Protamine

Anaphylaxis to Protamine During a Carotid Endarterectomy

Protamine sulfate is commonly used to reverse the anticoagulant effects of unfractionated heparin (UFH) during surgical procedures, but its administration can sometimes trigger severe adverse reactions, including life-threatening anaphylaxis. We present the case of a 77-year-old male undergoing carotid endarterectomy who developed profound hypotension and tachycardia following protamine infusion. Anaphylaxis was confirmed by elevated tryptase levels. This case emphasizes the importance of vigilant monitoring during protamine administration, particularly in high-risk patients, and highlights the need to consider alternative reversal strategies to enhance patient safety.

Review of Target-Specific Anticoagulation Reversal Agents

Bleeding related to direct oral anticoagulants accounts for nearly half of emergency department visits annually and until recently there were no reversal antidotes available. As there continues to be a shift in prescribing practices away from warfarin, it is essential to have these reversal agents readily available for the treatment of life-threatening bleeds associated with these anticoagulants. In addition, for agents that continue to lack a targeted reversal agent (eg, low-molecular-weight heparin, antiplatelets, and new antithrombotics), it is imperative that research continues to evaluate improved reversal strategies. This review focuses on target-specific anticoagulation reversal agents currently available in the United States (protamine, idarucizumab, and andexanet alfa) and summarizes agents that are in the pipeline for these anticoagulants and antiplatelets.

Anaphylaxis during the perioperative period

Anesthesiologists use a myriad of drugs during the provision of an anesthetic. Many of these drugs have side effects that are dose related, and some lead to severe immune-mediated adverse reactions. Anaphylaxis is the most severe immune-mediated reaction; it generally occurs on reexposure to a specific antigen and requires the release of proinflammatory mediators. Anaphylactoid reactions occur through a direct non-immunoglobulin E-mediated release of mediators from mast cells or from complement activation. Muscle relaxants and latex account for most cases of anaphylaxis during the perioperative period. Symptoms may include all organ systems and present with bronchospasm and cardiovascular collapse in the most severe cases. Management of anaphylaxis includes discontinuation of the presumptive drug (or latex) and anesthetic, aggressive pulmonary and cardiovascular support, and epinephrine. Although a serum tryptase confirms the diagnosis of an anaphylactic reaction, the offending drug can be identified by skin-prick, intradermal testing, or serologic testing. Prevention of recurrences is critical to avoid mortality and morbidity.