Protamine-related non-cardiogenic pulmonary edema during routine heparin reversal for cardiopulmonary bypass

A 62-year-old male presented for coronary artery bypass graft (CABG) and aortic valve replacement (AVR). Following initiation of intravenous (IV) protamine for heparin reversal, the patient developed acute pulmonary edema characterized by reduced oxygen saturations and increasing airway pressures necessitating venoarterial extracorporeal membrane oxygenation (VA-ECMO) for lung recovery. This case report discusses the pathophysiology of protamine-related non-cardiogenic pulmonary edema (NCPE) and its comparison to typical protamine reactions. Anesthesiologists must be aware of this potentially life-threatening complication during procedures where protamine is commonly used to reverse the effects of heparin anticoagulation. Anesthesiology, Cardiac/Thoracic/Vascular Surgery