Reversal Information
- Protamine sulfate can be used – however, it does not fully reverse enoxaparin – (about 70% reversal; molecular weight not as big as UFH)
- Protamine combines with the strongly acidic heparin to form a stable salt complex neutralizing the anticoagulant activity
- Protamine requires a high level of caution when being prescribed and administered. Protamine should be administered IV in a concentration of 10 mg/mL at a rate not to exceed 5 mg/minute (over a 10-minute period). If administered too quickly it may cause cardiovascular collapse/hypotension. Patients with known hypersensitivity reactions to fish, and those who have received protamine containing insulin or previous protamine therapy may be at risk of hypersensitivity reactions to protamine sulfate
- The dosage of protamine sulfate is based on the both the amount of enoxaparin and the time since the last dose, as follows:
| Time Since Last Enoxaparin Dose | Protamine Dose per 1 mg Enoxaparin Received |
| < 4 hours | 1 mg per 1 mg (100 units) enoxaparin received |
| 4-8 hours | 0.5-0.75 mg per 1 mg (100 units) enoxaparin received |
| >8-12 hours | 0.25-0.5 mg per 1 mg (100 units) enoxaparin received |
| >12 hours | Do not give protamine |
Critical site bleeds: Intracranial hemorrhage, including intraparenchymal, subdural, epidural, and subarachnoid hemorrhages; Other CNS hemorrhage, including intraocular, intra- or extra-axial spinal hemorrhages; Pericardial tamponade; Airway, including posterior epistaxis; Hemothorax, intraabdominal bleeding, and retroperitoneal hemorrhage; Extremity bleeds, including intramuscular and intraarticular bleeding concerning for compartment syndrome, bleeding associated with hemodynamic instability, bleeding in a noncompressible vessel (e.g., subclavian)
