Neutralization of the anticoagulant activity of low molecular weight heparin LU 47311 (Clivarin®) in man by protamine chloride
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Protamine sulfate
Thrombin time
This experiment studied the interactions of protamine sulfate with mouse whole blood components. BALB/c/Tex mice were inoculated i.p. with varying concentrations of protamine sulfate. At selected time intervals, blood samples were obtained and examined by electrophoretic, immunological and morphological methods. Detectable changes were evident when 1 mg of protamine was used. At one and four hours after inoculation, serum protein electrophoretic results were abnormal but returned to normal by 24 hours. Prothrombin times were abnormal until 48 hours postinoculation. The latter results correlated with the blood protamine level. After inoculation with protamine, an absolute increase in circulating leukocytes also occurred with a relative percent increase in neutrophils and a decrease in lymphocytes. These values were normal by 24 hours postinoculation. Changes in red cell lactate dehydrogenase isoenzyme patterns were observed. The significance of this observation is discussed.
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The effect of protamine sulfate on several cardiovascular and biochemical variables was studied in man under clinical conditions. This study was performed to quantitate these effects in 15 adult patients who had undergone cardiopulmonary bypass for coronary artery bypass grafting. Protamine was administered in typical clinical doses (3 mg/kg) at typical clinical rates (total dose infused over 5 minutes). This infusion rate is greatly in excess of the 50 mg/10 min suggested in the protamine package insert. No statistically significant changes in mean arterial blood pressure, cardiac output, central venous pressure, total or ionized calcium, Pao2, Paco2, pH, Na+, or K+ were found during or after administration of protamine sulfate. Hypotension was observed after administration of protamine to one patient, but no etiologic mechanism was apparent. Previous reports suggest cardiovascular depression by protamine in the dog, a species highly susceptible to these effects. Data obtained in man in this study do not corroborate the canine studies.
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Protamine sulfate is given routinely in the operating room after many vascular procedures. There are many reported side effects of protamine including anaphylaxis. The presented patient had an unusual reaction to protamine. A review of protamine sulfate is given along with a hypothesis to the etiology of a case of cardiac arrest following protamine administration.
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In vitro, PF4 is comparable to protamine sulfate in the neutralization of heparin, but the complexes formed with heparin are different. Even with an excess of PF4, no large PF4-heparin complexes are formed and none of the complexes are able to activate ATIII, nor do these complexes dissociate on incubation in plasma at 37 degrees C. The action of PF4 and protamine is complementary. However, excess protamine displaces PF4 or prevents its complexing with heparin. When excess protamine is used to neutralize heparin in the presence of PF4, large heparin-protamine complexes are formed incorporating PF4. In contrast to the heparin-protamine complexes formed without PF4, these do not activate ATIII nor do they dissociate on incubation. Since PF4 is liberated during ECB procedures, its contribution to the stability of heparin-protamine complexes in vivo may influence the amount of protamine needed to neutralize heparin as well as affect the reactions which have been reported on injection of protamine after ECB.
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Abstract The cause of hypotension after reversal of heparin by protamine has not been well defined. In this study we evaluated complement activation (C3a and C4a) by the heparin‐protamine complex in 46 consecutive patients (40 received protamine sulfate to reverse heparin, and six did not) during and after coronary angiography. In patients receiving protamine sulfate, there was a significant increase in C3a over the value before protamine sulfate administration ( P <.001) or in patients who did not receive protamine sulfate ( P <.05): 807 ± 100 ng/ml vs. 274 ± 75 ng/ml. There were no significant changes in C4a after protamine sulfate administration. These results indicate that the alternate complement pathway is activated when protamine sulfate is administered after coronary angiography. This may induce hypotension as well as platelet aggregation and thrombus formation and may contribute to coronary instability. Therefore, in unstable patients, heparin reversal by protamine should not be done routinely.
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The paper presents data of a study comparing two schemes (Scheme 1: a heparin/protamine ratio of 1:2; Scheme 2: a heparin/protamine ratio of 1:3) for administering protamine sulfate to neutralize heparin in patients after extracorporeal circulation. A larger dose of protamine sulfate is shown to induce significant thrombocytic dysfunction, resulting in increased postoperative hemorrhage. To minimize protamine sulfate doses required for neutralization of the anticoagulant effect of heparin is a way of preventing these complications.
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Protamine sulfate (protamine), a low molecular weight poly-cationic amine, has been used for some time on patients undergoing cardiac operations and procedures. It is particularly used on patients who have been treated with heparin (an anticoagulant), in order to neutralize the anticoagulant effects of heparin on the person's blood. In this in vitro study, various 500 /spl mu/L one-day old citrated whole human blood samples (n=18) have been subjected to different amounts of protamine of a single concentration (10 mg/mL in saline), using 0.9% saline added to blood as control. It is known that saline, by itself, has no effect on blood clotting. After thorough mixing and incubation for 10 min. at 37/spl deg/C, the time it takes for 200 /spl mu/L of each sample to clot, in presence of 20 /spl mu/L 0.1 M CaCl/sub 2/ was measured. The results show that protamine acts as an anticoagulant in the absence of heparin. Clotting time also increases with more protamine added.
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