• Mohanad R Youssef, Eryberto Martinez, Terrique M Pinnock, Alexei Gonzalez-Estrada, Mark M Smith, and Bradford B Smith.
• Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ.
• J. Cardiothorac. Vasc. Anesth. 2024 Dec 1; 38 (12): 292529312925-2931.

ObjectivesTo retrospectively assess the incidence and severity of perioperative protamine reactions in adult patients with documented history of fish allergy.DesignRetrospective observational study.SettingLarge academic tertiary referral center.ParticipantsAdults with fish allergies undergoing surgeries involving protamine, between January 1, 2008, and March 1, 2018.InterventionsPerioperative protamine administration in patients with documented fish allergy.Measurements And Main ResultsPerioperative protamine and anaphylactic reactions were reviewed. A diagnosis of anaphylaxis or protamine reaction was based on clinical suspicion, perioperative events, and postoperative evaluations. Among 214 patients, 2 cases (<1%) of anaphylaxis or protamine reactions occurred. Cardiac procedures were most common (67%). The median intraoperative heparin dosage was 46,000 IU, and the median protamine dosage was 310 mg. Nearly all patients (99%) were admitted to the intensive care unit postoperatively, with a median hospital stay of 6.5 days (interquartile range, 5.2-14.6 days). There were 3 deaths (1%) within 30 days, and 15 (7%) within 1 year.ConclusionsThe study findings suggest that in patients with a history of fish allergy, cross-reactivity with protamine is unlikely, as anaphylaxis and/or protamine reactions were rare in this patient population in the perioperative environment. Based on these findings, this study does not recommend avoiding protamine solely based on a history of fish allergy when heparin reversal is required during surgery.Copyright © 2024 Elsevier Inc. All rights reserved.

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