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The Journal of Thoracic and Cardiovascular Surgery, Vol 84, 505-514, Copyright © 1982 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
N Shapira, HV Schaff, JM Piehler, RD White, JC Still and JR Pluth
Systemic hypotension is commonly observed in association with the
administration of protamine after cardiopulmonary bypass. Previous studies
have not conclusively demonstrated whether protamine induces its effect by
altering myocardial performance or by changing systemic vascular resistance
(SVR) or both. To elucidate the hemodynamic effects of protamine sulfate
administration (150 mg/m2 body surface area), we studied 22 patients
following cardiopulmonary bypass. In Group I (N = 8) protamine was infused
over 30 seconds and while in Group II (N = 8), over 60 seconds. Group III
(N = 6) received calcium chloride (20 mg/kg) prior to protamine
administration. The hemodynamic response was assessed by continuous
recording of myocardial contractile element velocity (maximal value-Vpm),
aortic blood flow, systemic and pulmonary arterial and right atrial
pressures, and electrocardiogram. A significant (p less than 0.05) decrease
in the systolic, diastolic and mean blood pressure was observed in all
groups. A significant increase in cardiac index and a significant decrease
in SVR was observed in all groups. A small depression in Vpm was detected
in those patients who experienced a mean blood pressure fall greater than
10 mm Hh. Heart rate and left ventricular end-diastolic pressure (LVEDP)
did not change significantly. The response to protamine sulfate among the
three groups was similar. These results demonstrate that protamine-induced
hypotension is primarily the result of peripheral vasodilatation only
partically compensated by an increase in cardiac index. In some patients,
these changes were associated with a small decline in myocardial
contractile state. Hemodynamic changes were transient (less that 3 to 4
minutes), unrelated to the rate of administration, and not prevented by
preinjection of calcium chloride.
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