• J O Just-Viera, C R Fischer, O Gago, and J D Morris.
• Am Surg. 1984 Jan 1; 50 (1): 52-60.

AbstractThree open heart surgery patients developed noncardiogenic pulmonary edema after administration of protamine following cardiopulmonary bypass. A catastrophic series of events are characteristic of this reaction: 1) sudden onset; 2) severe bronchoconstriction with early extreme difficulty in ventilation; 3) hyperinflation of the lungs; 4) pulmonary hypertension with normal pulmonary wedge or left atrial pressures; 5) progression to fulminant noncardiogenic pulmonary edema; 6) significant mortality; and 7) ventilatory perfusion abnormalities in survivors. Review of the literature reveals three types of reactions to protamine injection of varying severity: 1) brief hypotension; 2) anaphylactoid generalized reaction; and 3) high protein noncardiogenic pulmonary edema with cardiopulmonary collapse. The severity of the reaction had no relation to the dose of protamine. Previous protamine exposure was documented in 14 of 35 cases. Awareness of this reaction is essential for prompt treatment if fulminant pulmonary edema occurs. Administration of epinephrine, steroids, vasopressors, and potassium replacement may be required. Needless use of protamine sulfate should be discouraged.

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