Anaphylaxis to Protamine During a Carotid Endarterectomy

Area of Science:

• Cardiovascular Surgery
• Anesthesiology
• Pharmacology

Background:

• Protamine sulfate is the standard reversal agent for unfractionated heparin (UFH) post-surgery.
• UFH reversal is critical for hemostasis during procedures like carotid endarterectomy.
• Protamine administration carries a risk of severe adverse reactions, including anaphylaxis.

Observation:

• A 77-year-old male experienced severe hypotension and tachycardia post-protamine infusion during carotid endarterectomy.
• The patient's symptoms were indicative of an anaphylactic reaction.
• Elevated tryptase levels confirmed the diagnosis of anaphylaxis.

Findings:

• Protamine sulfate administration can precipitate anaphylaxis, even in elective surgical settings.
• Profound hemodynamic instability (hypotension, tachycardia) is a key clinical manifestation.
• Biochemical markers like elevated tryptase confirm the diagnosis of mast cell degranulation.

Implications:

• Vigilant patient monitoring during protamine sulfate administration is essential.
• High-risk patient populations may require heightened surveillance for adverse events.
• Exploring alternative heparin reversal agents is necessary to improve patient safety and mitigate anaphylaxis risk.