Hydrocortisone pretreatment for attenuation of protamine-induced adverse hemodynamic reactions

Baraka, Anis; Choueiry, Patrick; Taha, Samar K.; Yazbeck, V.; Chidiac, Gilbert; Azar, Iman Abi; Zughbi, Jarir P.

doi:10.1016/s1053-0770(05)80124-7

Cited by 11 publications

(3 citation statements)

References 5 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…• Baraka et al . [7] investigated the effect of hydrocortisone in 20 patients prior to protamine sulfate administration compared to 20 patients without pre-treatment. No patients developed genuine anaphylaxis, but a higher degree of hypotension was noted in the group without pre-treatment.…”

Section: Resultsmentioning

confidence: 99%

Serious Anaphylactic Reactions due to Protamine Sulfate: A Systematic Literature Review

Nybo

Madsen

2008

Basic Clin Pharma Tox

136

View full text Add to dashboard Cite

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.Protamine sulfate is a strongly alkaline polypeptide, mainly used to reverse anticoagulant effects of heparin. When injected intravenously, the alkaline protamine combines with the acidic heparin to form a neutral salt, thereby eliminating the anticoagulating properties of heparin. Another major use of protamine sulfate occurs in neutral protamine Hagedorn (NPH ) insulin, where complexion with insulin delay absorption and prolong the duration of action. Although being a relatively safe drug, it can cause severe systemic reactions with pronounced morbidity and mortality [1], and protamine sulfate is reported as one of the most common causes of life-threatening adverse reactions during cardiac surgery when used for rapid neutralization of heparin. Anaphylactic reactions to protamine sulfate have been known for many years, but the incidence reported varies from 0.06% to 10.6% [2] and range from minor haemodynamic instability to fatal cardiovascular collapse. The incidence of catastrophic reactions to protamine sulfate during cardiovascular surgery is reported to be 0.13% [3], and a recent study has confirmed the relation between protamine sulfate reactions and mortality risk [4]. The protamine-heparin complexes are thought to be responsible for the adverse effects observed, including allergic reactions, systemic hypotension and increased pulmonary arterial pressure, but most articles gathering this knowledge have been either...

show abstract

Section: Resultsmentioning

confidence: 99%

Serious Anaphylactic Reactions due to Protamine Sulfate: A Systematic Literature Review

Nybo

Madsen

2008

Basic Clin Pharma Tox

136

View full text Add to dashboard Cite

show abstract

“…Pre-medication guidelines are also being tested, to prevent secondary effects from the administration of protamine; antiH1/H2 or hydrocortisone have been used with variable results [18,19]. In conclusion, protamine provokes dosage-dependent vasodilatation mediated through endothelium on the systemic circuit.…”

Section: Discussionmentioning

confidence: 99%

The systemic vasodilatory action of protamine: is it inhibited or mediated by heparin?

et al. 1997

View full text Add to dashboard Cite

Our results show that the administration in vitro of protamine induces endothelium-dependent vasodilatation of the systemic circulation. Likewise, this relaxing effect mediated through endothelium is not blocked when protamine forms a complex with heparin in comparable concentrations of both drugs. Based on these preliminary findings, we believe that in high-risk patients the prevention of systemic vasodilatation and cardiovascular collapse produced by protamine should move towards the use of other substances that can neutralize the anticoagulant effect of heparin or towards pre-medication guidelines that prevent these secondary effects in the case of protamine administration.

show abstract

“…Although the mechanisms by which protamine produces adverse reactions are still not clearly understood, it is believed that intravascular administration of protamine exposes basophils and tissue mast cells to the compound resulting in mast cell degranulation and the release of histamines (14). Several studies have investigated the effects of pretreatment medications to minimize the cardiovascular effects of protamine (15,16). Antihistamines are one of the pretreatment drugs being examined (17)(18)(19)(20)(21)(22)(23).…”

Section: Introductionmentioning

confidence: 99%

H1 and H2 antihistamines pretreatment for attenuation of protamine reactions after cardiopulmonary bypass: a randomized-controlled study

Suksompong¹,

Wongsripuemtet²,

Srinoulprasert³

et al. 2023

Ann Palliat Med

View full text Add to dashboard Cite

Background: Protamine administration post-cardiopulmonary bypass (CPB) can potentially cause hemodynamic instability. Histamine released from mast cells is believed to be responsible for hypotension after protamine administration. The aim of this study was to examine the effects of pretreatment with H 1 and H 2 antihistamines on changes in systemic arterial pressure following protamine administration.Methods: This study was a randomized, triple-blinded, placebo-controlled study, conducted at a university hospital. Forty adult patients undergoing elective coronary bypass graft surgery (CABG) or single valve surgery were included. The patients were randomly allocated (20 patients in each group) to receive a single dose of combined chlorpheniramine 10 mg and ranitidine 50 mg or normal saline intravenously immediately after separation from CPB prior to protamine administration. Trajectory changes in systolic blood pressure (SBP), mean arterial pressure (MAP), and vasoactive-inotropic score (VIS) from baseline until 35 minutes following protamine administration (24-time points) were compared between the two groups. Serial serum tryptase levels were also obtained at baseline, 30 and 60 minutes after protamine was given.Results: Forty patients were included in the analysis. Demographic and baseline blood pressure were similar between the two groups. At 30 minutes after protamine administration, there were no significant differences in both crude SBP [mean difference: −7.1 mmHg, 95% confidence interval (CI), −1.1 to 15.3 mmHg, P=0.09] and SBP after adjustment for the European System for Cardiac Operative Risk Evaluation (EuroSCORE II), CPB time, and VIS (mean difference: −3.9 mmHg, 95% CI, −11.9 to 4.0 mmHg, P=0.33).There were also no significant differences in crude MAP (mean difference: −2.1 mmHg, 95% CI, −6.9 to 2.7 mmHg, P=0.39) and adjusted MAP (mean difference: −0.7 mmHg, −5.9 to 4.4 mmHg, P=0.78) between the two groups. None of the patients in both groups had a significant increase in serum tryptase from baseline. No differences in median serum tryptase levels at baseline, 30 and 60 minutes were demonstrated between the two groups.Conclusions: Pretreatment with H 1 and H 2 antihistamines does not attenuate blood pressure responses to protamine administration in patients after CPB. Mechanisms other than histamine release from mast cells might be responsible for protamine-induced cardiovascular changes.

show abstract

Hydrocortisone pretreatment for attenuation of protamine-induced adverse hemodynamic reactions

Cited by 11 publications

References 5 publications

Serious Anaphylactic Reactions due to Protamine Sulfate: A Systematic Literature Review

Serious Anaphylactic Reactions due to Protamine Sulfate: A Systematic Literature Review

The systemic vasodilatory action of protamine: is it inhibited or mediated by heparin?

H1 and H2 antihistamines pretreatment for attenuation of protamine reactions after cardiopulmonary bypass: a randomized-controlled study

Contact Info

Product

Resources

About