Heparin reversal with protamine

Three hours later, the patient received 21 000 units of heparin in preparation for cardiopulmonary bypass (CPB). After CPB the heparin was reversed with protamine. Forty-nine hours post-operatively, intravenous heparin was started for thrombophylaxis of the prosthetic aortic valve. Fifty-three hours post-operatively, the PICC line became clotted and 2 mg of alteplase was administered. Intense back pain and blood in the epidural catheter and around the epidural 205 puncture site were noted. The pediatric team removed... 

I 77. A 60-year-old female with deep-vein thrombosis (DVT) is given a bolus of heparin, and a heparin drip is also started. Thirty minutes later, she is bleeding profusely from the intravenous site. The heparin is stopped, but the bleeding continues. You decide to give protamine to reverse the adverse effect of heparin. How does protamine act ... 

Adverse effects. When bleeding is induced by heparin, the heparin action can be instantly reversed by protamine. Against fractionated heparins and fondaparinux, protamine is less or not effective. Heparin-induced thrombocytopenia type II (HIT II) is a dangerous complication. It results from formation of antibodies that precipitate with bound heparin on platelets. The platelets aggregate and give rise to vascular occlusions. Because of the thrombocytopenia, hemorrhages may occur. Fondaparinux is also contraindicated in HIT II. 

The answer is d. (Hardman, p 1346.) A slow intravenous infusion of protamine sulfate will quickly reverse the bleeding. Protamine binds to heparin to form a stable complex with no anticoagulant activity It may also have its own anticoagulant effect by binding with platelets and fibrinogen. 

Cardiovascular In 242 consecutive patients (mean age 58 years, 193 men) with drug refractory atrial fibrillation who underwent catheter ablation and received protamine immediately after catheter ablation to reverse the effects of heparin, 58 had prior exposure to protamine three developed an adverse reaction to protamine (1.2%), each with profound hypotension [212 ]. 

Heparinization is usually recommended when coaxial catheter assembly systems are used to prevent fibrin clot formation. Initial prothrombin time, partial thromboplastin time and activation coagulation time is recommended to use as a baseline to calculate the dose of the protamine sulfate dosage when heparinization is to be reversed. Complete heparinization of the patient can be achieved with a bolus dose (50 lU/Kg) and a maintenance infusion (500 UI/Kg in 24 hours) that is initiated once the arterial access is obtained. 

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