1
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Takeichi T, Morimoto Y, Yamada A, Tanaka T. A case of the effective inhalation of nitric oxide therapy for caused severe pulmonary hypertension with protamine neutralization of systemic heparinization during totally endoscopic minimally invasive cardiac surgery. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2024; 56:120-124. [PMID: 39303134 DOI: 10.1051/ject/2024018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/08/2024] [Indexed: 09/22/2024]
Abstract
Severe pulmonary vasoconstriction induced by protamine is a rare complication. We report a case of a 77-year-old male patient with a history of mitral valve plasty (MVP). He underwent redo MVP via right thoracotomy under the totally endoscopic procedure (MICS redo-MVP). Immediately after weaning cardiopulmonary bypass (CPB), protamine was administrated. 10 min later peak systolic pulmonary arterial pressure (sys PAP) rose to 62 mmHg, and 30 min later to 80 mmHg. Due to the negative impact of protamine administration, nitric oxide inhalation (iNO) therapy was started with a concentration of 20 ppm. 10 min after iNO therapy started, sys PAP decreased to 63 mmHg. After entering the intensive care unit (ICU), sys PAP decreased to 35 mmHg. Here, we present an effective iNO therapy case for pulmonary hypertension due to protamine and the patient had a good postoperative recovery. This study was approved by the Institutional Review Board at Kitaharima Medical Center (IRB-0602) with the waiver of informed consent.
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Affiliation(s)
- Tomohisa Takeichi
- Department of Clinical Engineering, Kitaharima Medical Center, 926-250, Ichiba-cho, Ono-shi, Hyogo 675-1392, Japan
| | - Yoshihisa Morimoto
- Department of Cardiovascular Surgery, Kitaharima Medical Center, 926-250, Ichiba-cho, Ono-shi, Hyogo 675-1392, Japan
| | - Akitoshi Yamada
- Department of Cardiovascular Surgery, Kitaharima Medical Center, 926-250, Ichiba-cho, Ono-shi, Hyogo 675-1392, Japan
| | - Takanori Tanaka
- Department of Clinical Engineering, Kitaharima Medical Center, 926-250, Ichiba-cho, Ono-shi, Hyogo 675-1392, Japan
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2
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Roosendaal LC, Hoebink M, Wiersema AM, Yeung KK, Blankensteijn JD, Jongkind V. Perprocedural Heparinization in Non-cardiac Arterial Procedures: The Current Practice in the Netherlands. J Endovasc Ther 2023:15266028231199714. [PMID: 37746826 DOI: 10.1177/15266028231199714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
PURPOSE Heparin is the most widely-used anticoagulant to prevent thrombo-embolic complications during non-cardiac arterial procedures (NCAP). Unfortunately, there is a lack of evidence and consequently non-uniformity in guidelines on perprocedural heparin management. Detailed insight into the current practice of antithrombotic strategies during NCAP in the Netherlands is important, aiming to identify potential optimal protocols and local differences concerning perprocedural heparinization. MATERIALS AND METHODS A comprehensive online survey was distributed electronically to vascular surgeons of every hospital in the Netherlands in which NCAP were performed. Data were collected from September 2020 to October 2021. RESULTS The response rate was 90% (53/59 hospitals). During NCAP, all surgeons generally administered heparin before arterial clamping. In 74% (39/54) of hospitals, a single heparin dosing protocol was used for all types of patients and vascular procedures. In 40%, there was no uniformity in heparin dosing between vascular surgeons. Depending on the procedure, a fixed bolus heparin, predominantly 5000 IU, was administered in 73% to 93%. In the remaining hospitals (7%-27%), a bodyweight-based heparin protocol was used, with an initial dose of 70 or 100 IU/kg. A minority (28%) monitored the effect of heparin in patients using the activated clotting time add (ACT) after activated clotting time. Target values varied between 180 and 250 seconds or 2 times the baseline ACT. CONCLUSION This survey demonstrates considerable variability in perprocedural heparinization during NCAP in the Netherlands. Future research on heparin dosing is needed to harmonize and optimize heparin dosage protocols and contemporary guidelines during NCAP, and thereby improve vascular surgical care and patient safety. CLINICAL IMPACT This survey demonstrated persisting intra- and inter-hospital variability in perprocedural heparinization during non-cardiac arterial procedures (NCAP) in the Netherlands. The observed variability in heparinization strategies highlights the need for high quality evidence on perprocedural anticoagulation strategies. This is needed in order to harmonize and optimize heparin dosage protocols and contemporary guidelines and thereby improve vascular surgical patient care. Based on the current results, an international survey will be conducted by the authors to gain additional insight into the antithrombotic strategies used during NCAP, aiming to harmonize anticoagulation protocols worldwide.
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Affiliation(s)
- Liliane C Roosendaal
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
- Microcirculation, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Max Hoebink
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
- Microcirculation, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Arno M Wiersema
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
- Microcirculation, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Kak K Yeung
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
- Microcirculation, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jan D Blankensteijn
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
- Microcirculation, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Vincent Jongkind
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
- Microcirculation, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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3
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Erdem S, An SY, McAlister CA, Basra SS. Suicide left ventricle following protamine: A case report. Catheter Cardiovasc Interv 2023; 101:592-595. [PMID: 36626268 DOI: 10.1002/ccd.30528] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/31/2022] [Accepted: 12/10/2022] [Indexed: 01/11/2023]
Abstract
A patient with severe aortic stenosis and left ventricular hypertrophy underwent a transcatheter aortic valve replacement. The patient's blood pressure significantly dropped after protamine administration. A diagnosis of suicide left ventricle post-valve replacement was made. The diagnosis and management of the protamine reaction are detailed. This case highlights the need to slowly infuse protamine sulfate and monitor for adverse events.
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Affiliation(s)
- Saliha Erdem
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sin Y An
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Courtney A McAlister
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sukhdeep S Basra
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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4
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Leentjens J, Middeldorp S, Jung C. A short review of ciraparantag in perspective of the currently available anticoagulant reversal agents. Drug Discov Today 2022; 27:103332. [PMID: 35933085 DOI: 10.1016/j.drudis.2022.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/29/2022] [Indexed: 12/15/2022]
Abstract
Despite the improved safety-profile of direct oral anticoagulants (DOACs), bleeding complications remain an important side effect of anticoagulant treatment. Although anticoagulant-specific antidotes are available, an universal anticoagulant reversal agent in case of life-threatening bleeding or emergency surgery is not yet available. Ciraparantag, a synthetic small molecule that inactivates heparins and DOAC, is a promising new reversal agent that has been investigated in phase 2 trials. In this short review we provide an overview of the preclinical and clinical evidence of ciraparantag, and compare strengths and weaknesses of ciraparantag and the currently available anticoagulant reversal strategies.
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Affiliation(s)
- J Leentjens
- Department of Internal Medicine & Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - S Middeldorp
- Department of Internal Medicine & Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - C Jung
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany
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5
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Pethő Á, Piecha D, Mészáros T, Urbanics R, Moore C, Canaud B, Rosivall L, Mollnes TE, Steppan S, Szénási G, Szebeni J, Dézsi L. A porcine model of hemodialyzer reactions: roles of complement activation and rinsing back of extracorporeal blood. Ren Fail 2021; 43:1609-1620. [PMID: 34882053 PMCID: PMC8667923 DOI: 10.1080/0886022x.2021.2007127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Hemodialysis reactions (HDRs) resemble complement-activation-related pseudoallergy (CARPA) to certain i.v. drugs, for which pigs provide a sensitive model. On this basis, to better understand the mechanism of human HDRs, we subjected pigs to hemodialysis using polysulfone (FX CorDiax 40, Fresenius) or cellulose triacetate (SureFlux-15UX, Nipro) dialyzers, or Dialysis exchange-set without membranes, as control. Experimental endpoints included typical biomarkers of porcine CARPA; pulmonary arterial pressure (PAP), blood cell counts, plasma sC5b-9 and thromboxane-B2 levels. Hemodialysis (60 min) was followed by reinfusion of extracorporeal blood into the circulation, and finally, an intravenous bolus injection of the complement activator zymosan. The data indicated low-extent steady rise of sC5b-9 along with transient leukopenia, secondary leukocytosis and thrombocytopenia in the two dialyzer groups, consistent with moderate complement activation. Surprisingly, small changes in baseline PAP and plasma thromboxane-B2 levels during hemodialysis switched into 30%-70% sharp rises in all three groups resulting in synchronous spikes within minutes after blood reinfusion. These observations suggest limited complement activation by dialyzer membranes, on which a membrane-independent second immune stimulus was superimposed, and caused pathophysiological changes also characteristic of HDRs. Thus, the porcine CARPA model raises the hypothesis that a second "hit" on anaphylatoxin-sensitized immune cells may be a key contributor to HDRs.
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Affiliation(s)
- Ákos Pethő
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Dorothea Piecha
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | | | - Christoph Moore
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Bernard Canaud
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany.,School of Medicine, Montpellier University, Montpellier, France
| | - László Rosivall
- International Nephrology Research and Training Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Tom Eirik Mollnes
- Department of Immunology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Research Laboratory, Nordland Hospital Bodø and Faculty of Health Sciences and TREC, University of Tromsø, Tromsø, Norway.,Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sonja Steppan
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Gábor Szénási
- International Nephrology Research and Training Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - János Szebeni
- SeroScience Ltd, Budapest, Hungary.,Nanomedicine Research and Education Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - László Dézsi
- SeroScience Ltd, Budapest, Hungary.,Nanomedicine Research and Education Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
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6
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Goyal P, Joshi S, Raut MS. Administration of Protamine Through Radial Arterial Access: A Prospective Observational Study. Heart Views 2021; 22:30-34. [PMID: 34276886 PMCID: PMC8254157 DOI: 10.4103/heartviews.heartviews_55_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 05/23/2017] [Indexed: 11/24/2022] Open
Abstract
Protamine is mainly used to reverse the anticoagulant effect of heparin after cardiopulmonary bypass (CPB). Unfortunately, it is associated with adverse clinical reactions ranging from minor cardiopulmonary instability to fatal cardiovascular collapse. In the present prospective observational study, effects of protamine administration through peripheral intra-arterial route, i.e., radial artery, were investigated.
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Affiliation(s)
- Priyanka Goyal
- Department of Cardiac Anaesthesiology, M.M. Institute of Medical Science and Research, Mullana, Ambala, Haryana, India
| | - Sandeep Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Monish S Raut
- Department of Cardiac Anesthesia, Sir Ganga Ram Hospital, New Delhi, India
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7
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Neuroprotective Cationic Arginine-Rich Peptides (CARPs): An Assessment of Their Clinical Safety. Drug Saf 2020; 43:957-969. [DOI: 10.1007/s40264-020-00962-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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8
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Peeters M, Yilmaz A, Vandekerkhof J, Kaya A. Protamine Induced Anaphylactic Shock after Peripheral Vascular Surgery. Ann Vasc Surg 2020; 69:450.e13-450.e15. [PMID: 32554194 DOI: 10.1016/j.avsg.2020.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 10/24/2022]
Abstract
Anaphylactic reactions to protamine are quite rare and almost exclusively reported during cardiac surgery. In this report, we illustrate a rare case of protamine reaction after peripheral vascular surgery a couple of months after cardiac surgery and how the patient survived this critical complication.
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Affiliation(s)
- Maxim Peeters
- Department of Vascular Surgery, Jessa Hospital, Hasselt, Belgium.
| | - Alaaddin Yilmaz
- Department of Cardiothoracic Surgery, Jessa Hospital, Hasselt, Belgium
| | - Jos Vandekerkhof
- Department of Vascular Surgery, Jessa Hospital, Hasselt, Belgium
| | - Abdullah Kaya
- Department of Cardiothoracic Surgery, Jessa Hospital, Hasselt, Belgium
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9
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Abstract
Purpose Experiments were carried out to test the efficacy and safety of the heparin removal device, a plasmapheresis filter that binds and eliminates heparin, in the context of extracorporeal circulation. Procedures and Findings Six dogs were put on cardiopulmonary bypass after heparinization. Upon weaning, additional heparin was administered to obtain an activated clotting time above 900s. The animals were connected to the heparin removal device and with flows of 500 ml/min, activated clotting time, activated partial thromboplastin time and plasma heparin concentrations were normalised to baseline after 30 min. Hemodynamic parameters remained unaffected. A slight decrease in red and white blood cell count and in platelets was observed which however recovered spontaneously two hours after the filter procedure. No damage to blood components could be observed. Conclusions The use of a heparin removal device is as efficient as systemic administration of protamine to reverse the effects of heparinization. It may prevent the adverse reactions linked to protamine administration and therefore be indicated in certain subgroups of patients undergoing cardiopulmonary bypass.
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10
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Müller MCA, Stanworth SJ, Coppens M, Juffermans NP. Recognition and Management of Hemostatic Disorders in Critically Ill Patients Needing to Undergo an Invasive Procedure. Transfus Med Rev 2017. [PMID: 28647217 DOI: 10.1016/j.tmrv.2017.05.008] [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: 01/09/2023]
Abstract
Abnormal laboratory coagulation test results are frequently documented in critically ill patients, and these patients often also need to undergo invasive procedures. Clinicians have an understandable desire to minimize any perceived heightened risk of bleeding complications in those patients who require invasive procedures. In this setting, prophylactic administration of platelets or plasma is commonplace. This review explores the nature of these sequential statements and the degree to which these statements are supported by evidence. We discuss the complexity of managing the low risk of procedure-related bleeding in a setting where coagulation tests fail to reliably predict this risk. The role of prophylactic transfusion of platelets and plasma and correction of medication-induced coagulopathy is also reviewed. New strategies are required to improve the evidence base, including novel methodological approaches or the use of a clinical scoring system.
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Affiliation(s)
- Marcella C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands.
| | - Simon J Stanworth
- Department of Haematology, NHS Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
| | - Michiel Coppens
- Department of Internal Medicine, Academic Medical Center, Amsterdam, the Netherlands.
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands.
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11
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Kim JB, Kim JH, Song KS. Catastrophic Bronchial Spasm Due to a Severe Anaphylactic Reaction to Protamine. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:472-474. [PMID: 27965927 PMCID: PMC5147475 DOI: 10.5090/kjtcs.2016.49.6.472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/21/2016] [Accepted: 06/13/2016] [Indexed: 11/16/2022]
Abstract
Fatal anaphylactic reactions to protamine sulfate during cardiac surgery are very rare. We report a case of catastrophic bronchial spasm due to an anaphylactic reaction to protamine. The patient was managed successfully using a bronchodilator, steroid treatment, and extracorporeal membrane oxygenation.
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Affiliation(s)
- Jae-Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine
| | - Jae Hyun Kim
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine
| | - Kyung Sub Song
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine
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12
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Bakchoul T, Jouni R, Warkentin TE. Protamine (heparin)-induced thrombocytopenia: a review of the serological and clinical features associated with anti-protamine/heparin antibodies. J Thromb Haemost 2016; 14:1685-95. [PMID: 27378603 DOI: 10.1111/jth.13405] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Indexed: 01/04/2023]
Abstract
Protamine is widely used in medicine as a rapidly-acting antidote to heparin, particularly for reversing heparin anticoagulation after cardiac surgery. Protamine is also used as a stabilizing additive to certain preparations of insulin. Recent reports demonstrate that protamine and heparin form multimolecular complexes that result in high rates of immunization in post-cardiac surgery patients, particularly of immunoglobulin G (IgG) class antibodies; a subset of these anti-protamine/heparin IgG antibodies activates platelets through their FcγIIA (IgG) receptors. Although the clinical consequences of anti-protamine/heparin antibodies that are newly generated after cardiac surgery are unknown, there is evidence that platelet-activating anti-protamine/heparin antibodies already present at the time of cardiac surgery might occasionally explain more severe thrombocytopenia with delayed platelet count recovery, as well as thromboembolic complications, in the post-cardiac surgery setting. Triggers for such antibodies remain poorly-defined, but could include preoperative administration of heparin to diabetic patients receiving protamine-insulin as well as recent previous cardiac surgery. Anti-protamine/heparin antibodies have several features in common with anti-platelet factor 4 (PF4) PF4/heparin antibodies implicated in heparin-induced thrombocytopenia (HIT), including immunization by heparin-containing multimolecular complexes, predominant IgG class, pathological platelet-activating properties, relatively rapid IgG formation without IgM precedence, and antibody transience. Despite these similarities, the risk of anti-protamine/heparin antibody-mediated complications seems to affect the early post-cardiac surgery period, whereas HIT usually occurs at least 5 days following cardiac surgery. Clinicians need to become aware of this recently recognized immunohematological disorder, and research is needed to identify triggers of immunization, improve detection of pathological antibodies and identify patients at risk of this complication.
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Affiliation(s)
- T Bakchoul
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany. ,
| | - R Jouni
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - T E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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13
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Sokolowska E, Kalaska B, Miklosz J, Mogielnicki A. The toxicology of heparin reversal with protamine: past, present and future. Expert Opin Drug Metab Toxicol 2016; 12:897-909. [DOI: 10.1080/17425255.2016.1194395] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Emilia Sokolowska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Joanna Miklosz
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
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14
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Grieshaber P, Bakchoul T, Wilhelm J, Wagner A, Wollbrück M, Böning A, Sachs U. Platelet-activating protamine-heparin-antibodies lead to higher protamine demand in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg 2015; 150:967-73.e1. [PMID: 26298870 DOI: 10.1016/j.jtcvs.2015.07.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 05/14/2015] [Accepted: 07/16/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Platelet-activating antibodies against protamine-heparin-complexes were described in patients undergoing cardiac surgery, but their clinical consequences remain unclear. This prospective single-center observational study aimed to describe the prevalence and clinical consequences of protamine-heparin-complex antibodies in patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS A total of 200 patients undergoing cardiac surgery with cardiopulmonary bypass were included. Blood samples were collected preoperatively and 1 hour, 24 hours, and 7 days after weaning from cardiopulmonary bypass. All sera were tested for the presence of protamine-heparin-complex antibodies using a modified heparin-induced platelet-activation assay. Specific Fcγ receptor IIa-dependent platelet activation was confirmed by repeated testing in the presence of the Fcγ receptor IIa-blocking antibody IV.3. RESULTS Samples from 185 patients were obtained, of whom 24 patients (13%) were positive for protamine-heparin-complex antibodies preoperatively. In all positive samples, functional reactivity was reversible in the presence of IV.3. Although patients with a preoperative presence of protamine-heparin-complex antibodies were significantly older compared with patients negative for protamine-heparin-complex antibodies (73 ± 9.8 years vs 68 ± 10 years, P = .037), no other potential risk factors were identified at 1 day before operation. Patients with protamine-heparin-complex antibodies required significantly more protamine to neutralize heparin (47.66 mg vs 41.67 mg, P = .027). Protamine-heparin-complex antibodies have no significant influence on perioperative platelet numbers, bleeding complications, transfusion requirement, thromboembolic events, major cardiovascular and cerebrovascular events, inflammation parameters, or kidney function. CONCLUSIONS Protamine-heparin-complex antibodies occur frequently in patients undergoing cardiac surgery on cardiopulmonary bypass, resulting in specific platelet activation in vitro. Protamine-heparin-complex antibodies are associated with increased protamine requirement after cardiopulmonary bypass and possibly slower recovery of platelet numbers.
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Affiliation(s)
- Philippe Grieshaber
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany.
| | - Tamam Bakchoul
- Department of Transfusion Medicine, Ernst-Moritz-Arndt University Greifswald, Greifswald, Germany
| | - Jochen Wilhelm
- Department of Internal Medicine, German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Alexander Wagner
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Matthias Wollbrück
- Department of Anaesthesiology and Intensive Care Medicine University Hospital Giessen, Giessen, Germany
| | - Andreas Böning
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Ulrich Sachs
- Institute for Clinical Immunology und Transfusion Medicine, Justus Liebig University Giessen, Giessen, Germany
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15
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Kalaska B, Kaminski K, Sokolowska E, Czaplicki D, Kujdowicz M, Stalinska K, Bereta J, Szczubialka K, Pawlak D, Nowakowska M, Mogielnicki A. Nonclinical evaluation of novel cationically modified polysaccharide antidotes for unfractionated heparin. PLoS One 2015; 10:e0119486. [PMID: 25781030 PMCID: PMC4362941 DOI: 10.1371/journal.pone.0119486] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/13/2015] [Indexed: 01/25/2023] Open
Abstract
Protamine, the only registered antidote of unfractionated heparin (UFH), may produce a number of adverse effects, such as anaphylactic shock or serious hypotension. We aimed to develop an alternative UFH antidote as efficient as protamine, but safer and easier to produce. As a starting material, we have chosen generally non-toxic, biocompatible, widely available, inexpensive, and easy to functionalize polysaccharides. Our approach was to synthesize, purify and characterize cationic derivatives of dextran, hydroxypropylcellulose, pullulan and γ-cyclodextrin, then to screen them for potential heparin-reversal activity using an in vitro assay and finally examine efficacy and safety of the most active polymers in Wistar rat and BALB/c mouse models of experimentally induced arterial and venous thrombosis. Efficacy studies included the measurement of thrombus formation, activated partial thromboplastin time, bleeding time, and anti-factor Xa activity; safety studies included the measurement of hemodynamic, hematologic and immunologic parameters. Linear, high molecular weight dextran substituted with glycidyltrimethylammonium chloride groups at a ratio of 0.65 per glucose unit (Dex40-GTMAC3) is the most potent and the safest UFH inhibitor showing activity comparable to that of protamine while possessing lower immunogenicity. Cationic polysaccharides of various structures neutralize UFH. Dex40-GTMAC3 is a promising and potentially better UFH antidote than protamine.
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Affiliation(s)
- Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Kamil Kaminski
- Faculty of Chemistry, Jagiellonian University, Krakow, Poland
| | - Emilia Sokolowska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Dominik Czaplicki
- Department of Cell Biochemistry, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | | | - Krystyna Stalinska
- Department of Cell Biochemistry, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | - Joanna Bereta
- Department of Cell Biochemistry, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | | | - Dariusz Pawlak
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | | | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
- * E-mail:
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Quan H, Tan H, Li Q, Li J, Li S. Immunological hypoglycemia associated with insulin antibodies induced by exogenous insulin in 11 Chinese patients with diabetes. J Diabetes Res 2015; 2015:746271. [PMID: 25961056 PMCID: PMC4413037 DOI: 10.1155/2015/746271] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/26/2015] [Accepted: 03/30/2015] [Indexed: 02/05/2023] Open
Abstract
AIMS To investigate the characteristics of immunological hypoglycemia associated with insulin antibodies (IAbs) induced by exogenous insulin in Chinese patients with diabetes. METHODS The clinical data of patients with immunological hypoglycemia due to IAbs were retrospectively analyzed by screening patients with diabetes discharged from West China Hospital from 2007 to 2013. RESULTS A total of 11 patients (eight men and three women) were identified. Insulin-C-peptide separation was found in all patients via insulin and C-peptide release test. Previous insulin use was ceased after admission and was switched to oral hypoglycemic agents (OHAs) (8/11), lifestyle modification only (2/11), or regular human insulin (1/11). Hypoglycemia was ameliorated after a median of 20 days (interquartile range [IQR], 11-40), while IAbs turned negative after a median of 17 months (IQR, 4-19), and serum immunoreactive insulin (IRI) levels dropped substantially after a median of 22 months (IQR, 9-32) in these cases. CONCLUSIONS In insulin-treated patients with unexpected and refractory hypoglycemia even after insulin therapy was gradually reduced or even withdrawn, IAbs induced by exogenous insulin should be considered, and insulin withdrawal might be promptly needed. The course of immunological hypoglycemia was benign and self-limited.
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Affiliation(s)
- Heng Quan
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Huiwen Tan
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Qianrui Li
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Jianwei Li
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
- *Jianwei Li: and
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
- *Sheyu Li:
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17
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Low molecular weight protamine (LMWP): A nontoxic protamine substitute and an effective cell-penetrating peptide. J Control Release 2014; 193:63-73. [DOI: 10.1016/j.jconrel.2014.05.056] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 05/21/2014] [Accepted: 05/27/2014] [Indexed: 01/07/2023]
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Abstract
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RNA
interference (RNAi) is an endogenous process in which small
noncoding RNAs, including small interfering RNAs (siRNAs) and microRNAs
(miRNAs), post-transcriptionally regulate gene expressions. In general,
siRNA and miRNA/miRNA mimics are similar in nature and activity except
their origin and specificity. Although both siRNAs and miRNAs have
been extensively studied as novel therapeutics for a wide range of
diseases, the large molecular weight, anionic surface charges, instability
in blood circulation, and intracellular trafficking to the RISC after
cellular uptake have hindered the translation of these RNAs from bench
to clinic. As a result, a great variety of delivery systems have been
investigated for safe and effective delivery of small noncoding RNAs.
Among these systems, peptides, especially cationic peptides, have
emerged as a promising type of carrier due to their inherent ability
to condense negatively charged RNAs, ease of synthesis, controllable
size, and tunable structure. In this review, we will focus on three
major types of cationic peptides, including poly(l-lysine)
(PLL), protamine, and cell penetrating peptides (CPP), as well as
peptide targeting ligands that have been extensively used in RNA delivery.
The delivery strategies, applications, and limitations of these cationic
peptides in siRNA/miRNA delivery will be discussed.
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Affiliation(s)
- Ravi S Shukla
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City , Kansas City, Missouri 64108, United States
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19
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Gurzun MM, Hussain F, Zaidi A, Dasari S, Ionescu A. Severe Transient Mitral and Tricuspid Regurgitation. J Cardiothorac Vasc Anesth 2014; 28:1171-3. [DOI: 10.1053/j.jvca.2013.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Indexed: 11/11/2022]
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20
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Potential food allergens in medications. J Allergy Clin Immunol 2014; 133:1509-18; quiz 1519-20. [PMID: 24878443 DOI: 10.1016/j.jaci.2014.03.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 02/18/2014] [Accepted: 03/12/2014] [Indexed: 12/31/2022]
Abstract
Excipients are substances in pharmaceuticals other than the active ingredients. Some excipients are foods or substances derived from foods, raising the possibility that these substances would pose a hazard to patients with food allergy. This review describes which food-derived substances are used as pharmaceutical excipients in which medications and reviews published data regarding the safety of the administration of these medications to recipients with food allergy. Such reactions are rare, usually because the amount of food protein is not present in a large enough quantity to elicit a reaction. When a food protein appears as an unintentional contaminant, the amount, if any, that is present might be variable and might elicit reactions only from some lots of medication or only in some patients. In most circumstances these medications should not be routinely withheld from patients who have particular food allergies because most will tolerate the medications uneventfully. However, if a particular patient has had an apparent allergic reaction to the medication, potential allergy to the food component should be investigated.
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21
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Thiele RH, Raphael J. A 2014 Update on Coagulation Management for Cardiopulmonary Bypass. Semin Cardiothorac Vasc Anesth 2014; 18:177-89. [DOI: 10.1177/1089253214534782] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Coagulopathy after cardiac surgery with cardiopulmonary bypass is a serious complication that may result in massive bleeding requiring transfusion of significant amounts of blood products, plasma, and platelets. In addition to increased patient morbidity and mortality it is associated with longer hospital stay and increased resource utilization. The current review discusses aspects in cardiopulmonary bypass–induced coagulopathy with emphasis on point-of-care testing and individualized “goal-directed” therapy in patients who develop excessive bleeding after cardiac surgery.
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Affiliation(s)
| | - Jacob Raphael
- University of Virginia Health System, Charlottesville, VA, USA
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22
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Lee GM, Welsby IJ, Phillips-Bute B, Ortel TL, Arepally GM. High incidence of antibodies to protamine and protamine/heparin complexes in patients undergoing cardiopulmonary bypass. Blood 2013; 121:2828-35. [PMID: 23422751 PMCID: PMC3624931 DOI: 10.1182/blood-2012-11-469130] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 02/09/2013] [Indexed: 12/26/2022] Open
Abstract
Protamine is routinely used to reverse heparin anticoagulation during cardiopulmonary bypass (CPB). Heparin interacts with protamine to form ultralarge complexes that are immunogenic in mice. We hypothesized that patients exposed to protamine and heparin during CPB will develop antibodies (Abs) to protamine/heparin (PRT/H) complexes that are capable of platelet activation. Specimens from a recently completed prospective clinical trial (HIT [for heparin-induced thrombocytopenia] 5801 study; n = 500) of CPB patients were examined for PRT/H Abs at baseline, at time of hospital discharge (between days 3 through 7), and 30 days after CPB. PRT/H antibody features were characterized and correlated with adverse cardiovascular outcomes. We found a high incidence of PRT/H antibody formation (29%) in patients undergoing cardiac surgery. PRT/H Abs were of high titer (mean titer 1:14,744), showed heparin-dependent binding, and activated platelets in the presence of protamine. PRT/H Abs showed no cross-reactivity to platelet factor 4/heparin complexes, but were cross-reactive with protamine-containing insulin preparations. In the absence of circulating antigen at day 30, there were no complications of thrombocytopenia, thrombotic events, or long-term cardiovascular events. These studies show that Abs to PRT/H occur commonly after cardiac bypass surgery, share a number of serologic features with HIT Abs, including platelet activation, and may pose health risks to patients requiring drug reexposure.
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Affiliation(s)
- Grace M Lee
- Division of Hematology, Duke University Medical Center, Durham, NC 27710, USA
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23
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Rajasekhar A, Beyth R, Crowther MA. Newer anticoagulants in critically ill patients. Crit Care Clin 2012; 28:427-51, vii. [PMID: 22713616 DOI: 10.1016/j.ccc.2012.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Critically ill patients are at increased risk for development of thrombosis. In addition, thrombosis is often unrecognized in this population. Furthermore, these patients are particularly susceptible to bleeding complications from anticoagulants. Herein the authors review the pharmacology, data from clinical trials, management of bleeding complications, and perioperative use of these agents in the intensive care unit population. Well-designed clinical trials are needed to improve our understanding of the safety and efficacy of these newer agents in critically ill patients.
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Affiliation(s)
- Anita Rajasekhar
- Department of Medicine, University of Florida, College of Medicine, Gainesville, FL 32610-0278, USA
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24
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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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25
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Bhagirath VC, O'Malley L, Crowther MA. Management of bleeding complications in the anticoagulated patient. Semin Hematol 2012; 48:285-94. [PMID: 22000094 DOI: 10.1053/j.seminhematol.2011.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
As new anticoagulants become available, and the number of anticoagulated patients continues to rise, it is necessary to know how to deal with associated bleeding complications. In this review, reversal strategies for traditional anticoagulants (warfarin and heparin) as well as newer anticoagulants are described. Prothrombin complex concentrates (PPCs) can be used to reverse vitamin K antagonists (VKA), and plasma may be used where they are not available. Recombinant activated factor VII (rFVIIa) may be useful to reverse pentasaccharide anticoagulants. 1-Desamino-8-D-arginine vasopressin (DDAVP), cryoprecipitate, PCCs, and dialysis may help to reverse direct thrombin inhibitors, while rFVIIa seems to be ineffective. The effect of direct factor Xa inhibitors may be reversed by PCCs, FVIIa, or factor Xa concentrates.
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Noui N, Zogheib E, Walczak K, Werbrouck A, Amar AB, Dupont H, Caus T, Remadi JP. Anticoagulation monitoring during extracorporeal circulation with the Hepcon/HMS device. Perfusion 2012; 27:214-20. [DOI: 10.1177/0267659112436632] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective: The objective of our study was to compare the standard protocol of anticoagulation to the Hepcon/HMS. Method: This study included forty-four patients who underwent coronary bypass grafting surgery (CABG), or biological aortic valve replacement (AVR). Unfractionated heparin (UH) was used for patients who underwent operations in the control group (n = 22) (300U/Kg of UH with a goal of an ACT of 400s). The heparin was antagonized dose/dose by protamine. For the patients who underwent operations in the HMS group (n = 22), the heparin and protamine doses were assessed by the Hepcon/HMS device. Results: The sex ratio amounted to 1.93 (29 men and 15 women) and the mean age was 70 ± 11 years. The patients in the HMS group had a chest closure time that was significantly shorter than patients in the control group. The times were, respectively, 42 ± 15 minutes and 68 ± 27 minutes (p = 0.001). The protamine/heparin ratio was significantly lower in the HMS group (0.62 ± 0.13 vs. 1 ± 0.11) (p = 0.0001). The postoperative bleeding amounted to 804 ± 729 ml in the HMS group versus 1416 ± 1103 in the control group (p = 0.016). In multivariate linear regression analysis, only two independent factors were significantly associated with bleeding: the Hepcon/HMS (OR = 0.1-p = 0.03) and the preoperative hemoglobin rate (OR = 1.4 - p = 0.05). Postoperatively, within 72 hours, the red blood cell transfusion was 1.04 ± 1.5 units for the HMS group and 2.1 ± 1.87 units for the control group (p = 0.05). Conclusion: During cardiac surgery under CPB, heparin and protamine titration with the Hepcon/HMS device could predict a lower protamine dose and lower postoperative bleeding without higher thromboembolic events, and lower perioperative red blood cell transfusion with a shorter chest closure time.
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Affiliation(s)
- N Noui
- Anesthesiology Unit, South Hospital, Amiens, France
| | - E Zogheib
- Anesthesiology Unit, South Hospital, Amiens, France
| | - K Walczak
- Anesthesiology Unit, South Hospital, Amiens, France
| | - A Werbrouck
- Anesthesiology Unit, South Hospital, Amiens, France
| | - A Ben Amar
- Cardio-vascular Surgery Unit, University Hospital, CHU Amiens, France
| | - H Dupont
- Anesthesiology Unit, South Hospital, Amiens, France
| | - T Caus
- Cardio-vascular Surgery Unit, University Hospital, CHU Amiens, France
| | - JP Remadi
- Cardio-vascular Surgery Unit, University Hospital, CHU Amiens, France
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Abstract
Heparin is the mainstay in the treatment and prevention of thrombosis in such diverse clinical settings as venous thromboembolism, acute coronary syndrome, cardiopulmonary bypass, and hemodialysis. However, the major complication of heparin - like that of all anticoagulants - is bleeding. Heparin may need to be reversed in the following settings: clinically significant bleeding; prior to an invasive procedure; at the conclusion of a procedure involving extracorporeal circulation (e.g., cardiopulmonary bypass, dialysis). This chapter discusses protamine sulfate, as well as several other agents that are able to neutralize heparin, including their pharmacological properties, indications, dosing, and efficacy.
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Affiliation(s)
- Menaka Pai
- Department of Medicine, McMaster University, Hamilton General Hospital, Hamilton, ON, Canada.
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28
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Caffarelli C, Stringari G, Pajno GB, Peroni D, Franceschini F, Iacono ID, Bernardini R. Perioperative Allergy: Risk Factors. Int J Immunopathol Pharmacol 2011; 24:S27-34. [DOI: 10.1177/03946320110240s305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Perioperative anaphylactic as well as anaphylactoid reactions can be elicited by drugs, diagnostic agents, antiseptics, disinfectants and latex. In some individuals, allergic reactions occur in the absence of any evident risk factor. Previous history of specific safe exposure to a product does not permit to exclude the risk of having a reaction. We have systematically reviewed characteristics in the patient's history or clinical parameters that affect the risk of developing reactions during anesthesia. Evidence shows that patients with previous unexplained reaction during anesthesia are at risk for perioperative allergic reactions. An allergic reaction to an agent is associated with previous reaction to a product that is related with the culprit agent. Multiple surgery procedures, professional exposure to latex and allergy to fruit are associated with an increased frequency of latex allergy. It has been shown that in some instances, allergic perioperative reactions may be more common in atopic patients and in female.
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Affiliation(s)
- C. Caffarelli
- Pediatric Clinic, Department of Pediatrics, University of Parma, Parma, Italy
| | - G. Stringari
- Pediatric Clinic, Department of Pediatrics, University of Parma, Parma, Italy
| | - G. B. Pajno
- Allergy Unit, Department of Pediatrics, University of Messina, Messina, Italy
| | - D.G. Peroni
- Department of Pediatrics, University of Verona, Verona, Italy
| | - F. Franceschini
- Pediatric Unit, “Ospedali Riuniti“, University Hospital, Ancona, Italy
| | - I. Dello Iacono
- Pediatric Unit, “Fatebenefratelli” Hospital, Benevento, Italy
| | - R. Bernardini
- Pediatric Unit, “San Giuseppe” Hospital, Empoli, Florence, Italy
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29
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Abstract
Peri-operative anaphylaxis is an important cause for mortality and morbidity associated with anaesthesia. The true incidence is unknown and is most likely under reported. Diagnosis can be difficult, particularly as a number of drugs are given simultaneously and any of these agents can potentially cause anaphylaxis. This review covers the clinical features, differential diagnosis and management of anaphylaxis associated with anaesthesia. The investigations to confirm the clinical suspicion of anaphylaxis and further tests to identify the likely drug(s) are examined. Finally the salient features of common and rare causes including non-drug substances are described.
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Affiliation(s)
- Linda Nel
- Department of Anaesthetics, Southampton University Hospitals NHS TrustTremona Road, Southampton, United Kingdom
| | - Efrem Eren
- Department of Immunology, Southampton University Hospitals NHS TrustTremona Road, Southampton, United Kingdom
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30
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Hanna N, Fiorilli P, Gaglia MA, Torguson R, Vita A, Ben-Dor I, Xue Z, Waksman R, Bernardo NL. Low-Dose Protamine to Facilitate Earlier Sheath Removal from the Femoral Artery After Peripheral Endovascular Intervention. J Interv Cardiol 2011; 24:278-84. [PMID: 21535150 DOI: 10.1111/j.1540-8183.2011.00642.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Nicholas Hanna
- Division of Cardiology, Washington Hospital Center, Washington, DC, USA
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31
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A randomized, partially blinded, multicenter, active-controlled, dose-ranging study assessing the safety, efficacy, and pharmacodynamics of the REG1 anticoagulation system in patients with acute coronary syndromes: design and rationale of the RADAR Phase IIb trial. Am Heart J 2011; 161:261-268.e1-2. [PMID: 21315207 DOI: 10.1016/j.ahj.2010.10.022] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 10/15/2010] [Indexed: 11/23/2022]
Abstract
Anticoagulants are the cornerstone of current acute coronary syndrome (ACS) therapy; however, anticoagulation regimens that aggressively reduce ischemic events are almost uniformly associated with more bleeding. REG1, an anticoagulation system, consists of RB006 (pegnivacogin), an RNA oligonucleotide factor IXa inhibitor, and RB007 (anivamersen), its complementary controlling agent. Phase I and IIa studies defined predictable relationships between doses of RB006, RB007, and degree of antifactor IX activity. The efficacy and safety of REG1 for the treatment of patients with ACS managed invasively and the safety of reversing RB006 with RB007 after cardiac catheterization are unknown. Randomized, partially-blinded, multicenter, active-controlled, dose-ranging study assessing the safety, efficacy, and pharmacodynamics of the REG1 anticoagulation system compared to unfractionated heparin or low molecular heparin in subjects with acute coronary syndrome (RADAR) is designed to assess both the efficacy of the anticoagulant RB006 and the safety of a range of levels of RB006 reversal with RB007. The objectives of RADAR are (1) to determine the safety of a range of levels of RB006 reversal with RB007 after catheterization, (2) to confirm whether a dose of 1 mg/kg RB006 results in near-complete inhibition of factor IXa in patients with ACS, and (3) to assess the efficacy of RB006 as an anticoagulant in patients with ACS undergoing percutaneous coronary intervention.
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32
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Chu YQ, Cai LJ, Jiang DC, Jia D, Yan SY, Wang YQ. Allergic shock and death associated with protamine administration in a diabetic patient. Clin Ther 2010; 32:1729-32. [DOI: 10.1016/j.clinthera.2010.09.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2010] [Indexed: 01/22/2023]
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33
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Reversal of heparin-induced increases in aPTT in the rat by PM102, a novel heparin antagonist. Eur J Pharmacol 2010; 635:165-70. [DOI: 10.1016/j.ejphar.2010.03.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 02/18/2010] [Accepted: 03/04/2010] [Indexed: 11/22/2022]
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Collins C, O’Donnell A. Does an allergy to fish pre-empt an adverse protamine reaction? A case report and a literature review. Perfusion 2009; 23:369-72. [DOI: 10.1177/0267659109105543] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The operating theatre exposes patients to myriad potential agents which could result in a life-threatening anaphylactic reaction. Anaesthetic drugs, blood products, and latex are only some of the possible allergens. Reactions are deemed to be anaphylactic when immediate sensitivity is combined with cardiovascular collapse. A patient who had a known allergy to shellfish presented for first time cardiopulmonary bypass. The perfusion team were concerned that there was a realistic possibility that an adverse reaction to protamine could occur. Anaphylactic reactions to protamine in patients allergic to fish have been reported. The anaesthetic team were informed and the necessary precautions taken. We report on the outcome for our patient and also discuss other risk factors and the types of reactions that can result when an adverse reaction to protamine occurs.
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Affiliation(s)
- C Collins
- Cardiac Theatre, Cork University Hospital, Wilton, Cork, Ireland
| | - A O’Donnell
- Cardiac Theatre, Cork University Hospital, Wilton, Cork, Ireland
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35
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Chilukuri K, Henrikson CA, Dalal D, Scherr D, MacPherson EC, Cheng A, Spragg D, Nazarian S, Sinha S, Berger R, Marine JE, Calkins H. Incidence and outcomes of protamine reactions in patients undergoing catheter ablation of atrial fibrillation. J Interv Card Electrophysiol 2009; 25:175-81. [DOI: 10.1007/s10840-009-9364-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Accepted: 01/20/2009] [Indexed: 11/24/2022]
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36
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Nybo M, Madsen JS. Serious anaphylactic reactions due to protamine sulfate: a systematic literature review. Basic Clin Pharmacol Toxicol 2008; 103:192-6. [PMID: 18816305 DOI: 10.1111/j.1742-7843.2008.00274.x] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Anaphylactic reactions caused by injection of protamine sulfate during cardiac surgery are a well-known complication. A systematic literature review was therefore conducted to gather evidence of the knowledge concerning these side effects, and to see if any prospective randomized studies supported this. Studies investigating the effect of protamine sulfate in human beings were extracted from MEDLINE, Embase and the Cochrane Library, retrieving 487 articles. Abstracts were evaluated by both authors, and referred articles not found in the primary search were furthermore extracted from reviews and case reports, resulting in a total of 272 relevant articles. Of these, 9 retrospective studies and 16 prospective studies were performed in an evidence-based manner. However, only 3 of the 16 prospective articles had an optimal design as far as inclusion criteria, randomization, and description of symptoms were concerned. Incidence of anaphylactic reactions in the prospective studies was 0.69% compared to 0.19% in the retrospective studies, but caution should be taken due to a pronounced heterogeneity of those studies. One study found heparinase I unsuitable as replacement for protamine sulfate. Overall, our findings support the low incidence of anaphylactic reactions reported in previous studies, but of note only few prospective investigations was conducted on the subject. Our study also emphasizes the need for critical appraisal of many routine procedures: in all aspects of medical care, systematic literature review conducted in a well-structured, repeated manner should be given high priority.
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Affiliation(s)
- Mads Nybo
- Department of Biochemistry, Pharmacology and Genetics, Odense University Hospital, Odense, Denmark.
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37
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Kamiński K, Zazakowny K, Szczubiałka K, Nowakowska M. pH-Sensitive Genipin-Cross-Linked Chitosan Microspheres For Heparin Removal. Biomacromolecules 2008; 9:3127-32. [DOI: 10.1021/bm800724q] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kamil Kamiński
- Faculty of Chemistry, Jagiellonian University, Ingardena 3, 30-060 Kraków, Poland
| | - Karolina Zazakowny
- Faculty of Chemistry, Jagiellonian University, Ingardena 3, 30-060 Kraków, Poland
| | | | - Maria Nowakowska
- Faculty of Chemistry, Jagiellonian University, Ingardena 3, 30-060 Kraków, Poland
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38
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Möller MG, Lewis JM, Dessureault S, Zager JS. Toxicities associated with hyperthermic isolated limb perfusion and isolated limb infusion in the treatment of melanoma and sarcoma. Int J Hyperthermia 2008; 24:275-89. [PMID: 18393005 DOI: 10.1080/02656730701805520] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Hyperthermic isolated limb perfusion (HILP) and isolated limb infusion (ILI) may play a significant role in the treatment of patients with recurrent or in transit extremity melanoma or sarcoma that is unresectable. These procedures may be indicated when patients are otherwise faced with the possibility of a debilitating amputation. Not entirely benign treatment modalities, HILP and ILI can be associated with regional and systemic toxicities. We conducted a literature search of published studies using HILP and ILI for the treatment of extremity sarcomas and melanomas, and associated toxicities was performed. The regional toxicities of HILP and ILI are similar. The most common toxicities reported are mild to moderate. However, when severe regional toxicity occurs, albeit infrequently (<5%), fasciotomies or even amputation may be necessary. Some studies have showed a relationship between acute regional toxicities and long term regional morbidity. Systemic toxicity appears to be more frequent when TNF-alpha is used in combination with other drugs during HILP, however the use of TNF-alpha in the United States is limited to trials. Although regional toxicities are similar, systemic toxicity of ILI is minimal compared to HILP. ILI is easier to repeat, technically less complex, and may be more acceptable in infirmed patients. Long term morbidity and outcomes for ILI are still being evaluated. Both of these techniques may be suitable options in patients with unresectable advanced or recurrent, or in transit extremity melanoma or sarcoma.
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Affiliation(s)
- Mecker G Möller
- H Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa. FL 33612, USA
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Bleeding risk and the management of bleeding complications in patients undergoing anticoagulant therapy: focus on new anticoagulant agents. Blood 2008; 111:4871-9. [DOI: 10.1182/blood-2007-10-120543] [Citation(s) in RCA: 207] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractFor more than 60 years, heparin and coumarin have been mainstays of anticoagulation therapy. They are widely available, inexpensive, effective, and have specific antidotes but are regarded as problematic because of their need for careful monitoring. In addition, coumarin has a delayed onset of action, interacts with many medications, has a narrow therapeutic window, and is paradoxically prothrombotic in certain settings (ie, can precipitate “coumarin necrosis”). Heparin may require monitoring of its therapeutic effect and can also cause thrombosis (heparin-induced thrombocytopenia/thrombosis syndrome). These limitations have led to the development of new anticoagulants with the potential to replace current agents. These newer agents fall into 2 classes, based on whether they are antithrombin dependent (low-molecular-weight heparin, fondaparinux) or antithrombin independent (direct inhibitors of factor Xa and thrombin [factor IIa]). This paper addresses newer anticoagulants, reviewing their efficacy and limitations, and focuses on the risk of major bleeding that may complicate their use. In contrast to heparin and coumarin, none of these newer agents has a specific antidote that completely reverses its anticoagulant effect. Available data on the efficacy and safety of current and experimental agents for anticoagulant reversal are reviewed, and a plan for management of anticoagulant-induced bleeding is presented.
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Fineberg SE, Kawabata TT, Finco-Kent D, Fountaine RJ, Finch GL, Krasner AS. Immunological responses to exogenous insulin. Endocr Rev 2007; 28:625-52. [PMID: 17785428 DOI: 10.1210/er.2007-0002] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Regardless of purity and origin, therapeutic insulins continue to be immunogenic in humans. However, severe immunological complications occur rarely, and less severe events affect a small minority of patients. Insulin autoantibodies (IAAs) may be detectable in insulin-naive individuals who have a high likelihood of developing type 1 diabetes or in patients who have had viral disorders, have been treated with various drugs, or have autoimmune disorders or paraneoplastic syndromes. This suggests that under certain circumstances, immune tolerance to insulin can be overcome. Factors that can lead to more or less susceptibility to humoral responses to exogenous insulin include the recipient's immune response genes, age, the presence of sufficient circulating autologous insulin, and the site of insulin delivery. Little proof exists, however, that the development of insulin antibodies (IAs) to exogenous insulin therapy affects integrated glucose control, insulin dose requirements, and incidence of hypoglycemia, or contributes to beta-cell failure or to long-term complications of diabetes. Studies in which pregnant women with diabetes were monitored for glycemic control argue against a connection between IAs and fetal risk. Although studies have shown increased levels of immune complexes in patients with diabetic microangiopathic complications, these immune complexes often do not contain insulin or IAs, and insulin administration does not contribute to their formation. The majority of studies have shown no relationship between IAs and diabetic angiopathic complications, including nephropathy, retinopathy, and neuropathy. With the advent of novel insulin formulations and delivery systems, such as insulin pumps and inhaled insulin, examination of these issues is increasingly relevant.
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Affiliation(s)
- S Edwin Fineberg
- Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
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Parker JT, Beutler DS, Sukavaneshvar S, Jacobs N, Solen KA, Mohammad SF. Mitigation of Coagulation by Removing Clotting Factors Part 1: In Vitro Feasibility Study. ASAIO J 2007; 53:415-20. [PMID: 17667224 DOI: 10.1097/mat.0b013e3180cab642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Heparin is associated with adverse effects in some patients during extracorporeal circulation. A potential alternate anticoagulation strategy explored in this investigation involved mitigation of coagulation by removing clotting factors from blood by adsorption on a protamine-immobilized Sepharose matrix (PSM). Human or porcine plasmas treated with PSM in vitro were tested for clotting factors I (fibrinogen), II (prothrombin), VIII, and X, and proteins C and S, and for prothrombin time (PT), activated partial thromboplastin time (APTT), and total protein concentration. Bovine blood treated with PSM was also perfused through a hollow-fiber cartridge to assess thrombogenic potential in a shear flow system. PT increased with increasing protamine-Sepharose-to-plasma ratios and with increasing mixing time. When the PT and APTT of treated plasma were prolonged three to six times the baseline, Factors II and X were significantly removed (>90%), Factors I and VIII were partly removed (<35%), and total protein concentration remained >80% of the initial value. When blood depleted of clotting factors was perfused through hollow-fiber cartridges without an anticoagulant, cartridge patency was prolonged compared with cartridges perfused with untreated blood. This investigation demonstrated that inhibition of blood coagulation by removal of key clotting proteins is feasible.
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Affiliation(s)
- Jared T Parker
- Chemical Engineering Department, Brigham Young University, Provo, Utah 84602, USA
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Abstract
Correct management of anaphylaxis during anaesthesia requires a multidisciplinary approach with prompt recognition and treatment of the acute event by the attending anaesthesiologist, and subsequent determination of the responsible agent(s) with strict avoidance of subsequent administration of all incriminated and/or cross-reacting compounds. However, correct identification of the causative compound(s) and safe alternatives is not always straightforward and, too often, not done. This review is not intended to discuss acute management of anaesthesia-related anaphylaxis but summarizes the major causes of anaphylaxis during anaesthesia and the diagnostic approach of this rare but potentially life-threatening complication. Apart from general principles about the diagnostic approach, history taking and importance of tryptase quantification, more specific confirmatory diagnostic procedures are organized on the basis of the major causes of perioperative anaphylactic reactions.
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Affiliation(s)
- D G Ebo
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerpen, Belgium
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Wang T, Yang Z, Emregul E, David A, Balthasar JP, Liang J, Yang VC. Strategies for improving the functionality of an affinity bioreactor. Int J Pharm 2005; 306:132-41. [PMID: 16246511 DOI: 10.1016/j.ijpharm.2005.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2005] [Revised: 09/14/2005] [Accepted: 09/15/2005] [Indexed: 11/23/2022]
Abstract
Heparin employed in extracorporeal blood circulation (ECBC) procedures (e.g. open heart operations) often leads to a high incidence of bleeding complications. Protamine employed in heparin neutralization, on the other hand, can cause severe adverse reactions. We previously developed an approach that could prevent both heparin- and protamine-induced toxic side effects concomitantly. This approach consisted of placing a hollow fiber-based bioreactor device containing immobilized protamine (termed a "protamine bioreactor") at the distal end of the ECBC procedure. This protamine bioreactor would remove heparin after heparin served its anticoagulant purpose in the ECBC device, thereby eliminating heparin-induced bleeding risks. In addition, this protamine bioreactor would prevent protamine from entering the patients, thereby aborting any protamine-induced toxic effects. Both in vitro and in vivo studies have successfully demonstrated the feasibility of this approach. Despite promises, early findings also revealed two shortcomings that must be overcome for the protamine bioreactor to be applied clinically. The first drawback was that the cyanate ester linkages, involved in conjugating protamine to the bioreactor device, were unstable and prone to hydrolysis, resulting in the leakage of a significant amount of protamine into circulation during application of the protamine bioreactor. The second deficiency was that the capacity of the protamine bioreactor in heparin removal was rather low, owing to the limited surface area of the hollow fibers for protamine immobilization and subsequently heparin adsorption. In this paper, we present novel strategies to overcome these two limitations. A new conjugation method based on the use of 4-(oxyacetyl)phenoxyacetic acid (OAPA) as the activating reagent was employed to yield stable linkages, via the abundant arginine residues of protamine, onto the hollow fibers. Results showed that while the amount of protamine immobilized on each gram of fibers was relatively comparable between the OAPA and the previous CNBr activation methods (7.45 mg/g versus 7.69 mg/g fibers), there was virtually no detectable leaching of immobilized protamine from the bioreactor by the OAPA method, comparing to 35% leaching of protamine by the previous CNBr method following 72 h of storage of the bioreactor in PBS buffer at 37 degrees C. To improve the capacity and functionality of the protamine bioreactor, two novel approaches were adopted. Long chain and high molecular weight poly-lysine was linked to the hollow fibers, prior to protamine coupling, to create multiple layers of immobilized protamine for subsequent heparin adsorption. In addition, a poly(ethylene glycol) (PEG) chain was inserted between protamine and the hollow fibers to yield a three-dimensional, free dynamic motion for immobilized protamine. Preliminary observations indicated that a four- to five-fold enhancement in heparin adsorption was attained by utilizing each of these new approaches. Aside from their current use, these new strategies can also be employed generically to improve the functionality of any affinity-type bioreactor. Indeed, efforts have been made recently in utilizing these approaches to develop a clinically usable GPIIb/IIIa bioreactor for the treatment of immune thrombocytopenic purpura (ITP)-an autoimmune disease.
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Affiliation(s)
- Tanya Wang
- College of Pharmacy, University of Michigan, Ann Arbor, MI 48109-1065, USA
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Abstract
Although screening tests to prevent anaphylaxis during anaesthesia have been advocated, such tests are unlikely to have significant impact on reducing the incidence of anaphylaxis during anaesthesia. This is due to the low prevalence of the disease, the diversity of drugs used in anaesthesia and the incidence of false positive and negative tests. The suggested risk factors of allergy, i.e. atopy, asthma, family history, female sex, previous exposure, vasectomy, use of zinc protamine sulfate insulin and allergy to cosmetics, eggs, fish and non-anaesthetic drugs are not valid. Although all have theoretical or real associations with anaphylaxis during anaesthesia the majority of patients with such a history undergo uneventful anaesthesia. Fruit allergy, anaphylaxis to cephalosporins and penicillin, barbiturate allergy, gelatin allergy and allergy to metabisulphite and eggs require consideration in avoiding particular drugs. The incidence of anaesthetic anaphylaxis can be reduced by avoiding latex exposure in patients with spina bifida or latex allergy, and preventing second reactions in patients with a history of anaphylaxis, or major undiagnosed or undocumented adverse events during anaesthesia. Determining the cause of an adverse event and the drug responsible, and adequately communicating those findings can reduce second reactions. Avoiding neuromuscular blocking drugs (NMBDs) in patients who have reacted to an NMBD, and use of non-intravenous techniques should also reduce the incidence of second reactions. Desensitisation, and blocking with monovalent quaternary ammonium compounds may allow improved safety of NMBDs and pretreatment with antihistamines and corticosteroids may block or ameliorate the severity of reactions, but there is currently little evidence to support their routine use.
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Affiliation(s)
- Malcolm M Fisher
- Intensive Therapy Unit, University of Sydney, Royal North Shore Hospital of Sydney, Sydney, NSW, Australia.
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Abstract
GREAT PROGRESS: The use of purified insulins obtained by genetics has dramatically lowered the frequency of insulin hypersensitivity. This frequency has decreased from 1 to 55% with non purified insulins and to 0.1 to 2% with newly generated insulins. DIAGNOSTIC MEASURES The anamnesis should clarify the allergic background of the patient, previous treatments with insulin, their duration of use and any eventual reactions. Examination of the lesions must assess the type (papule, eczema, purpura), the localization and extent. The second step skin tests, when negative, eliminate the responsibility of the insulin tested. They also participate in the search for cross-reactions between the various insulines. Their positivity is not always synonymous of hypersensitivity. STRATEGY TO BE APPLIED: In the case of localised cutaneous reactions, spontaneous regression is generally observed, the association of an oral antihistamine and/or the fractioning of the dose and its injection on several different sites often leads to the disappearance of these reactions. If the reactions persist, topical or oral corticosteroids of short duration can be useful. Finally, the switch to another insulin or even a tolerance induction with the least skin test reactive insulin as a last resource. The most severe systemic reactions are an indication for tolerance induction.
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Affiliation(s)
- Djamel Messaad
- Exploration des allergies, maladies respiratoires, Inserm U454 - IFR3, Hôpital Arnaud de Villeneuve, CHU, Montpellier.
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Kessler CM. Current and future challenges of antithrombotic agents and anticoagulants: strategies for reversal of hemorrhagic complications. Semin Hematol 2004; 41:44-50. [PMID: 14872421 DOI: 10.1053/j.seminhematol.2003.11.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Recent years have seen the introduction of a number of new anticoagulant agents, each offering a unique profile of benefits and potential drawbacks. Anticoagulants are now available or in development that target platelet recruitment, aggregation, and adhesion, in addition to a growing number of direct or indirect thrombin inhibitors. However, the potential for anticoagulant-induced hemorrhage and the need for effective antidotes that can reverse this adverse effect remain major considerations when prescribing any anticoagulant therapy. The expanding range of anticoagulants brings with it a renewed challenge of identifying suitable treatments to reverse anticoagulant-induced hemorrhage. This paper reviews different mechanisms of anticoagulant action and the theoretical role of recombinant factor VIIa (rFVIIa) and other agents currently in development to reverse bleeding complications associated with both traditional and novel anticoagulant therapies.
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Affiliation(s)
- Craig M Kessler
- Department of Medicine, Georgetown University of Medicine, Washington, DC 20007, USA
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Seifert HA, Jobes DR, Ten Have T, Kimmel SE, Montenegro LM, Steven JM, Nicolson SC, Strom BL. Adverse events after protamine administration following cardiopulmonary bypass in infants and children. Anesth Analg 2003; 97:383-389. [PMID: 12873922 DOI: 10.1213/01.ane.0000072545.13681.fa] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED We performed this study to determine the incidence of and risk factors for adverse events (AEs) in infants and children after the IV administration of protamine after cardiopulmonary bypass. In a retrospective cohort study, all relevant anesthesia records from a 3-yr period were examined to identify AEs after protamine. The AEs were then grouped into three categories by applying increasingly strict criteria. Among 1249 anesthesia records, there were no documented episodes of isolated or hypotension-associated right-sided cardiac failure or acute pulmonary dysfunction. The incidence of systemic hypotension after protamine was between 1.76% (95% confidence interval [CI], 1.11%-2.65%) and 2.88% (95% CI, 2.03%-3.97%), depending on the strictness of case definition. To identify risk factors, we performed a nested case-control study in which unmatched controls were randomly selected from the parent cohort at a 4:1 ratio to cases. Cases of hypotension after protamine were more likely during operations on girls (odds ratio [OR], 6.47; 95% CI, 1.66-32.8), after larger doses of protamine (OR, 1.88; 95% CI, 1.03-3.63), or after smaller doses of heparin (OR, 0.49; 95% CI, 0.17-0.67). IMPLICATIONS Systemic hypotension after protamine administration occurred in 1.76%-2.88% of pediatric patients having cardiac surgery. Female sex, larger protamine dose, and smaller heparin dose were each associated with increased risk. The development of protamine alternatives or prophylactic therapies may be useful for reducing the frequency of these events.
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Affiliation(s)
- Harry A Seifert
- *Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; and †Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
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Mortality and Adverse Events After Protamine Administration in Patients Undergoing Cardiopulmonary Bypass. Anesth Analg 2002. [DOI: 10.1213/00000539-200206000-00005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kimmel SE, Sekeres M, Berlin JA, Ellison N. Mortality and adverse events after protamine administration in patients undergoing cardiopulmonary bypass. Anesth Analg 2002; 94:1402-8, table of contents. [PMID: 12031996 DOI: 10.1097/00000539-200206000-00005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED We designed this study to determine whether adverse hemodynamic events after a protamine administration increase the risk of in-hospital mortality. Using a retrospective cohort study design, medical and anesthesia records of patients undergoing cardiopulmonary bypass (CPB) at the Hospital of the University of Pennsylvania, Philadelphia, between 1990 and 1994 were reviewed. Adverse events after a protamine administration were determined using strict, predefined criteria, and in-hospital mortality was assessed without knowledge of exposure status. Mortality was more frequent among the 53 patients with adverse events (13.2%) than the 223 patients without events (2.7%; crude odds ratio 5.50; 95% confidence interval, 1.49-20.6). After adjusting for confounders, the odds ratio was 6.98 (95% confidence interval, 1.36-35.9; P = 0.017). Those suffering severe events had the highest mortality (23.5% compared with 8.3% among those with less severe events versus 2.7% among those without any event, P = 0.001 for trend). In addition, the odds ratio was largest when using the strictest definition for protamine-related events. In conclusion, patients undergoing CPB who experience adverse events after a protamine administration have an increased risk of in-hospital mortality. Further studies to confirm these findings and development and testing of protamine alternatives or prophylactic therapies are required to determine if mortality can be reduced. IMPLICATIONS A retrospective cohort study demonstrated an association between adverse events after a protamine administration and increased in-hospital mortality.
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Affiliation(s)
- Stephen E Kimmel
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, 717 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021, USA.
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