protamine sulfate

protamine sulfate

Indications

Action

Pharmacokinetics

Time/action profile (reversal of heparin effect)

Contraindications/Precautions

Adverse Reactions/Side Effects

Respiratory

• dyspnea

Cardiovascular

• bradycardia
• hypertension
• hypotension
• pulmonary hypertension

Gastrointestinal

• nausea
• vomiting

Dermatologic

• flushing
• warmth

Hematologic

• bleeding

Musculoskeletal

• back pain

Miscellaneous

• hypersensitivity reactions, including anaphylaxis (life-threatening)
• angioedema, and pulmonary edema (life-threatening)

Interactions

Drug-Drug interaction

Route/Dosage

Availability (generic available)

Nursing implications

Nursing assessment

• Assess for bleeding and hemorrhage throughout therapy. Hemorrhage may recur 8–9 hr after therapy because of rebound effects of heparin. Rebound may occur as late as 18 hr after therapy in patients heparinized for cardiopulmonary bypass.
• Assess for allergy to fish (salmon), previous reaction to or use of protamine insulin or protamine sulfate. Vasectomized and infertile men also have higher risk of hypersensitivity reaction.
• Observe patient for signs and symptoms of hypersensitivity reaction (hives, edema, coughing, wheezing). Keep epinephrine, an antihistamine, and resuscitative equipment close by in the event of anaphylaxis.
• Assess for hypovolemia before initiation of therapy. Failure to correct hypovolemia may result in cardiovascular collapse from peripheral vasodilating effects of protamine sulfate.
• Lab Test Considerations: Monitor clotting factors, activated clotting time (ACT), activated partial thromboplastin time (aPTT), and thrombin time (TT) 5–15 min after therapy and again as necessary.

Potential Nursing Diagnoses

Implementation

• Do not confuse protamine with Protonix (pantoprazole).
• Discontinue heparin infusion. In milder cases, overdosage may be treated by heparin withdrawal alone.
  • In severe cases, fresh frozen plasma or whole blood may also be required to control bleeding.
  • Dose varies with type of heparin, route of heparin therapy, and amount of time elapsed since discontinuation of heparin.
  • Do not administer >100 mg in 2 hr without rechecking clotting studies, as protamine sulfate has its own anticoagulant properties.

• Intravenous Administration

• pH: 6.0–7.0.
• Diluent: May be administered undiluted. If further dilution is desired, D5W or 0.9% NaCl may be used.Concentration: 10 mg/mL.
• Rate: Administer by slow IV push over 1–3 min. Rapid infusion rate may result in hypotension, bradycardia, flushing, or feeling of warmth. If these symptoms occur, stop infusion and notify physician. No more than 50 mg should be administered within a 10-min period.
• Y-Site Compatibility: alfentanil, amikacin, aminophylline, ascorbic acid, atropine, azathioprine, aztreonam, benztropine, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, ceftazidime, chlorpromazine, clindamycin, cyanocobalamin, cyclosporine, digoxin, diphenhydramine, dobutamine, dopamine, doxycycline, enalaprilat, ephedrine, epinephrine, epoetin alfa, erythromycin, esmolol, famotidine, fentanyl, fluconazole, ganciclovir, gentamicin, glycopyrrolate, imipenem/cilastatin, isoproterenol, labetalol, lidocaine, magnesium sulfate, mannitol, meperidine, metaraminol, methoxamine, methyldopate, metoclopramide, metoprolol, midazolam, morphine, multivitamins, nalbuphine, naloxone, nitroglycerin, nitroprusside, norepinephrine, ondansetron, oxytocin, papaverine, pentazocine, phentolamine, phenylephrine, potassium chloride, procainamide, prochlorperazine, promethazine, propranolol, pyridoxime, ranitidine, sodium bicarbonate, succinylcholine, sufentanil, tobramycin, tolazoline, trimetaphan, vancomycin, vasopressin, verapamil
• Y-Site Incompatibility: amphotericin B colloidal, ampicillin, ampicillin/sulbactam, cefazolin, cefotaxime, cefoxitin, ceftazidime, cefuroxime, chloramphenicol, dantrolene, dexamethasone sodium phosphate, diazepam, diazoxide, folic acid, furosemide, heparin, hydrocortisone sodium succinate, indomethacin, insulin, ketorolac, methylprednisolone sodium succinate, nafcillin, oxacillin, penicillin G, pentamidine, pentobarbital, phenobarbital, phenytoin, ticarcillin/clavulanate, trimethoprim/sulfamethoxazole

Patient/Family Teaching

• Explain purpose of the medication to patient. Instruct patient to report recurrent bleeding immediately.
• Advise patient to avoid activities that may result in bleeding (shaving, brushing teeth, receiving injections or rectal temperatures, or ambulating) until risk of hemorrhage has passed.

Evaluation/Desired Outcomes

• Control of bleeding.
• Normalization of clotting factors in heparinized patients.