Key result
Intravenous administration of 250 mg of protamine to reverse heparin anticoagulation in a patient with chronic exposure to protamine zinc insulin resulted in profound cardiovascular collapse.
Case Report (n=1)
No
Prior chronic exposure to protamine in insulin preparations may sensitize patients, leading to severe allergic reactions upon receiving large intravenous doses of protamine for heparin reversal.
May signal protamine allergy risk in insulin users during cardiac surgery; hypothesis-generating for preoperative screening.
A 59 year-old male with a 37-year history of diabetes mellitus treated with protamine zinc insulin (26 units daily) experienced cardiovascular collapse shortly after infusion of protamine (250 mg) at the conclusion of cardiopulmonary bypass for elective coronary artery bypass graft surgery. Generalized erythema of the face and arms and massive facial edema accompanied the hypotension suggesting an allergic reaction to protamine. Presumably, the patient’s prior chronic exposure to low doses of protamine in the insulin preparation (25 units contains 0.7 mg of protamine) caused the formation of antibodies to protamine. The massive dose of intravenous protamine used to reverse heparin anticoagulation relative to that present in the insulin preparation resulted in an antigen-antibody interaction manifesting as cardiovascular collapse.
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Stoelting et al. (1984) conducted a case report in Coronary artery disease requiring bypass surgery; Diabetes mellitus (n=1). Protamine was evaluated on Cardiovascular collapse (allergic reaction). Intravenous administration of 250 mg of protamine to reverse heparin anticoagulation in a patient with chronic exposure to protamine zinc insulin resulted in profound cardiovascular collapse.
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