Anaphylactic reaction protamine

Protamine sulfate can result in severe hypotension and anaphylactic reaction. When administering protamine sulfate, the nurse should make sure that resuscitation equipment is readily available. 

HHMC can also be directly activated by agents injected intravenously for therapeutic (general anesthetics, protamine, etc.) or diagnostic purposes (radiocontrast media, etc.), which can cause non-IgE-mediated anaphylactic reactions in vitro [24,... 

Protamine. Protamine, whose use to reverse heparin anticoagulation has increased over the last two decades, has also been incriminated. Reactions may involve a number of mechanisms including IgE, IgG and complement. The incidence of anaphylactic reactions is estimated at 0.19% (retrospective studies) and 0.69% (prospective studies), respectively [27]. 

Nybo M, Madsen JS Serious anaphylactic reactions due to protamine sulfate a systematic literature review. Basic Clin Pharmacol Toxicol 2008 103 192. Moneret-Vautrin DA, Kanny G Anaphylaxis to muscle relaxants rational for skin tests. Allerg Immunol (Paris) 2002 34 233. 

Semilente insulin is a suspension of amorphous insulin zinc. The onset is 1-3 hours after subcutaneous administration, reaches maximum effect in 5-10 hours and the effect lasts 10-16 hours. Isophane insulin (NPH Neutral solution. Protamine, Hagedorn s laboratoiy insulin) is an intermediate-acting preparation prepared with protamine. The maximum effect is reached in 4-12 hours and lasts 8-26 hours. Patients using these preparations who present for cardiac surgery are at increased risk for anaphylactic reactions to protamine. Ultralente insulin is a long-acting preparation formed with zinc rather than protamine. Zinc retards the release of insulin and these preparations have a duration of up to 36 hours. Protamine zinc insulin, which contains both protamine and zinc, has a duration of 28-36 hours. 

About 28% of patients develop IgG or IgE antibodies after a single exposure to protamine, but fortunately few develop a catastrophic allergic reaction on subsequent exposure to the drug. Nonetheless, prior exposure does increase the risk for an anaphylactic reaction. Other risk factors are fish allergy and patients with diabetes mellitus treated with neutral protamine Flagedorn (NPFI) insulin. After vasectomy, 22%... 

Anaphylactic reactions occur in 1% of patients with diabetes mellitus who have received protamine-containing insulin NPFl insulin or protamine zinc insulin) but are not limited to this group. A less common reaction consisting of pulmonary vasoconstriction, right ventricular dysfunction, systemic hypotension, and transient neutropenia also may occur after protamine administration. 

Whereas complement and its role in immune complex diseases have been described above (Sect. D.1.2), there appears to be a number of instances of untoward reactions to drugs in which complement activation may play a major role. Anaphylactic reactions have been described following the development of drug-specific antibodies of the IgG type capable of activating complement. In some cases, such as an immediate-type reaction following the intravenous injection of protamine sulfate (Lakin et al. 1978), homocy to tropic antibodies of IgG type capable of passively transferring the reaction have been demonstrated. Such antibodies have a short sensitization period, are stable to heating at 56 °C and seem to require complement to induce the anaphylactic reaction. 

Anaphylactic reactions to protamine and apro-tinin occur infrequently and anaphylaxis to latex has decreased markedly in recent years. The overall incidence of adverse reactions to heparin has been estimated at 0.2 % with heparin-induced thrombocytopenia, rare cases of anaphylaxis, a few delayed reactions, and some adverse skin reactions making up most of the reports. 

Immunologic Anaphylactic reactions to protamine sulfate during cardiac surgery have been systematically reviewed in a survey of nine retrospective studies and 16 prospective studies, of which only three of the latter were optimally designed as far as inclusion criteria, randomization, and description of symptoms were concerned the incidence of anaphylactic reactions in the prospective studies was 0.69% and 0.19% in the retrospective studies [215 ]. 

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