Kasuistik mit Literaturübersicht – Protamingabe bei Patientin mit Fischeiweißallergie

Zusammenfassung

Protamin wird routinemäßig zur Neutralisierung der Antikoagulation mit Heparin bei großen herz- und gefäßchirurgischen Eingriffen nach extrakorporaler Zirkulation (EKZ) eingesetzt. Zwischenfälle nach Protamingabe sind selten. Wenn sie auftreten, verlaufen sie häufig katastrophal. Anhand des Fallberichtes einer Patientin mit Fischeiweißallergie und einer Literaturübersicht werden Risikofaktoren für Zwischenfälle nach Protamingabe sowie das perioperative Management und Outcome bei entsprechendem Risikoprofil dargestellt.

Abstract

Protamine is a protein mainly used to reverse anticoagulant effects of heparin during cardiac or vascular surgery with extracorporeal circulation. Adverse events after protamine administration are rare but if they occur they can be catastrophic. Based on a case report with an elective cardiac surgery patient with known allergy to fish, we discuss the related events and risk factors for an adverse reaction after protamine. The patient management and its outcome are presented.

Kernaussagen

• Protamin ist ein Protein, das vorwiegend aus dem Sperma bestimmter Lachsarten isoliert wird. In der Medizin wird es zur Neutralisierung der Heparinwirkung nach großen herz- und gefäßchirurgischen Eingriffen eingesetzt.

• Unverträglichkeiten sind selten und äußern sich als Hypotension, pulmonale Vasokonstriktion und allergische Reaktionen. Patienten mit insulinpflichtigem Diabetes mellitus und der Einnahme von NPH-Insulin, einer Allergie auf Fischeiweiß oder Patienten mit Z.n. Vasektomie haben ein erhöhtes Risiko, auf eine Protamingabe zu reagieren.

• Bei Patienten mit bekannter Reaktion auf Protamin soll die Substanz möglichst vermieden werden. Der Transfusionsbedarf kann durch den Einsatz eines Cell-Savers zur Wiederaufbereitung des Drainageblutes sowie ein gezieltes Gerinnungsmanagement (ROTEM-gesteuert) reduziert werden. Je nach Befund- und Patientenkonstellation sind auch alternative OP-Verfahren wie Off-Pump-Chirurgie oder TAVI mit geringerem Heparinbedarf und Verzicht auf eine Antagonisierung zu diskutieren.

• In der Literatur sind als Alternativen zu Heparin in der Herzchirurgie Bivalirudin, Argatroban oder eine Kombination von unfraktioniertem Heparin mit GP IIb/IIIa-Inhibitoren beschrieben.

• Sollte die Gabe von Protamin unumgänglich sein, ist eine präoperative Testung mittels Hauttest oder – sofern verfügbar – mittels Agarose-RAST-Test auf Protamin-IgE-Antikörper dringend anzuraten. Die H₁- und H₂-Blocker Clemastin und Ranitidin sowie Glukokortikoide (Prednisolon) sollten bei unklaren Fällen vor Applikation von Protamin verabreicht werden. Die Infusion von Protamin muss grundsätzlich langsam erfolgen.

Schlüsselwörter:

Protamin - Fischallergie - ExtrakorporaleZirkulation

Keywords:

Protamine - fish allergy - extracorporeal circulation

• Literatur

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