{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T10:43:42Z","timestamp":1788345822362,"version":"build-2803163510"},"reference-count":23,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2024,1,24]],"date-time":"2024-01-24T00:00:00Z","timestamp":1706054400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Transfusion"],"published-print":{"date-parts":[[2024,3]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Background<\/jats:title><jats:p>Bleeding after cardiac surgery is common and continues to require 10\u201320% of the national blood supply. Transfusion of allogeneic blood is associated with increased morbidity and mortality. Excessive protamine in the absence of circulating heparin after weaning off CPB can cause anticoagulation and precipitate bleeding. Hence, adequate dose calculation of protamine is crucial yet under evaluated.<\/jats:p><\/jats:sec><jats:sec><jats:title>Study Design<\/jats:title><jats:p>Retrospective cohort study.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>We conducted a retrospective bi\u2010institutional analysis of cardiac surgical patients who underwent cardiopulmonary bypass (CPB)\u2010assisted cardiac surgery to assess the impact of protamine dosing in transfusion practice. Total 762 patients were identified from two institutions using electronic medical records and the Society of Thoracic Surgery (STS) database who underwent cardiac surgery using CPB. Patients were similar in demographics and other baseline characteristics. We divided patients into two groups based on mg of protamine administered to neutralize each 100\u2009U of unfractionated heparin (UFH)\u2014low\u2010ratio group (Protamine: UFH\u2009\u2264\u20090.8) and high\u2010ratio group (Protamine: UFH\u2009&gt;\u20090.8).<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>We observed a higher rate of blood transfusion required in high\u2010ratio group (ratio &gt;0.8) compared with low\u2010ratio group (ratio \u22640.8) (<jats:italic>p<\/jats:italic>\u2009&lt;\u2009.001). The increased requirement was consistently demonstrated for intraoperative transfusions of red blood cells, plasma, platelets, and cryoprecipitate.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>High protamine to heparin ratio may cause increased bleeding and transfusion in cardiac surgical patients. Protamine to heparin ratio of 0.8 or lower is sufficient to neutralize circulating heparin after weaning off cardiopulmonary bypass.<\/jats:p><\/jats:sec>","DOI":"10.1111\/trf.17730","type":"journal-article","created":{"date-parts":[[2024,1,24]],"date-time":"2024-01-24T08:50:38Z","timestamp":1706086238000},"page":"467-474","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Protamine dosing and its impact in cardiac surgery transfusion practice\u2014A retrospective bi\u2010institutional analysis"],"prefix":"10.1111","volume":"64","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0897-0998","authenticated-orcid":false,"given":"Samhati","family":"Mondal","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, Cardiothoracic Division University of Maryland School of Medicine  Baltimore Maryland USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ezeldeen","family":"Abuelkasem","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Cardiothoracic Division University of Pittsburgh School of Medicine and UPMC  Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roumen","family":"Vesselinov","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Public Health, Biostatistics Division; Department of Anesthesiology National Study Center, University of Maryland  Baltimore Maryland USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Reney","family":"Henderson","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Cardiothoracic Division University of Maryland School of Medicine  Baltimore Maryland USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Seung","family":"Choi","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology WakeMed Health System  Raleigh North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ahmad","family":"Mousa","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Cardiothoracic Division University of Pittsburgh School of Medicine and UPMC  Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khaled J.","family":"Zaza","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Cardiothoracic Division University of Pittsburgh School of Medicine and UPMC  Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5051-1365","authenticated-orcid":false,"given":"Kenichi A.","family":"Tanaka","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology University of Oklahoma Health Sciences Center  Oklahoma City Oklahoma USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2024,1,24]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.jvca.2022.06.021"},{"key":"e_1_2_7_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.bja.2018.01.023"},{"key":"e_1_2_7_4_1","doi-asserted-by":"publisher","DOI":"10.1051\/ject\/201850005"},{"key":"e_1_2_7_5_1","doi-asserted-by":"publisher","DOI":"10.1093\/icvts\/ivz251"},{"key":"e_1_2_7_6_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.jvca.2017.06.026"},{"issue":"2","key":"e_1_2_7_7_1","first-page":"210","article-title":"2019 EACTS\/EACTA\/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery","volume":"57","author":"Wahba A","year":"2020","journal-title":"Eur J Cardiothorac Surg"},{"issue":"2","key":"e_1_2_7_8_1","first-page":"251","article-title":"Effect of high or low protamine dosing on postoperative bleeding following heparin anticoagulation in cardiac surgery. A randomised clinical trial","volume":"116","author":"Meesters MI","year":"2016","journal-title":"Thromb Haemost"},{"key":"e_1_2_7_9_1","doi-asserted-by":"publisher","DOI":"10.1213\/00000539-199601000-00004"},{"key":"e_1_2_7_10_1","doi-asserted-by":"publisher","DOI":"10.1007\/s12630-022-02364-4"},{"key":"e_1_2_7_11_1","doi-asserted-by":"publisher","DOI":"10.4103\/aca.ACA_26_19"},{"key":"e_1_2_7_12_1","doi-asserted-by":"publisher","DOI":"10.1213\/00000539-199810000-00008"},{"key":"e_1_2_7_13_1","doi-asserted-by":"publisher","DOI":"10.1213\/00000539-198604000-00013"},{"key":"e_1_2_7_14_1","doi-asserted-by":"publisher","DOI":"10.1155\/2019\/4310407"},{"key":"e_1_2_7_15_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00216-010-4220-8"},{"key":"e_1_2_7_16_1","doi-asserted-by":"publisher","DOI":"10.1182\/blood-2009-05-222109"},{"issue":"3","key":"e_1_2_7_17_1","first-page":"M715","article-title":"Tissue distribution, circulating half\u2010life, and excretion of intravenously administered protamine sulfate","volume":"39","author":"DeLucia A","year":"1993","journal-title":"ASAIO J"},{"key":"e_1_2_7_18_1","doi-asserted-by":"publisher","DOI":"10.1097\/00000539-200203000-00008"},{"key":"e_1_2_7_19_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.athoracsur.2016.01.006"},{"key":"e_1_2_7_20_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.jvca.2023.01.038"},{"issue":"11","key":"e_1_2_7_21_1","article-title":"Prothrombin complex concentrate in cardiac surgery for the treatment of coagulopathic bleeding","volume":"11","author":"Hayes K","year":"2022","journal-title":"Cochrane Database Syst Rev"},{"key":"e_1_2_7_22_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamasurg.2022.6818"},{"key":"e_1_2_7_23_1","doi-asserted-by":"publisher","DOI":"10.1097\/ALN.0000000000004520"},{"key":"e_1_2_7_24_1","doi-asserted-by":"publisher","DOI":"10.1213\/ANE.0000000000004355"}],"container-title":["Transfusion"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/trf.17730","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,3,16]],"date-time":"2024-03-16T06:20:42Z","timestamp":1710570042000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/trf.17730"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,1,24]]},"references-count":23,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2024,3]]}},"alternative-id":["10.1111\/trf.17730"],"URL":"https:\/\/doi.org\/10.1111\/trf.17730","archive":["Portico"],"relation":{},"ISSN":["0041-1132","1537-2995"],"issn-type":[{"value":"0041-1132","type":"print"},{"value":"1537-2995","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,1,24]]},"assertion":[{"value":"2023-09-16","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2023-12-29","order":1,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2024-01-24","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}