PMID: 10492491 DOI: 10.1345/aph.18341] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report the case of a rare, potentially preventable, immediate noncardiogenic pulmonary edema reaction to the rapid administration of protamine during coronary artery bypass graft (CABG) surgery. CASE SUMMARY A 74-year-old white man was administered a 250-mg bolus of protamine sulfate toward the end of CABG surgery to reverse the heparin anticoagulation. Immediately following the administration of protamine, oxygen saturation declined, pink frothy sputum was suctioned from the trachea, and 1500 mL of serous fluid was removed from the airway. The patient was stabilized, but the surgeons were unable to close his chest because of the profound edema. Chest closure occurred on hospital day 6, with discharge from the intensive care unit on hospital day 28. DISCUSSION Noncardiogenic pulmonary edema is a rare adverse event that occurs in 0.2% of cardiopulmonary bypass patients, with mortality rates approaching 30%. Complement activation or direct pharmacologic release of histamine by high concentrations of protamine is the suspected cause. High concentrations of protamine in the lungs may directly release histamine, with significant vasodilating effects. CONCLUSIONS Immediate reversal of heparin anticoagulation with protamine is necessary to control bleeding; however, rapid protamine injection can be associated with life-threatening pulmonary edema. Slower, cautious administration and accurate calculation of protamine doses may prevent such an event.
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Affiliation(s)
- J C Brooks
- Intensive Care, Veterans Affairs Medical Center, Gainesville, FL 32608, USA.
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Silver PJ, Broughton R, Bouthillier J, Quinn TA, Wallace AM, Weishaar RE. Neutralase reverses the anti-coagulant but not the anti-thrombotic activity of heparin in a rabbit model of venous thrombosis. Thromb Res 1998; 91:143-50. [PMID: 9733158 DOI: 10.1016/s0049-3848(98)00093-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Neutralase (heparinase I; E.C. 4.2.2.7) is a heparin-degrading enzyme undergoing clinical evaluation as an alternative to protamine for reversing the anticoagulant effects of heparin in coronary bypass surgery. The objective of this study was to assess the relative effects of Neutralase and protamine on reversal of heparin-dependent elevations in coagulation parameters and inhibition of clot formation in a rabbit vena caval stasis model. Rabbits were treated with saline or heparin (300 U/kg) for 10 minutes, followed by saline, protamine (2.6 mg/kg), or Neutralase (10 or 30 microg/kg, representing 1.23 IU/kg and 3.69 IU/kg, respectively). Twenty minutes later, venous stasis was induced, and vena caval clots were excised, weighed, and characterized. Coagulation parameters [activated partial thromboplastin time (aPTT) and thrombin clotting time (TCT)] and antiFactor IIa and Xa levels were measured throughout the protocol. Both protamine and Neutralase reversed heparin-mediated increases in aPTT (>300 seconds to 26-35 seconds) and TCT (>300 seconds to 29-56 seconds) to values that were not different from saline-treated, nonheparinized animals. Thrombus weight in the nonheparinized saline group was 62+/-7 mg; heparin-treated animals had no detectable clots. Protamine reversal of heparin was associated with clot formation (89+/-20 mg) while Neutralase reversal was not (no clots). Heparin-induced increases in antiFactor IIa activity were reversed similarly by protamine and Neutralase (from 4.3-8.8 U/ml to 0.2-0.3 U/ml) while antiFactor Xa activity was differentially reversed (from 3.9-5.9 U/ml to 0.7-1.3 U/ml Neutralase; 5.5 U/ml to 0.02 U/ml protamine). These results are consistent with a hypothesis that Neutralase cleaves heparin into fragments, which are devoid of antiFactor IIa activity that retain modest antiFactor Xa activity, resulting in reversal of anticoagulant, but not antithrombotic, heparin activity. This property of Neutralase may be beneficial in reducing post-surgical thrombotic events after reversal of heparin.
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Affiliation(s)
- P J Silver
- IBEX Technologies Inc., Malvern, Pennsylvania 19355, USA.
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20
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Abstract
Protamine reversal of heparin anticoagulation occasionally results in pulmonary hypertension as well as systemic hypotension. To examine the contribution of blood components to this induction of pulmonary hypertension, we developed an isolated rat lung perfusion model and perfused heparinized plasma, heparinized serum, and Hepes (4% bovine serum albumin, 20 mM N-2-hydroxyethylpiperazine-N'-2-ethanesulfonic acid, 5 mM glucose, in warm physiological saline) buffer solution with or without fibrinogen. Perfusion with heparinized plasma and Hepes buffer solution with fibrinogen caused pulmonary hypertension; perfusion with heparinized serum or Hepes buffer solution without fibrinogen did not, suggesting that fibrinogen is involved in the induction of pulmonary hypertension. We also labeled protamine with 125I and compared the amounts of protamine accumulating in the lung with different concentrations of fibrinogen. The amount of protamine trapped in the lung increased according to the concentration of fibrinogen. Fibrinogen may accelerate the reaction between pulmonary endothelial cells and protamine or protamine-heparin complexes. In the mechanism of protamine-induced pulmonary hypertension, fibrinogen, as well as heparin and protamine, may be an essential component.
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Affiliation(s)
- M Sogawa
- Institute for Biomedical Engineering, University of Utah, 803 North 300 West, Salt Lake City, Utah 84103, USA
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21
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Funaki B, Szymski GX, Hackworth CA, Rosenblum JD. Vascular or interventional procedures in patients with diabetes. J Vasc Interv Radiol 1997; 8:1080. [PMID: 9399483 DOI: 10.1016/s1051-0443(97)70715-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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22
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Zavela NG, Gravlee GP, Benckart DH, Park SB, Gahtan V. Case 3--1996. Unusual cause of hypotension after cardiopulmonary bypass. J Cardiothorac Vasc Anesth 1996; 10:553-6. [PMID: 8776656 DOI: 10.1016/s1053-0770(05)80023-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- N G Zavela
- Department of Anesthesiology, Medical College of Pennsylvania, USA
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23
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Dehmer GJ, Fisher M, Tate DA, Teo S, Bonnem EM. Reversal of heparin anticoagulation by recombinant platelet factor 4 in humans. Circulation 1995; 91:2188-94. [PMID: 7697848 DOI: 10.1161/01.cir.91.8.2188] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Protamine is used to reverse the anticoagulant effects of heparin, but it can have important side effects. Platelet factor 4 (PF4) is a protein found in platelet alpha granules that binds to and thereby neutralizes heparin. We evaluated the safety and effectiveness of intravenous recombinant PF4 to neutralize heparin anticoagulation after cardiac catheterization in a phase 1, open-label trial. METHODS AND RESULTS The study group consisted of 18 patients having diagnostic cardiac catheterization. Heparin (5000 U) was given after vascular access was obtained. In the first 12 patients, additional heparin was given at the conclusion of the procedure so that all patients had activated coagulation times > 300 seconds before rPF4 was given. Three patients each received 0.5, 1.0, 2.5, or 5.0 mg/kg rPF4 over a period of 3 minutes at the conclusion of the catheterization procedure. In 6 additional patients, extra heparin was not given at the conclusion of the procedure, and 1.0 mg/kg rPF4 was given. Hemodynamic measurements, cardiac output, and serial blood tests were performed 5, 10, 20, and 30 minutes after rPF4 and then into the next 24 hours. There were no serious side effects in any patient, despite transient rPF4 levels as high as 14,870 ng/mL in the patients receiving 5.0 mg/kg. One patient receiving 2.5 mg/kg had a slight transient rise in liver enzymes possibly related to the rPF4. There were no important hemodynamic effects of rPF4 administration at any dose used. Doses of 2.5 and 5.0 mg/kg were uniformly effective in reversing the anticoagulant effect of heparin. At lower doses, rPF4 neutralized the effects of heparin in most but not all patients. Pharmacokinetic analysis suggested a monophasic and one-compartment clearance of the PF4-heparin complex. No neutralizing factors to rPF4 were detected in the samples collected 7 days after dosing. CONCLUSIONS rPF4, in doses ranging from 0.5 to 5.0 mg/kg over 3 minutes, had no serious side effects. Given in sufficient amounts, rPF4 can completely and rapidly reverse the anticoagulant effects of heparin.
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Affiliation(s)
- G J Dehmer
- C.V. Richardson Cardiac Catheterization Laboratory, University of North Carolina Hospital, Chapel Hill 27514, USA
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24
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Katircioglu SF, Küçükaksu DS, Bozdayi M, Dalva K, Mavitaş B, Zorlutuna Y, Taşdemir O, Bayazit K. The beneficial effects of aminophylline administration on heparin reversal with protamine. Surg Today 1994; 24:99-102. [PMID: 8054806 DOI: 10.1007/bf02473388] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The aim of this study was to demonstrate the beneficial effects of aminophylline on protamine cardiotoxicity. Thirty-four patients were examined, 17 of whom received aminophylline 3 mg/kg before protamine administration, being the study group, while the other 17, being the control group, did not. All cardiac output and biochemical measurements were evaluated 5 min following protamine administration. The cAMP level was 43.4 +/- 3.51 pmol/ml in the study group and 18.7 +/- 2.98 in the control group (P < 0.0001) before protamine administration, while the oxygen extraction rate decreased from 49% to 44 +/- 2% in the control group, and from 51.2% to 47 +/- 3% in the study group (P < 0.03). The N-acetyl glucosaminidase value was 16.9 +/- 13.9 pmol/ml in the study group and 27.8 +/- 1.47 pmol/ml in the control group (P < 0.01), and myocardial lactate extraction was -0.20 +/- 0.03 in the control group and -0.07 +/- 0.07 in the study group (P < 0.001). The left ventricular stroke work index was 28.6 +/- 3.14 gm/m2 in the control group and 37 +/- 6.77 gm/m2 in the study group (P < 0.002). The findings of this study led us to conclude that the adverse effects of heparin neutralization using protamine can be relieved by aminophylline.
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Affiliation(s)
- S F Katircioglu
- Department of Cardiovascular Surgery, Türkiye Yüksek Ihtisas Hastanesi, Sihhiye, Ankara, Turkey
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26
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Elferink JG. Protamine-induced permeability changes in the neutrophil plasma membrane as the basis of activation of exocytosis. Cell Biochem Funct 1992; 10:35-40. [PMID: 1576729 DOI: 10.1002/cbf.290100107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Protamine induces a gradual change in plasma membrane permeability in rabbit neutrophils, which is evident from the increase of indol fluorescence, and the leakage of quin2 from quin2-loaded neutrophils. The influx of extracellular Ca2+ into the neutrophil provides an explanation for exocytosis which occurs in the presence of Ca2+ and protamine. The dependence of exocytosis on Ca2+ concentration follows the same pattern as is observed in neutrophils permeabilized by other means. In the absence of Ca2+, and in the presence of protamine, La3+ has an activating effect on exocytosis. At higher concentrations La3+ inhibits exocytosis that occurs in the presence of Ca2+ and protamine, as do some other metal ions. The resemblance between the membrane effects of a number of toxins, as reported in literature, and protamine-induced membrane damage suggests that they occur via the same mechanism.
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Affiliation(s)
- J G Elferink
- Department of Medical Biochemistry, University of Leiden, The Netherlands
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27
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Cook JJ, Niewiarowski S, Yan Z, Schaffer L, Lu W, Stewart GJ, Mosser DM, Myers JA, Maione TE. Platelet factor 4 efficiently reverses heparin anticoagulation in the rat without adverse effects of heparin-protamine complexes. Circulation 1992; 85:1102-9. [PMID: 1537108 DOI: 10.1161/01.cir.85.3.1102] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND It has been observed that the reversal of heparin anticoagulation in humans by protamine sulfate (PS) results in various adverse reactions including leukopenia, thrombocytopenia, activation of complement, increased vascular permeability, systemic hypotension, pulmonary vasoconstriction, and pulmonary edema. The purpose of this study was to compare the efficacy and effects of native platelet factor 4 (PF4) and recombinant platelet factor 4 (rPF4) with those of PS in heparin neutralization in vivo, using a rat model. METHODS AND RESULTS Sprague-Dawley rats were anesthetized with sodium pentobarbital, and the right femoral vein and carotid artery were cannulated. For determination of activated partial thromboplastin time, platelet count, white blood cell count, and complement titer, arterial blood samples were taken before and immediately after heparin (10 units/100 g) infusion and at several time points after the infusion of the neutralizing agent (PS, 0.1 mg/100 g; PF4, 0.5 mg/100 g). In separate groups of animals, mean arterial blood pressure was monitored throughout identical protocols and the lungs were prepared for histological examination. The anticoagulant activity of heparin was effectively reversed by all of the neutralizing agents (PS, PF4, and rPF4). Platelet count (48% of initial), white blood cell count (52% of initial), complement titer (60% of initial), and mean arterial pressure (20% decrease) decreased significantly in heparinized animals receiving PS but not in those receiving PF4 or rPF4. Lung interstitium appeared normal when heparin was followed by PF4; however, interstitial edema and hemorrhage were observed with heparin-PS. CONCLUSIONS These results suggest that PF4 efficiently reverses heparin anticoagulation in the rat without the adverse effects of heparin-protamine complexes. Therefore, rPF4 may be an appropriate substitute for PS in patients undergoing cardiovascular surgery and other procedures that require heparin anticoagulation.
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Affiliation(s)
- J J Cook
- Department of Physiology, Temple University School of Medicine, Philadelphia, PA 19140
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28
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Affiliation(s)
- C R Reed
- Division of Pulmonary and Critical Care Medicine, Medical College of Virginia, Richmond
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29
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Vincent GM, Janowski M, Menlove R. Protamine allergy reactions during cardiac catheterization and cardiac surgery: risk in patients taking protamine-insulin preparations. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1991; 23:164-8. [PMID: 1831070 DOI: 10.1002/ccd.1810230303] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Protamine insulin use may immunologically sensitize patients to protamine, leading to anaphylactoid reactions upon subsequent exposure to protamine sulfate during cardiac catheterization or cardiovascular surgery. The risk of such reactions in protamine insulin-dependent patients is uncertain. One catheterization study reported a 50-fold greater risk while a second showed no increased risk! To clarify the risk, the records of 7,750 cardiac catheterization procedures between 1984 and 1987 were analyzed for presence of NPH or PZI insulin use, protamine administration, and any complications or adverse reactions. Protamine was administered in 3,341/7,750 procedures (43%), including 171 in diabetics receiving NPH insulin. Adverse reactions to protamine occurred in 2/3, 170 noninsulin patients, 0.06%, and adverse reactions due to probable NPH insulin sensitization occurred in 1/171, 0.6%, of NPH diabetics, p = .034. Meta-analysis of risk showed an odds ratio of 7.96 for the NPH diabetic patients, and combining these results with the other large series in the literature (269 NPH diabetics total) showed an odds ratio of 4.19 compared to a non-NPH insulin group. Meta-analysis of the surgical literature showed the risk in surgical patients to be 2.1% in NPH patients versus 0.12% with no NPH, with an odds ratio of 15.52. The greater incidence in surgical patients may be due to protamine sensitization at prior catheterization and to the larger dose of protamine administered to surgical patients.
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Affiliation(s)
- G M Vincent
- Department of Medicine, LDS Hospital, University of Utah School of Medicine, Salt Lake City 84143
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30
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Lock R, Hessel EA. Probable reversal of protamine reactions by heparin administration. JOURNAL OF CARDIOTHORACIC ANESTHESIA 1990; 4:604-8. [PMID: 2132139 DOI: 10.1016/0888-6296(90)90410-h] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- R Lock
- Department of Anesthesiology, University of Kentucky School of Medicine, Lexington 40536-0084
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31
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Weiler JM, Gellhaus MA, Carter JG, Meng RL, Benson PM, Hottel RA, Schillig KB, Vegh AB, Clarke WR. A prospective study of the risk of an immediate adverse reaction to protamine sulfate during cardiopulmonary bypass surgery. J Allergy Clin Immunol 1990; 85:713-9. [PMID: 2182695 DOI: 10.1016/0091-6749(90)90189-b] [Citation(s) in RCA: 95] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Protamine sulfate administration may cause life-threatening reactions. We prospectively examined the incidence of immediate adverse reaction after protamine in 243 patients who underwent cardiopulmonary bypass surgery. Twenty-six patients (10.7%) had reactions, and 1.6% had a precipitous drop in blood pressure immediately after protamine administration. Risk factors were previous exposure to protamine, diabetes, history of receiving protamine-containing insulin, and possibly vasectomy. However, neither a positive skin test nor a positive IgE ELISA for antiprotamine antibody predicted that a patient would have a reaction. C4a levels were increased in patients who had reactions as compared with age-, sex-, and cardiac disease-matched patients who did not have reactions, suggesting a role for complement in some reactions. Immediate adverse reactions to protamine are very common, and alternative therapies are urgently needed to eliminate the use of protamine.
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Affiliation(s)
- J M Weiler
- Department of Medicine, University of Iowa, Iowa City
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32
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Lindblad B. Protamine sulphate: a review of its effects: hypersensitivity and toxicity. EUROPEAN JOURNAL OF VASCULAR SURGERY 1989; 3:195-201. [PMID: 2663545 DOI: 10.1016/s0950-821x(89)80082-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- B Lindblad
- Department of Surgery, University of Lund, Malmö General Hospital, Sweden
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33
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Gupta SK, Veith FJ, Ascer E, Wengerter KR, Franco C, Amar D, El-Gaweet ES, Gupta A. Anaphylactoid reactions to protamine: An often lethal complication in insulin-dependent diabetic patients undergoing vascular surgery. J Vasc Surg 1989. [DOI: 10.1016/0741-5214(89)90055-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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34
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Abstract
Anaphylactic shock may be provoked by a diverse group of substances and stimuli, which range from large molecular weight proteins and small drug molecules to some colloids, emulsions and even exercise. The underlying mechanism may be immunological or non-immunological but, regardless of the mechanism, the physiological effects and the observable symptoms of anaphylaxis are due to the release of potent pharmacologically-active mediators, including histamine. Although a number of predisposing factors are recognized, the appearance of most of the reactions cannot be predicted. Reactions occur suddenly and dramatically and progress rapidly. Cardiovascular collapse is the most common life-threatening clinical feature, while bronchospasm is the most difficult to treat. The primary aim of treatment should be to treat the underlying cause and to improve cellular oxygenation. The pharmacological agent of choice for treatment is adrenaline. It is direct-acting and is effective for both bronchospasm and cardiovascular collapse. It is imperative that the provoking substance or stimulus be identified in patients and there is no substitute for a carefully-gathered and detailed case history in the diagnosis of anaphylaxis. Patients should be issued with some form of warning identification together with written details concerning their reaction.
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Affiliation(s)
- M M Fisher
- Intensive Therapy Unit, Royal North Shore Hospital of Sydney, St Leonards, NSW
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35
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Affiliation(s)
- J C Horrow
- Department of Anesthesiology, Hahnemann University, Philadelphia, PA 19102-1192, USA
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36
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Shikuma LR, Eyer SD, Zaske DE. Protamine sulfate and fatal anaphylactoid shock. DRUG INTELLIGENCE & CLINICAL PHARMACY 1988; 22:211-3. [PMID: 3366061 DOI: 10.1177/106002808802200307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A 73-year-old male underwent uneventful three-vessel coronary artery bypass grafting after which he received iv protamine sulfate for reversal of systemic heparinization. Shortly thereafter, the patient developed and succumbed to an anaphylactoid reaction attributed to protamine. The patient had none of the previously reported risk factors for hypersensitivity to the drug and was therefore not considered at high risk for such a severe adverse reaction. Although uncommon, the fatal outcome of this low-risk patient seriously addresses the need for alternative measures for heparin reversal.
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Affiliation(s)
- L R Shikuma
- Critical Care/Pharmacokinetics, University of Minnesota College of Pharmacy, St. Paul-Ramsey Medical Center
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37
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Reed DC, Gascho JA. The safety of protamine sulfate in diabetics undergoing cardiac catheterization. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1988; 14:19-23. [PMID: 3349513 DOI: 10.1002/ccd.1810140105] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The frequency of anaphylactoid reactions to protamine sulfate was examined by reviewing the records of diabetic patients undergoing cardiac catheterization over a 5-year period, and by prospectively monitoring diabetic patients receiving NPH insulin during the infusion of protamine sulfate. No anaphylactoid reactions were noted after protamine administration (48 +/- 5 mg) in the retrospective study in either patients with prior exposure to protamine (74 catheterizations) or in diabetics with no exposure to protamine (132 catheterizations). In the prospective study, no anaphylactoid reactions were seen in the 24 NPH insulin-dependent diabetics during the infusion of protamine sulfate (45 +/- 5 mg). Five of the 42 patients (12%) from the retrospective study who underwent vascular surgery developed severe reactions to much larger doses of protamine (380 +/- 118 mg). Diabetics with prior exposure to protamine sulfate do not appear to be at increased risk of anaphylactoid reaction after the administration of protamine sulfate in the dose range of less than 50 mg at the time of cardiac catheterization.
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Affiliation(s)
- D C Reed
- University of Virginia School of Medicine, Charlottesville
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38
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Katz NM, Kim YD, Siegelman R, Ved SA, Ahmed SW, Wallace RB. Hemodynamics of protamine administration. J Thorac Cardiovasc Surg 1987. [DOI: 10.1016/s0022-5223(19)36160-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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39
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Abstract
The administration of protamine sulfate for the reversal of heparin anticoagulation has been associated with adverse hemodynamic changes including hypotension and decreased cardiac output. The possible direct toxic effect of protamine on human right atrial trabeculae contracting isometrically in vitro was studied. Muscles were stimulated to contract at 1 Hz in Tyrode's solution (maintained at 34 degrees C, pH 7.4) into which protamine was continuously added. Following a polynomial regression analysis, a parabolic dose-response curve resulted. The equation was: y = 95.13 + 38.76x - 278.71x2 where y = relative developed force and x = concentration of protamine (milligrams per milliliters) (r = 0.82). The estimated concentration of protamine resulting in 50% developed force was 0.48 mg/ml. In a second series of experiments, protamine was added to the bath along with a neutralizing amount of heparin. This resulted in a limited reduction in the fall of relative developed force. Thus, protamine in high concentrations alone or in complex with heparin has a direct toxic effect on human myocardial muscle mechanics, and care is warranted in its clinical use.
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40
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Abstract
The clinical syndrome of anaphylactic shock is a disorder produced by multiple mechanisms and pharmacological and environmental factors. The syndrome may be produced by both immunologic and nonimmunologic mechanisms and is due to the release of preformed biologically active mediators and the generation of biologically active mediators. The main mediator appears to be histamine. Although there are a number of defined predisposing factors, the majority of first reactions appear unpredictably. The mainstay of treatment is the use of epinephrine, volume replacement, and positive pressure ventilation. The follow-up and documentation of details of the reaction and exhaustive efforts to determine the precipitating factor are important aspects of the subsequent safety of the patient. History may be of more value than diagnostic testing. The use of H1 and H2 blockers, with steroids and sympathomimetics, may reduce the risk or magnitude of reactions in patients with a past history of a reaction.
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41
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Wakefield TW, Hantler CB, Lindblad B, Whitehouse WM, Stanley JC. Protamine pretreatment attenuation of hemodynamic and hematologic effects of heparin-protamine interaction. J Vasc Surg 1986. [DOI: 10.1016/0741-5214(86)90155-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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42
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Cooper DM, Bazaral MG, Furlan AJ, Sevilla E, Ghattas MA, Sheeler LR, Little JR, Hahn JF, Sheldon WC, Loop FD. Pituitary apoplexy: a complication of cardiac surgery. Ann Thorac Surg 1986; 41:547-50. [PMID: 3486645 DOI: 10.1016/s0003-4975(10)63039-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Pituitary apoplexy occurred in 3 patients in the immediate postoperative period following cardiac operation with cardiopulmonary bypass. In this setting, this complication is extremely rare and not widely recognized. Precipitating factors may be related to the extracorporeal bypass apparatus, anticoagulation, low cerebral blood flow, and even anesthetic agents. Neurosurgical decompression can be safely performed in the early postoperative period following open-heart operations.
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43
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Solomon DR. Anaphylactoid reaction and non-cardiac pulmonary edema following intravenous contrast injection. Am J Emerg Med 1986; 4:146-9. [PMID: 3947443 DOI: 10.1016/0735-6757(86)90161-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
A case of severe anaphylactoid reaction following injection of intravenous contrast is described, and a discussion of the treatment of severe allergic reactions follows. The patient's presentation was unusual in that she rapidly developed massive non-cardiac pulmonary edema as the primary symptom, along with hypotension and hypokalemia, a syndrome similar to adult respiratory distress syndrome. The development of the reaction along with the unusual presentation is discussed and a detailed discussion of the generalized treatment of anaphylactoid and anaphylactic reactions is presented. Additionally, several errors in management that may have delayed resolution of the symptoms and prolonged the period of instability in the patient's condition are discussed and critiqued.
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44
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Sharath MD, Metzger WJ, Richerson HB, Scupham RK, Meng RL, Ginsberg BH, Weiler JM. Protamine-induced fatal anaphylaxis. J Thorac Cardiovasc Surg 1985. [DOI: 10.1016/s0022-5223(19)38667-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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45
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Fiser WP, Fewell JE, Hill DE, Barnes RW, Read RC. Cardiovascular effects of protamine sulfate are dependent on the presence and type of circulating heparin. J Thorac Cardiovasc Surg 1985. [DOI: 10.1016/s0022-5223(19)38849-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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