intra-aortic protamine

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anybody else have a surgeon who does this when off pump?

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anybody else have a surgeon who does this when off pump?

What's the benefit? Bypass first pass through the lungs and possible PA HTN/rxn issues?

It's been a while since I've done a pediatric heart, but I seem to remember our pedi CT surgeon giving heparin prior to bypass. I'm don't remember what we did with protamine.
 
Just read you can give it faster through the aorta. I also read there is a posdibity of systemic embolization since the filtering function of the lungs are bypassed.


http://ats.ctsnetjournals.org/cgi/reprint/35/6/637.pdf

We don't do that here. Not sure about other institutions. I still hang mine on a mini dripper and open it wide depending on what I see on my pa tracing and bps.
 
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is the thought that you can avoid some of the effects of the drug (hypotension, elevated PA pressures) or just that you can give it faster...cause, i mean...its like ten minutes max.
 
anybody else have a surgeon who does this when off pump?

Yes. Works ok. I see more hypotension just because they give it in a few seconds. Pressure comes back quickly.
 
Not in my place. Reactions are rare.

I have only seen one real reaction. We were giving the protamine.
 
Yes. Works ok. I see more hypotension just because they give it in a few seconds. Pressure comes back quickly.

yep, the bp crashes pretty much every time. i pick up the calcium every time he does it b/c its inevitable. he's been doing it for years, and it's only to speed things up. i do have to say, he's a bad-ass, like a ninja with a scalpel, so i dont make a big deal about it
 
We don't do it routinely, but if we are worried about the PA pressures or we have problems with them on initiating protamine infusion through the PIV, then we will give it into the aorta. We don't give it any faster, and we do mix it with calcium so we don't see big drops in bp or spikes in PA pressures.

- pod
 
yep, the bp crashes pretty much every time. i pick up the calcium every time he does it b/c its inevitable. he's been doing it for years, and it's only to speed things up. i do have to say, he's a bad-ass, like a ninja with a scalpel, so i dont make a big deal about it

I guess if he's willing to tolerate the nosedive...
 
I'm going to bump this thread, as one of my cardiac surgeons just came back to us after spending a few weeks at another facility where they gave protamine via a 20-ga butterfly in the aorta coming off pump. She was so excited to try it with us, as it's "faster" (1 min vs 5-10 minutes), and she said it didn't cause hypotension. Well, I gave her my usual reversal dose, she injected it into the aorta, and the pressure plummeted from 110s to 30s within seconds. I responded during the nosedive with calcium, norepi, and epi, and the pressure rebounded rapidly. The second case we tried this, I gave calcium as she pushed protamine, and the pressure still tanked, but not quite as severely (only to the 50s). She swears it never did that at the other hospital. For those of you who do this, do you adjust your protamine dose, as you're bypassing first-pass in the lungs? Do you just give more calcium before and during the injection? Our other two surgeons seemed rather nonplussed about the idea, so hopefully, this will fade away and no longer be an issue. However, in the event that she wants to keep at it, any pointers from the group would be welcome.

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Many years ago, I worked with a surgeon who did it routinely. On average it did have less hypotension. There were some that bottomed out, but I did like it better at the time. This was 20 years ago.


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Negative.

But we've had TWO full blown crash back on pump/ECMO protamine reactions in the last month. Craziness.
 
The reason to give it into the aorta is more to protect the right heart than to prevent systemic hypotension. But if they give it rapidly, a significant portion will come back into the right side without tissue or organ uptake.
 
I'm going to bump this thread, as one of my cardiac surgeons just came back to us after spending a few weeks at another facility where they gave protamine via a 20-ga butterfly in the aorta coming off pump. She was so excited to try it with us, as it's "faster" (1 min vs 5-10 minutes), and she said it didn't cause hypotension. Well, I gave her my usual reversal dose, she injected it into the aorta, and the pressure plummeted from 110s to 30s within seconds. I responded during the nosedive with calcium, norepi, and epi, and the pressure rebounded rapidly. The second case we tried this, I gave calcium as she pushed protamine, and the pressure still tanked, but not quite as severely (only to the 50s). She swears it never did that at the other hospital. For those of you who do this, do you adjust your protamine dose, as you're bypassing first-pass in the lungs? Do you just give more calcium before and during the injection? Our other two surgeons seemed rather nonplussed about the idea, so hopefully, this will fade away and no longer be an issue. However, in the event that she wants to keep at it, any pointers from the group would be welcome.

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Your surgeon likely didn't notice that the perfusioninst at the other institution gave 1 liter from the reservoir as the protamine went in.
 
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Never had a surgeon do this. When I was doing lots of hearts we did them off pump so our dose was smaller and timing wasn't such an issue. I usually preempted the protamine with something like a fluid bolus but more often with some neo or rarely epi. So this got me thinking, if you are the one handing over the protamine to the field couldn't you just add some epi to the mixture? I would think something like 20-50 mcg would do the trick.
 
You should hand the surgeon a syringe filled with saline while you keep the protamine on your side the the drape and slowly give it.:whistle:

I doubt they would know the difference.
 
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I'm going to bump this thread, as one of my cardiac surgeons just came back to us after spending a few weeks at another facility where they gave protamine via a 20-ga butterfly in the aorta coming off pump. She was so excited to try it with us, as it's "faster" (1 min vs 5-10 minutes), and she said it didn't cause hypotension. Well, I gave her my usual reversal dose, she injected it into the aorta, and the pressure plummeted from 110s to 30s within seconds. I responded during the nosedive with calcium, norepi, and epi, and the pressure rebounded rapidly. The second case we tried this, I gave calcium as she pushed protamine, and the pressure still tanked, but not quite as severely (only to the 50s). She swears it never did that at the other hospital. For those of you who do this, do you adjust your protamine dose, as you're bypassing first-pass in the lungs? Do you just give more calcium before and during the injection? Our other two surgeons seemed rather nonplussed about the idea, so hopefully, this will fade away and no longer be an issue. However, in the event that she wants to keep at it, any pointers from the group would be welcome.

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Why would it be faster than bolusing it through the central line?

I give it pretty fast, faster than our best people here can put an a line (yes, I break the sound barrier while pushing the syringe), on a routine basis and have never seen the RV crash from it. Hypotension is very common but volume fixes it. Then it is time to decannulate.

Negative.

But we've had TWO full blown crash back on pump/ECMO protamine reactions in the last month. Craziness.

Are you sure it was the protamine?
 
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Absolutely both times.

First patient was on insulin (maybe NPH in past?) and second had a vasectomy.

Both PA pressures spiked then complete RV failure very very shortly following protamine and no other meds.
 
got a new heart surgeon and went back to hanging the protamine myself. it's soooo much smoother, no more bronco riding the bp
 
Thanks, guys. Urge, she gives it as a rapid bolus in under a minute, so that is faster than I ever [intentionally] give it, but it's a difference of less than a minute, compared to 5-10 minutes. As a time saving measure, I don't think it's worth it. If she still wants to try it when I get back, maybe I'll add some calcium and norepi to the mixture I give to her, and tell the perfusionist to fill the patient up as she injects.

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This is starting to sound like a few cardiac surgeons are tired of waiting on their overly cautious anesthesiologists to give the protamine. At least they are confident that you know how to treat the hypotension.
 
The worst protamine reaction I've seen was from intra aortic administration. PA hypertension, RV failure etc. So, giving it in the aorta doesn't prevent that sort of thing despite what the surgeons might think.
 
Circulation time of blood is about 1 minute (i.e. from aorta to aorta). From aorta to pulmonary artery would be about 30 seconds. From peripheral vein to pulmonary artery about 15 seconds. So yeah, it would make its way to the pulmonary artery pretty quickly regardless of where you push it.

The rate of infusion is thus more important than the location of infusion.
 
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