Severe Circulatory Shock Induced with Protamine Sulfate during Cardiac Surgery in a Diabetic Patient Who Had Exposure to Neutral Protamine Hagedorn Insulin / 日本心臓血管外科学会雑誌

ABSTRACT

A 60-year-old woman was admitted to our hospital due to abnormal findings on an electrocardiogram. She was a diabetic patient and had been taking neutral protamine Hagedorn insulin previously. After admission, since a coronary angiography was performed and showed three-vessel disease we performed coronary artery bypass grafting. After the cardiopulmonary bypass, she was given protamine sulfate. Subsequently her systolic blood pressure decreased below 35mmHg. Immediately cardiopulmonary bypass was restarted as an assist device for circulation. We administered epinephrine, and her blood pressure increased. After the second cardiopulmonary bypass, protamine administration was not given. Her postoperative course was uneventful, and she was discharged on the 18th postoperative day. A skin test titration to protamine was done. She had positive reaction at a dilution of 1mg/ml. Neutral protamine Hagedorn insulin use may immunologically sensitize patients to protamine, leading to anaphylactic reaction upon subsequent exposure to protamine sulfate during cardiac surgery. It is important to avoid adverse reaction to protamine.