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Vespe MW, Stone ME, Lin HM, Ouyang Y. Accurate protamine:heparin matching (not just smaller protamine doses) decreases postoperative bleeding in cardiac surgery; results from a high-volume academic medical center. Perfusion 2024; 39:1335-1347. [PMID: 37493300 DOI: 10.1177/02676591231190739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND A multidisciplinary Quality Assurance/Performance Improvement study to identify the incidence of "heparin rebound" in our adult cardiac surgical population instead detected a thromboelastometry pattern suggestive of initial protamine overdose in 34% despite Hepcon-guided anticoagulation management. Analysis of our practice led to an intervention that made an additional lower-range Hepcon cartridge available to the perfusionists. METHODS One year later, an IRB-approved retrospective study was conducted in >500 patients to analyze the effects of the intervention, specifically focusing on the impact of the initial protamine dose accuracy and 18-h mediastinal chest tube drainage (MCTd). RESULTS No differences were observed between group demographics, surgical procedures, duration of CPB or perioperative blood product transfusion. Both groups were managed using the same perfusion and anesthesia equipment, strategies, and protocols. The median initial protamine dose decreased by 19% (p < .001) in the intervention group (170 [IQR 140-220] mg; n = 295) versus the control group (210 [180-250] mg; n = 257). Mean 18-h MCTd decreased by 13% (p < .001) in the intervention group (405.15 ± 231.54 mL; n = 295) versus the control group (466.13 ± 286.73 mL; n = 257). Covariate-adjusted mixed effects model showed a significant reduction of MCTd in the intervention group, starting from hour 11 after surgery (group by time interaction p = .002). CONCLUSION Though previous investigators have associated lower protamine doses with less MCTd, this study demonstrates that more accurately matching the initial protamine dose to the remaining circulating heparin concentration reduces postoperative bleeding.
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Affiliation(s)
| | - Marc E Stone
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hung-Mo Lin
- Department of Anesthesiology and Yale Center for Analytical Science, Yale Schoold of Medicine, New Haven, CT, USA
| | - Yuxia Ouyang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Crivellari M, Landoni G, Ursoleo JD, Ferrante L, Oriani A. Protamine and Heparin Interactions: A Narrative Review. Ann Card Anaesth 2024; 27:202-212. [PMID: 38963354 PMCID: PMC11315261 DOI: 10.4103/aca.aca_117_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 11/18/2023] [Accepted: 12/08/2023] [Indexed: 07/05/2024] Open
Abstract
ABSTRACT Protamine, first isolated from salmon fish sperm and now produced through recombinant biotechnology, is an antidote that neutralizes the anticoagulant properties of heparin. Protamine function is based on the capacity to dissociate the heparin-antithrombin III (AT III) complex (an important link that promotes blood fluidification by inhibiting coagulation), forming the inactive heparin-protamine complex. Protamine has itself dose-dependent anticoagulant properties: It interferes with coagulation factors and platelet function; it stimulates fibrinolysis; it can lead to thrombocytopenia and reduction in thrombin-related platelet aggregation; it decreases platelet response to thrombin receptor agonist in a dose-dependent manner. In this review, we will focus on protamine and its interaction with heparin. Notably, protamine is able to antagonize not only unfractionated heparin (UFH) but also low molecular weight heparins to various degrees. Protamine-allergic and anaphylactoid systemic reactions may affect up to 1 in 10 people and should be prevented and treated early.
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Affiliation(s)
- Martina Crivellari
- IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Via Olgettina, 58, 20132, Milan, Italy
| | | | - Luca Ferrante
- Vita-Salute San Raffaele University, Via Olgettina, 58, 20132, Milan, Italy
| | - Alessandro Oriani
- IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
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Stone ME, Vespe MW. Heparin Rebound: An In-Depth Review. J Cardiothorac Vasc Anesth 2023; 37:601-612. [PMID: 36641308 DOI: 10.1053/j.jvca.2022.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/17/2022] [Accepted: 12/19/2022] [Indexed: 12/26/2022]
Abstract
The common conception of "heparin rebound" invokes heparin returning to circulation in the postoperative period after apparently adequate intraoperative reversal with protamine. This is believed to portend increased postoperative bleeding and provides the rationale for administering additional empiric doses of protamine in response to prolonged coagulation tests and/or bleeding. However, the relevant literature of the last 60+ years provides only a weak level of evidence that "rebounded" heparin itself is a significant etiology of postoperative bleeding after cardiac surgery with cardiopulmonary bypass. Notably, many of the most frequently cited heparin rebound investigators ultimately concluded that although exceedingly low levels of heparin activity could be detected by anti-Xa assay in some (but not all) patients postoperatively, there was no correlation with actual bleeding. An understanding of the literature requires a careful reading of the details because the investigators lacked standardized definitions for "heparin rebound" and "adequate reversal" while studying the phenomenon with significantly different experimental methodologies and laboratory tests. This review was undertaken to provide a modern understanding of the "heparin rebound" phenomenon to encourage an evidence-based approach to postoperative bleeding. Literature searches were conducted via PubMed using the following MeSH terms: heparin rebound, heparin reversal, protamine, platelet factor 4, and polybrene. Relevant English language articles were reviewed, with subsequent references obtained from the internal citations. Perspective is provided for both those who use HepCon-guided management and those who do not, as are practical recommendations for the modern era based on the published data and conclusions of the various investigators.
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Affiliation(s)
- Marc E Stone
- Icahn School of Medicine at Mount Sinai, New York, NY
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MacDougall G, Anderton RS, Mastaglia FL, Knuckey NW, Meloni BP. Mitochondria and neuroprotection in stroke: Cationic arginine-rich peptides (CARPs) as a novel class of mitochondria-targeted neuroprotective therapeutics. Neurobiol Dis 2018; 121:17-33. [PMID: 30218759 DOI: 10.1016/j.nbd.2018.09.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/26/2018] [Accepted: 09/11/2018] [Indexed: 01/11/2023] Open
Abstract
Stroke is the second leading cause of death globally and represents a major cause of devastating long-term disability. Despite sustained efforts to develop clinically effective neuroprotective therapies, presently there is no clinically available neuroprotective agent for stroke. As a central mediator of neurodamaging events in stroke, mitochondria are recognised as a critical neuroprotective target, and as such, provide a focus for developing mitochondrial-targeted therapeutics. In recent years, cationic arginine-rich peptides (CARPs) have been identified as a novel class of neuroprotective agent with several demonstrated mechanisms of action, including their ability to target mitochondria and exert positive effects on the organelle. This review provides an overview on neuronal mitochondrial dysfunction in ischaemic stroke pathophysiology and highlights the potential beneficial effects of CARPs on mitochondria in the ischaemic brain following stroke.
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Affiliation(s)
- Gabriella MacDougall
- Centre for Neuromuscular and Neurological Disorders, The University of Western Australia, Nedlands, Australia; Perron Institute for Neurological and Translational Science, Nedlands, Australia; School of Heath Sciences, and Institute for Health Research, The University Notre Dame Australia, Fremantle, Australia.
| | - Ryan S Anderton
- Centre for Neuromuscular and Neurological Disorders, The University of Western Australia, Nedlands, Australia; Perron Institute for Neurological and Translational Science, Nedlands, Australia; School of Heath Sciences, and Institute for Health Research, The University Notre Dame Australia, Fremantle, Australia
| | - Frank L Mastaglia
- Centre for Neuromuscular and Neurological Disorders, The University of Western Australia, Nedlands, Australia; Perron Institute for Neurological and Translational Science, Nedlands, Australia
| | - Neville W Knuckey
- Centre for Neuromuscular and Neurological Disorders, The University of Western Australia, Nedlands, Australia; Perron Institute for Neurological and Translational Science, Nedlands, Australia; Department of Neurosurgery, Sir Charles Gairdner Hospital, QEII Medical Centre, Nedlands, Western Australia, Australia
| | - Bruno P Meloni
- Centre for Neuromuscular and Neurological Disorders, The University of Western Australia, Nedlands, Australia; Perron Institute for Neurological and Translational Science, Nedlands, Australia; Department of Neurosurgery, Sir Charles Gairdner Hospital, QEII Medical Centre, Nedlands, Western Australia, Australia
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Albuquerque AAS, Margarido EA, Menardi AC, Scorzoni A, Celotto AC, Rodrigues AJ, Vicente WVA, Evora PRB. Methylene Blue to Treat Protamine-induced Anaphylaxis Reactions. An Experimental Study in Pigs. Braz J Cardiovasc Surg 2017; 31:226-231. [PMID: 27737405 PMCID: PMC5062710 DOI: 10.5935/1678-9741.20160054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 07/30/2016] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE: To examine if methylene blue (MB) can counteract or prevent protamine (P)
cardiovascular effects. METHODS: The protocol included five heparinized pig groups: Group Sham -without any
drug; Group MB - MB 3 mg/kg infusion; Group P - protamine; Group P/MB - MB
after protamine; Group MB/P - MB before protamine. Nitric oxide levels were
obtained by the nitric oxide/ozone chemiluminescence method, performed using
the Nitric Oxide Analizer 280i (Sievers, Boulder, CO, USA). Malondialdehyde
plasma levels were estimated using the thiobarbiturate technique. RESULTS: 1) Groups Sham and MB presented unchanged parameters; 2) Group P - a)
Intravenous protamine infusion caused mean arterial pressure decrease and
recovery trend after 25-30 minutes, b) Cardiac output decreased and remained
stable until the end of protamine injection, and c) Sustained systemic
vascular resistance increased until the end of protamine injection; 3)
Methylene blue infusion after protamine (Group P/MB) - a) Marked mean
arterial pressure decreased after protamine, but recovery after methylene
blue injection, b) Cardiac output decreased after protamine infusion,
recovering after methylene blue infusion, and c) Sustained systemic vascular
resistance increased after protamine infusion and methylene blue injections;
4) Methylene blue infusion before protamine (Group MB/P) - a) Mean arterial
pressure decrease was less severe with rapid recovery, b) After methylene
blue, there was a progressive cardiac output increase up to protamine
injection, when cardiac output decreased, and c) Sustained systemic vascular
resistance decreased after protamine, followed by immediate Sustained
systemic vascular resistance increase; 5) Plasma nitrite/nitrate and
malondialdehyde values did not differ among the experimental groups. CONCLUSION: Reviewing these experimental results and our clinical experience, we suggest
methylene blue safely prevents and treats hemodynamic protamine
complications, from the endothelium function point of view.
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Affiliation(s)
- Agnes Afrodite S Albuquerque
- Laboratory of Endothelium and Cardiovascular Function; Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), SP, Brazil
| | - Edson A Margarido
- Laboratory of Endothelium and Cardiovascular Function; Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), SP, Brazil
| | - Antonio Carlos Menardi
- Laboratory of Endothelium and Cardiovascular Function; Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), SP, Brazil
| | - Adilson Scorzoni
- Laboratory of Endothelium and Cardiovascular Function; Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), SP, Brazil
| | - Andrea Carla Celotto
- Laboratory of Endothelium and Cardiovascular Function; Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), SP, Brazil
| | - Alfredo J Rodrigues
- Laboratory of Endothelium and Cardiovascular Function; Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), SP, Brazil
| | - Walter Vilella A Vicente
- Laboratory of Endothelium and Cardiovascular Function; Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), SP, Brazil
| | - Paulo Roberto B Evora
- Laboratory of Endothelium and Cardiovascular Function; Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), SP, Brazil
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Stone JA, Willey JZ, Keyrouz S, Butera J, McTaggart RA, Cutting S, Silver B, Thompson B, Furie KL, Yaghi S. Therapies for Hemorrhagic Transformation in Acute Ischemic Stroke. Curr Treat Options Neurol 2017; 19:1. [DOI: 10.1007/s11940-017-0438-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bailey CJ, Koenigshof AM. The effects of protamine sulfate on clot formation time and clot strength thromboelastography variables for canine blood samples. Am J Vet Res 2014; 75:338-43. [DOI: 10.2460/ajvr.75.4.338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Olinger GN, Becker RM, Bonchek LI. Noncardiogenic pulmonary edema and peripheral vascular collapse following cardiopulmonary bypass: rare protamine reaction? Ann Thorac Surg 1980; 29:20-5. [PMID: 7356803 DOI: 10.1016/s0003-4975(10)61620-7] [Citation(s) in RCA: 74] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Four instances of severe anaphylactoid reaction occurring subsequent to cardiopulmonary bypass are described. These catastrophic reactions, from which 2 patients died, took place approximately an hour following administration of protamine and were characterized by marked peripheral vasodilatation, loss of capillary membrane integrity, and fulminant noncardiogenic pulmonary edema. Primary cardiac depression was not evident. We hypothesize that protamine was the causative agent in these unusually severe reactions. Differential diagnosis from other causes of acute cardiorespiratory dysfunction depended on early assessment of pulmonary artery and left ventricular filling pressures, cardiac output, respiratory mechanics, and arterial blood gases. Therapy was difficult; success in 1 of the patients seemed to have been effected in part by prompt administration of high-dose corticosteroids and maintenance of peripheral vascular tone with an alpha-adrenergic agonist.
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Douglas AS, McNicol GP, Bain WH, Mackey WA. The haemostatic defect following extracorporeal circulation. Br J Surg 1966; 53:455-67. [PMID: 4952897 DOI: 10.1002/bjs.1800530518] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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