Heparin/insulin suspension isophane/protamine sulfate

Abstract

Bleeding, and anaphylactic reaction leading to cardiac arrest: case report A 68-year-old woman developed bleeding during anticoagulation therapy with heparin. Additionally, she developed anaphylactic reaction leading to cardiac arrest during treatment with protamine sulphate and insulin suspension isophane for reversal of bleeding and type II diabetes mellitus (DM), respectively [routes, doses and times to reactions onsets not stated; not all frequencies and outcomes stated]. The woman, who had a history of peripheral artery disease (PAD) and type II DM, had been receiving insulin suspension isophane [isophane insulin; NPH insulin] daily. She underwent a lower extremity angiogram and femoral endarterectomy for the severe PAD, during which she received anticoagulation with heparin. After the procedure, she developed bleeding from the right groin puncture site secondary to heparin. The woman was treated with protamine sulphate [protamine] for reversal of anticoagulation induced by heparin. However, she became flushed and tachycardic. Also, she experienced breathing difficulty, and shortly thereafter, she went into cardiac arrest. On arrival of the emergency medical services (EMS), she was in a bradycardic pulseless electrical activity cardiac arrest. Hence, she was moved to the emergency department (ED) of another centre. While on the way, she was treated with epinephrine and received chest compressions. Also, a laryngeal mask airway was placed. She presented to the ED in cardiac arrest, and bedside ultrasound revealed cardiac standstill. Therefore, standard advanced cardiovascular life support (ACLS) protocol was started. She received additional epinephrine along with calcium chloride and bicarbonate. Then, she exhibited return of spontaneous circulation. However, she remained markedly hypotensive, and required epinephrine and vasopressin. Due to the concern of potential anaphylaxis, she was treated with diphenhydramine and methylprednisolone. Thereafter, her vitals signs stabilised, and vasopressors were rapidly weaned off. She was completely off vasopressors, and was extubated on hospital day 2. It was noted that she developed cardiac arrest likely due to an anaphylactic reaction to protamine sulphate, and the daily use of insulin suspension isophane had likely predisposed her to the severe anaphylactic reaction.