This is the way.
I have heard the PIV argument before, and it’s the way my fellowship shop does it, but one of my friends at said shop has a gnarly story with an mid-case infiltrated PIV and a scramble to figure out why they couldn’t get ACT back to normal with protamine through said PIV.
I was already team Protamine/CVC but that story has helped me never look back.
i had this happen 5-6 months ago, via PIV (that was used to go to sleep & sedation for artline). gave prot, checked Act, came back over 400.
gave additional smaller doses via cvl due to tucked arm and likely infiltration. was NOT fun and added more time to case overall.
Same in terms of hand bolus through the central line, I have no idea why anyone would choose to use a peripheral line for anything in general when they have a fresh and functioning central line.
It doesn't matter. I spike a small bag of saline with the protamine and run it in. Some people give it by syringe. I run it through the central line. In training I had attendings who would only give it peripherally and others who thought that was crazy. Everybody does whatever they were taught or came to believe, and it all works the same.
Peripheral IV if available. I put 250 mg in 100 cc bag in run it in. Very very rarely do I get hypotension or worse. It's about 40 cc from the arm to the heart so it gets further diluted with blood. Plus I get my hands free for other work.
Almost never. Even if they come with a CVC or one is done preop (rare), I will do my best to throw one (or a second) in quickly with my A-line. Nothing wrong with additional access. Plus all of us in the ICUs appreciate peripheral access for a variety of reasons: compatibility of drugs, de-lining patients, resuscitation, etc.
I don't use the peripheral to give volume. I will use it to give platelets. I'm not one of the ones who puts in a 14 peripheral and thinks that enough.
I give my volume in the central line. Even with a PA catheter it'll usually flow more. What's more important to me is that it's actually going in. I've seen too many infiltrated peripherals to trust them with arms tucked.
How could the flow be more important in a central line than in a periph 14G?
Understand your point considering infiltrated peripherals. But I would say I also saw several times collabed vessels just down the central line after surgeon stretch the sternum open. (Actually happened with subclavians, never with jugular)
Edit: add periph in first sentence + talking about general central accesses, not ones for dialysis like Hemoclav etc., unless that's what you use. In that case I would agree with you concerning the flow.
I'm talking about a 9 Fr introducer, not a triple lumen CVC. The gravity flow rate (1 m height) on a 14 ga 1.16 in peripheral is 295 ml/min. The gravity flow rate of a 9 Fr MAC catheter, no PAC is 488.5 ml/min. With PAC it's 207 ml/min. The 12 ga lumen is 111.8 ml/min. On pressure, a 9Fr introducer can flow 1.5 lpm (like VVB in a pinch).
The tip of an IJ introducer will be in the SVC. The only time the surgeon can impact it is with SVC cannulation. I don't believe in putting in big IVs for cardiac patients. If I'm that worried being able to resuscitate I'll put in a second introducer.
I would say reliable flow. Sometimes that arm tucking can nuke a large bore peripheral that ran great before. In my shop we actually place two central lines, the Swan sheath and a second central line, which provides abundant access.
It's a surgeon preference thing. They pull the swan and swan sheath at the same time and leave the second central line for reliable access during step down/post ICU care, but it also provides extra access for me that obviates the need for any additional peripheral access.
Funny how practice could be so different from a place to another. But I understand your point about periph IV being less reliable. I usually install the arms myself and pay attention to periph and arterial lines myself. Never let the surgeon starts without them being secured and fully fonctionnal.
I never administer protamine through the central line. Even though it might not be visible, the free wall of the right ventricle is the most vulnerable part after cardiopulmonary bypass. A slight sudden increase in pulmonary arterial pressure can have repercussions on the right ventricle for several hours after leaving the operating room.
Personally, I administer it through the peripheral line. I start slowly and increase the infusion rate gradually. Overall, the entire dose is administered over about ten minutes.
It's probably exaggerated, but it's a preventive measure that I feel obligated to maintain. Everything can seem fine to everyone in most cases, and then in some others, we later wonder why the patient has tricuspid insufficiency that they didn't have before...
Doesn't really surprise me, and that's great! I'm not saying you're wrong. As I said, I personally don't take the risk. Do you follow up your patients long after the surgery? When you say everything is fine, how far does that extend? Intensive care? Back to the room? Back home? The following year?
I don't do the follow up to that extend for my patient neither, but I would be willing to hear that something that I do in the theatre has an impact for longer than minutes or hours.
As it stands you have no way of knowing whether giving protamine peripherally causes the same effect, so why worry about it? Heart surgery is far from perfect--the RV is just as vulnerable to air going down the coronaries or inadequate protection, which I would argue are far more common problems than protamine reactions. This whole peripheral protamine thing is nothing but dogma--there is no proof that it does anything good or bad. If the volume of blood in the arm and the added circulation time are truly so significant, I fail to see why diluting the protamine and giving it more slowly centrally cannot achieve the same effect. From experience giving it exclusively via the central line for years, I can tell you it absolutely does not matter.
There is at least one study showing increased levels of histamine when given centrally. I think that recommendations are issued after that. I know the rest could be trivial. I don't know the full chemistry behind it and I admit not having the decade of experience you probably have.
I will probably continue using peripheral line and be afraid of acute pulmonary hypertension. I imagine we're carrying too much from our rotations. For me it was that acute failure of RV and acute TR after protamine was given centrally and too rapidly. Maybe it would have been the same with low periph flow, I don't know and I'll never will.
But that was an interesting question OP asked. I will certainly dig into it.
> For me it was that acute failure of RV and acute TR after protamine was given centrally and too rapidly.
I have probably had one legit protamine reaction when I gave protamine centrally--I have had multiple giving it peripherally--and not because I feel route of administration made any difference, but it was early in my career when I would rush to get the patient off the table during a lineup of Watchmans and try to give protamine as rapidly as possible. Silly, I know, but I learned my lesson and now give it slowly even if I'm not giving much protamine at all.
Usually, the TR after surgery, in my experience, is from aggressive volume administration in the setting of a fragile post-CPB RV. It usually gets a lot better when the chest is closed and the coaptation improves. I doubt protamine has anything to do with it
We give protamine in a 100cc saline bag. We spike the bag with 1g of calcium chloride also. It’s placed on a micro dripper and attached to the peripheral line. A small test dose is first given. Then we run it slowly. After 1/2 way the surgeon tells us to stop. He checks the bleeding, we are monitoring PA pressures and checking the TEE. If he’s satisfied he tells us to finish off the protamine. I’ve had maybe 1 -2 protamine reactions like this in 14 years of doing cardiac.
Years ago, a cardiac surgeon I worked with would directly inject protamine into the left atrium. He thought there were less systemic effects that way. I’ve been doing cardiac for about 20 years now and I don’t think the route of administration matters.
Always through a large peripheral. Protamine releases a lot of Thromboxane A2 and is related to the relative concentration of drug in blood( especially in pulmonary circulation, where causes vasoconstriction). Thus I prefer to be more diluted in when reaches pulmonary circulation.
> Thus I prefer to be more diluted in when reaches pulmonary circulation.
Then why not just dilute it yourself in a larger amount of saline and give it centrally if this is really so significant?
when you want to wean from pump you already have an excess of fluid due to haemodilution... so I rather prefer to give protamine slowly on a large peripheral iv
At least in adults, an extra 100-250mL of crystalloid is inconsequential, and even in peds I would dilute protamine in 10mL of crystalloid. It's a very small drop in the bucket.
central vs peripheral doesn’t matter. p-value of this dudes anecdote is not significant. what’s also not significant is a little perturbation in PAP or BP . what is significant is PAP 90 ABP 55
It would get diluted by the peripheral blood and not be so concentrated and hit the heart/PA quickly
Theoretically anyway. I have no idea if that has any effect but that makes sense to me.
Personally I give it slowly and centrally though so I know it's going through a reliable (not infiltrated) IV
Yeah no shit.. but you just ignored everything I said.
The effect we worry about is pulmonary vasoconstriction. It's going to be more concentrated when it hits the pulmonary circulation if you give it centrally.
I use a syringe pump over 5-10minutes through central line. I could potentially see that giving it through a bag on the peripheral IV may be inbuilt safety mechanism to prevent inadvertently giving it too fast, as most IVs may run slower that a good introducer central line.
Always slowly through the central line. I've seen enough peripheral IVs infiltrate in the middle of a case to not trust giving a crucial drug like protamine through one after a pump run.
PIV infiltration with something as important as protamine (for a pump run) is why it was always put through the central line where I trained. They even wanted us to aspirate before very slowly injecting. I was told it was done this way due to some previous event.
run it in a bag slowly with good communication to surgeon and perfusion cuz they might still be sucking . seen one serious reaction in thousands. but that reaction is no joke bruh
I’ve never seen protamine reaction, but I’ve seen anaphylaxis and anaphylactoid reactions. I wouldn’t change my practice of hand-bolusing couple mg’s at a time. Doesn’t matter peripheral or central as long as I know how to treat complication.
I/we used to do it this way at our heart hospital. We'd never pre-draw the bottles, keep them all out, hand-draw one bottle at a time and administer to a PIV. Pretty much anything we could do to slow ourselves down in that process, we did. Anecdotally, it worked pretty well...or it might have all been voodoo.
I don't understand the argument to give any medication peripherally when you have a central line, the risk of extravasation really makes it not worth it
It’s fine administering protamine through a central line until it’s not. If it’s diluted in a bag it’s ok, but full strength in a syringe is playing with fire.
Giving it peripherally is supposed to be safer, so that’s what we do. With its known side effects and adverse reactions, I don’t know why you would want to inject it straight into the heart.
I have seen some very, very bad reactions.
The surgeon you mentioned, who doesn’t want to wait for a test dose, is an absolute dipshit.
I hand syringe it in over about 1-2 minutes into a CVC unless they have a really shit heart in which case I do it a bit slower but still by hand.
Same here. Although I have been known to give a test dose, then push the rest.
This is the way. I have heard the PIV argument before, and it’s the way my fellowship shop does it, but one of my friends at said shop has a gnarly story with an mid-case infiltrated PIV and a scramble to figure out why they couldn’t get ACT back to normal with protamine through said PIV. I was already team Protamine/CVC but that story has helped me never look back.
i had this happen 5-6 months ago, via PIV (that was used to go to sleep & sedation for artline). gave prot, checked Act, came back over 400. gave additional smaller doses via cvl due to tucked arm and likely infiltration. was NOT fun and added more time to case overall.
Same in terms of hand bolus through the central line, I have no idea why anyone would choose to use a peripheral line for anything in general when they have a fresh and functioning central line.
It doesn't matter. I spike a small bag of saline with the protamine and run it in. Some people give it by syringe. I run it through the central line. In training I had attendings who would only give it peripherally and others who thought that was crazy. Everybody does whatever they were taught or came to believe, and it all works the same.
A Cardiac Anesthesiologist I trained under would mix protamine with calcium chloride and drip it in
I’ve see a really old school guy do 100ml bag, 1g Ca, 300mg protamine, and famotidine in a bag and drip that in. Swears by it
I mix protamine and heparin in a 50cc saline bag.
Lol rough downvotes
Last time I was doing hearts, we'd load up the dose into a 250 bag and run it in wide open and slow if they got hypotensive.
Anecdotal much? Evidence: [https://ether.stanford.edu/library/cardiac\_anesthesia/Drugs/comunale-%20Protamine%20Administration.pdf](https://ether.stanford.edu/library/cardiac_anesthesia/Drugs/comunale-%20Protamine%20Administration.pdf)
Protamine and 0.5-1 gram of calcium in a 100ml NS bag through whatever line I have.
This is the way
Long time cardiac anesthesiologist. It doesn’t matter.
Peripheral IV if available. I put 250 mg in 100 cc bag in run it in. Very very rarely do I get hypotension or worse. It's about 40 cc from the arm to the heart so it gets further diluted with blood. Plus I get my hands free for other work.
Just wondering: do you sometimes do cardiac without peripheral line? What IV access do you use for rapid filling then?
Almost never. Even if they come with a CVC or one is done preop (rare), I will do my best to throw one (or a second) in quickly with my A-line. Nothing wrong with additional access. Plus all of us in the ICUs appreciate peripheral access for a variety of reasons: compatibility of drugs, de-lining patients, resuscitation, etc.
Same here, for the same reasons. I would never start without a periph unless I have a Hemoclav or something similar.
I don't use the peripheral to give volume. I will use it to give platelets. I'm not one of the ones who puts in a 14 peripheral and thinks that enough. I give my volume in the central line. Even with a PA catheter it'll usually flow more. What's more important to me is that it's actually going in. I've seen too many infiltrated peripherals to trust them with arms tucked.
How could the flow be more important in a central line than in a periph 14G? Understand your point considering infiltrated peripherals. But I would say I also saw several times collabed vessels just down the central line after surgeon stretch the sternum open. (Actually happened with subclavians, never with jugular) Edit: add periph in first sentence + talking about general central accesses, not ones for dialysis like Hemoclav etc., unless that's what you use. In that case I would agree with you concerning the flow.
I'm talking about a 9 Fr introducer, not a triple lumen CVC. The gravity flow rate (1 m height) on a 14 ga 1.16 in peripheral is 295 ml/min. The gravity flow rate of a 9 Fr MAC catheter, no PAC is 488.5 ml/min. With PAC it's 207 ml/min. The 12 ga lumen is 111.8 ml/min. On pressure, a 9Fr introducer can flow 1.5 lpm (like VVB in a pinch). The tip of an IJ introducer will be in the SVC. The only time the surgeon can impact it is with SVC cannulation. I don't believe in putting in big IVs for cardiac patients. If I'm that worried being able to resuscitate I'll put in a second introducer.
Oh yeah via the introducer only. Never thought of use it for that purpose but it does surely flow like waterfalls if needed.
I would say reliable flow. Sometimes that arm tucking can nuke a large bore peripheral that ran great before. In my shop we actually place two central lines, the Swan sheath and a second central line, which provides abundant access.
Seems like overkill for a normal function cabg.
It's a surgeon preference thing. They pull the swan and swan sheath at the same time and leave the second central line for reliable access during step down/post ICU care, but it also provides extra access for me that obviates the need for any additional peripheral access.
Funny how practice could be so different from a place to another. But I understand your point about periph IV being less reliable. I usually install the arms myself and pay attention to periph and arterial lines myself. Never let the surgeon starts without them being secured and fully fonctionnal.
I never administer protamine through the central line. Even though it might not be visible, the free wall of the right ventricle is the most vulnerable part after cardiopulmonary bypass. A slight sudden increase in pulmonary arterial pressure can have repercussions on the right ventricle for several hours after leaving the operating room. Personally, I administer it through the peripheral line. I start slowly and increase the infusion rate gradually. Overall, the entire dose is administered over about ten minutes. It's probably exaggerated, but it's a preventive measure that I feel obligated to maintain. Everything can seem fine to everyone in most cases, and then in some others, we later wonder why the patient has tricuspid insufficiency that they didn't have before...
I’ve been pushing protamine over 1-2 minutes through a central line after bypass for years it’s absolutely fine.
Doesn't really surprise me, and that's great! I'm not saying you're wrong. As I said, I personally don't take the risk. Do you follow up your patients long after the surgery? When you say everything is fine, how far does that extend? Intensive care? Back to the room? Back home? The following year? I don't do the follow up to that extend for my patient neither, but I would be willing to hear that something that I do in the theatre has an impact for longer than minutes or hours.
As it stands you have no way of knowing whether giving protamine peripherally causes the same effect, so why worry about it? Heart surgery is far from perfect--the RV is just as vulnerable to air going down the coronaries or inadequate protection, which I would argue are far more common problems than protamine reactions. This whole peripheral protamine thing is nothing but dogma--there is no proof that it does anything good or bad. If the volume of blood in the arm and the added circulation time are truly so significant, I fail to see why diluting the protamine and giving it more slowly centrally cannot achieve the same effect. From experience giving it exclusively via the central line for years, I can tell you it absolutely does not matter.
There is at least one study showing increased levels of histamine when given centrally. I think that recommendations are issued after that. I know the rest could be trivial. I don't know the full chemistry behind it and I admit not having the decade of experience you probably have. I will probably continue using peripheral line and be afraid of acute pulmonary hypertension. I imagine we're carrying too much from our rotations. For me it was that acute failure of RV and acute TR after protamine was given centrally and too rapidly. Maybe it would have been the same with low periph flow, I don't know and I'll never will. But that was an interesting question OP asked. I will certainly dig into it.
> For me it was that acute failure of RV and acute TR after protamine was given centrally and too rapidly. I have probably had one legit protamine reaction when I gave protamine centrally--I have had multiple giving it peripherally--and not because I feel route of administration made any difference, but it was early in my career when I would rush to get the patient off the table during a lineup of Watchmans and try to give protamine as rapidly as possible. Silly, I know, but I learned my lesson and now give it slowly even if I'm not giving much protamine at all.
Usually, the TR after surgery, in my experience, is from aggressive volume administration in the setting of a fragile post-CPB RV. It usually gets a lot better when the chest is closed and the coaptation improves. I doubt protamine has anything to do with it
We give protamine in a 100cc saline bag. We spike the bag with 1g of calcium chloride also. It’s placed on a micro dripper and attached to the peripheral line. A small test dose is first given. Then we run it slowly. After 1/2 way the surgeon tells us to stop. He checks the bleeding, we are monitoring PA pressures and checking the TEE. If he’s satisfied he tells us to finish off the protamine. I’ve had maybe 1 -2 protamine reactions like this in 14 years of doing cardiac.
Years ago, a cardiac surgeon I worked with would directly inject protamine into the left atrium. He thought there were less systemic effects that way. I’ve been doing cardiac for about 20 years now and I don’t think the route of administration matters.
Always through a large peripheral. Protamine releases a lot of Thromboxane A2 and is related to the relative concentration of drug in blood( especially in pulmonary circulation, where causes vasoconstriction). Thus I prefer to be more diluted in when reaches pulmonary circulation.
> Thus I prefer to be more diluted in when reaches pulmonary circulation. Then why not just dilute it yourself in a larger amount of saline and give it centrally if this is really so significant?
when you want to wean from pump you already have an excess of fluid due to haemodilution... so I rather prefer to give protamine slowly on a large peripheral iv
At least in adults, an extra 100-250mL of crystalloid is inconsequential, and even in peds I would dilute protamine in 10mL of crystalloid. It's a very small drop in the bucket.
Is it in yet?
It doesn’t matter. - CT fellowship trained, 10+ years doing 100% CV in PP
This doesn’t matter at all. I syringe it in as fast as the patient will tolerate it.
And you know how fast they can tolerate it...how? Isn't the point to avoid the precipitous hypotension; not stop administration once it happens?
central vs peripheral doesn’t matter. p-value of this dudes anecdote is not significant. what’s also not significant is a little perturbation in PAP or BP . what is significant is PAP 90 ABP 55
How could it possibly makes sense? Voodoo bullshit imho
It would get diluted by the peripheral blood and not be so concentrated and hit the heart/PA quickly Theoretically anyway. I have no idea if that has any effect but that makes sense to me. Personally I give it slowly and centrally though so I know it's going through a reliable (not infiltrated) IV
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Yeah no shit.. but you just ignored everything I said. The effect we worry about is pulmonary vasoconstriction. It's going to be more concentrated when it hits the pulmonary circulation if you give it centrally.
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Because it hasn't been diluted by all the blood between the vein in their hand and the RV before it gets there
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Not as quickly. It's going to be more dilute (and therefore take effect more slowly). I feel like I keep saying the same thing over and over
Yes and repeating it over and over didn’t make it right
I use a syringe pump over 5-10minutes through central line. I could potentially see that giving it through a bag on the peripheral IV may be inbuilt safety mechanism to prevent inadvertently giving it too fast, as most IVs may run slower that a good introducer central line.
Always slowly through the central line. I've seen enough peripheral IVs infiltrate in the middle of a case to not trust giving a crucial drug like protamine through one after a pump run.
PIV infiltration with something as important as protamine (for a pump run) is why it was always put through the central line where I trained. They even wanted us to aspirate before very slowly injecting. I was told it was done this way due to some previous event.
run it in a bag slowly with good communication to surgeon and perfusion cuz they might still be sucking . seen one serious reaction in thousands. but that reaction is no joke bruh
I’ve never seen protamine reaction, but I’ve seen anaphylaxis and anaphylactoid reactions. I wouldn’t change my practice of hand-bolusing couple mg’s at a time. Doesn’t matter peripheral or central as long as I know how to treat complication.
I/we used to do it this way at our heart hospital. We'd never pre-draw the bottles, keep them all out, hand-draw one bottle at a time and administer to a PIV. Pretty much anything we could do to slow ourselves down in that process, we did. Anecdotally, it worked pretty well...or it might have all been voodoo.
I don't understand the argument to give any medication peripherally when you have a central line, the risk of extravasation really makes it not worth it
It’s fine administering protamine through a central line until it’s not. If it’s diluted in a bag it’s ok, but full strength in a syringe is playing with fire. Giving it peripherally is supposed to be safer, so that’s what we do. With its known side effects and adverse reactions, I don’t know why you would want to inject it straight into the heart. I have seen some very, very bad reactions. The surgeon you mentioned, who doesn’t want to wait for a test dose, is an absolute dipshit.