Incidence of hypersensitivity reactions

A Randomized Controlled Trial of Fibrin Glue to Prevent Bleeding After Gastric Endoscopic Submucosal Dissection

INTRODUCTION

This study evaluated the efficacy of fibrin glue for preventing postendoscopic submucosal dissection (ESD) bleeding in high-risk patients for bleeding (expected iatrogenic ulcer size ≥40 mm or receiving antithrombotic therapy).

METHODS

A multicenter, open-label, randomized controlled trial was performed at 4 tertiary medical centers in South Korea between July 1, 2020, and June 22, 2022. Patients with gastric neoplasm and a high risk of post-ESD bleeding were enrolled and allocated at 1:1 to a control group (standard ESD) or a fibrin glue group (fibrin glue applied to iatrogenic ulcers after standard ESD). The primary outcome was overall bleeding events within 4 weeks. The secondary outcomes were acute bleeding (within 48 hours post-ESD) and delayed bleeding (48 hours to 4 weeks post-ESD).

RESULTS

In total, 254 patients were randomized, and 247 patients were included in the modified intention-to-treat population (125 patients in the fibrin glue group and 122 patients in the control group). Overall bleeding events occurred in 12.0% (15/125) of the fibrin glue group and 13.1% (16/122) of the control group ( P = 0.791). Acute bleeding events were significantly less common in the fibrin glue group than in the control group (1/125 vs 7/122, P = 0.034). Delayed bleeding events occurred in 11.2% (14/125) in the fibrin glue group and 7.3% (9/122) in the control group ( P = 0.301).

DISCUSSION

This trial failed to show a preventive effect of fibrin glue on overall post-ESD bleeding in high-risk patients. However, the secondary outcomes suggest a potential sealing effect of fibrin glue during the acute period.

Aprotinin and transfusion requirements in pediatric craniofacial surgery

OBJECTIVE

To evaluate transfusion requirements in children receiving aprotinin during craniofacial surgery.

BACKGROUND

Pediatric craniofacial procedures may involve massive blood loss. Aprotinin may decrease perioperative blood loss and transfusion requirements.

METHODS

Patients (aged 1 month to 3 years) who had major reconstructive craniofacial surgery received intraoperative aprotinin (13 patients) or placebo (13 patients). Administered colloids and blood products were recorded.

RESULTS

Patients in the aprotinin and placebo groups had similar mean age, body weight, body surface area, operative time, and length of hospital stay. Mean volumes of total colloids (aprotinin group: 70 ± 40 ml; and placebo group: 120 ± 80 ml; P ≤ 0.05) and packed red blood cells (aprotinin group: 380 ± 90 ml; and placebo group: 550 ± 200 ml; P ≤ 0.004) were less in the aprotinin group than in the placebo group. Mean urine output during surgery was greater in the aprotinin group than in the placebo group (320 ± 200 ml vs 150 ± 70 ml, respectively; P ≤ 0.003). Mean blood urea nitrogen and serum creatinine values after surgery were similar between the groups. Complications of aprotinin included anaphylaxis (one patient) and rash (one patient); no deaths occurred.

CONCLUSIONS

Aprotinin was associated with decreased packed red blood cell transfusion requirements in children undergoing craniofacial surgery, with no renal toxicity or death. Aprotinin is no longer available for clinical use in the USA because of adverse effects in adults; re-evaluation of aprotinin is warranted for children scheduled to undergo surgery involving potentially high blood loss.

The use of aprotinin in children undergoing operative repair of isolated atrial septal defects

BACKGROUND

The purpose of this retrospective study was to examine the benefits, risks and costs associated with aprotinin use in children who underwent repair of an atrial septal defect (ASD). The primary aim was to determine whether the transfusion rate is lower in children who received aprotinin compared with those who did not during ASD repair. The use of aprotinin has been shown to reduce transfusion requirements for children undergoing primary or secondary repair of congenital cardiac anomalies. However, past studies have not reported the benefits of this agent during low complexity procedures such as ASD repair.

METHODS

All children who underwent ASD repair over 6 years (3 years pre- and postroutine use of aprotinin for all CPB cases in the institution) were identified, and their medical records reviewed. Children with multiple congenital cardiac lesions were excluded. The following data were recorded: demographics and baseline laboratory findings, intraoperative use of aprotinin, cardiopulmonary bypass information including details of ultrafiltration, all intraoperative and postoperative transfusions, postoperative bleeding and relevant laboratory findings.

RESULTS

One hundred and fifteen children were included, 66 of whom received aprotinin. Transfusion rates were not different between children who received aprotinin [n = 8 (12%)] and those who did not [n = 3 (6%)]. Furthermore, changes in hematocrit were not different between groups. These findings were similar when children </=15 kg were compared with those >15 kg.

CONCLUSIONS

This study suggests that aprotinin use offers no benefit for children undergoing isolated repair of an ASD.

Aprotinin and anaphylaxis: analysis of 12,403 exposures to aprotinin in cardiac surgery

BACKGROUND

Hypersensitivity reactions to the nonspecific proteinase inhibitor aprotinin may occur. The present study evaluates the incidence of hypersensitivity reactions to aprotinin.

METHODS

Data were prospectively collected as part of the institution's quality assurance program. The database was screened for anaphylactic reactions, especially those against aprotinin. The definition of an allergic reaction was predefined. A severe reaction was defined as hemodynamic instability of more than 10 minutes despite high dosages of vasopressors and inotropic medication.

RESULTS

Of 13,315 cardiac operations, 12,403 were done with aprotinin, with 801 reexposures in 697 patients. Eleven reactions to aprotinin (11 of 11,602; 0.09%, 95% confidence interval: 0.05% to 0.16%) were recorded after primary exposure, of which none was severe, while 12 reactions (12 of 801; 1.5%; 95% confidence interval: 0.86% to 2.6%) occurred after reexposure, of which 5 were severe. All severe reactions were in patients reexposed to aprotinin within 6 months after previous exposure. There was no reaction observed in patients reexposed to aprotinin within 3 days after the last exposure (n = 42). The incidence of hypersensitivity reactions was 4.1%, 1.9%, and 0.4% in the less than 6 months, 6 to 12 months, and more than 12 months reexposure intervals, respectively.

CONCLUSIONS

The risk of hypersensitivity reactions is low after primary exposure to aprotinin. This risk after reexposure reaches a maximum between the fourth day and the 30th day after previous exposure and declines considerably after 6 months. Consequently, application of aprotinin carries a high risk between the fourth and the 30th day after previous exposure, and cannot be recommended for the first 6 months, but is justifiable in previously aprotinin-exposed patients with a high risk of bleeding after this interval.

Postpneumonectomy and Postlobectomy Empyema

Although similar strategies are used in the management of PPE and PLE, these conditions need to be viewed as two separate entities. For the purpose of devising the appropriate management strategy, PPE should be divided into early and late, with and without mediastinal induration and extensive pleural space contamination. If at all possible, PLE should be managed as a postpneumonic empyema with prolonged chest tube drainage. The key to these conditions is prevention.

Review and application of serine protease inhibition in coronary artery bypass graft surgery

PURPOSE

Current pharmacologic agents, aprotinin, epsilon aminocaproic acid, and tranexamic acid, used to decrease blood loss and transfusion requirements during coronary artery bypass graft (CABG) surgery are discussed. Aprotinin is the only agent that also modulates the systemic inflammatory responses that are generated by contact activation during CABG surgery. These responses are largely mediated by serine proteases such as kallikrein, thrombin, and plasmin.

SUMMARY

Aprotinin is a naturally occurring polypeptide that has a concentration-dependent effect to inhibit serine proteases. Two aprotinin dosing regimens are indicated in the United States (U.S.) for prophylactic use to reduce perioperative blood loss and the need for blood transfusion in patients undergoing cardiopulmonary bypass (CPB) during the course of CABG surgery. Serum concentrations achieved with the full-dose regimen inhibit both kallikrein and plasmin activity resulting in attenuation of the systemic inflammatory response to bypass, whereas serum concentrations achieved with the half-dose regimen only inhibit plasmin activity. The efficacy and safety of aprotinin have been studied in randomized controlled trials in over 5,000 patients. Aprotinin is well tolerated compared to placebo. Treatment-emergent adverse events are similar to those associated with CPB surgery. However, because aprotinin is a bovine protein, there is a small, but manageable risk of hypersensitivity reactions. Epsilon aminocaproic acid and tranexamic acid are lysine analogs that reduce bleeding by inhibiting the conversion of plasminogen to plasmin, a serine protease responsible for breaking down fibrinogen to fibrin. Although they are commonly used to decrease bleeding associated with CABG surgery with CPB, they are not currently approved by the U.S. Food and Drug Administration (FDA) for CABG surgery.

CONCLUSION

Aprotinin is the only agent that has an FDA indication to prevent blood loss and transfusion during CABG surgery, and the additional benefit of attenuating the systemic inflammatory response associated with CABG with CPB.

Aprotinin and epsilon aminocaproic acid are effective in reducing blood loss after primary total hip arthroplasty--a prospective randomized double-blind placebo-controlled study

A prospective randomized double-blind placebo-controlled study was undertaken to determine the efficacy and mechanism of action of two antifibrinolytic drugs aprotinin and epsilon aminocaproic acid (EACA) in reducing blood loss in primary unilateral total hip arthroplasty (THA). Aprotinin was administered as a bolus of 2 x 10(6) kallikrein inhibitor units (KIU) followed by 0.5 x 10(6) KIU h(-1) for 3 h, EACA was given as 10 g over 30 min followed by 5 g over 3 h. The median postoperative blood loss 24 h postoperatively was reduced from 450 mL in the placebo group to 180 mL for aprotinin (60% reduction, P < 0.001) and to 210 mL for EACA (53% reduction, P < 0.01). In this population, there was no reduction in the perioperative transfusion requirements. The mechanism of both drugs was independent of platelets as indicated by flow cytometric measurement of change of their expression of P-selectin, platelet-monocyte aggregates, V/Va and CD40 ligand. There were no thrombotic or infective complications and no adverse events were attributable to use of either drug. Infusion of either aprotinin or EACA at the doses described is a safe and effective means of reducing blood loss after THA. These therapies provide a means of reducing blood loss in THA patients.

Forty Years of Clinical Aprotinin Use: A Review of 124 Hypersensitivity Reactions

Since its clinical introduction, the anaphylactic potential of aprotinin has been a major concern. World wide, its use is expanding so there is an increased chance that patients have reexposure from various sources. The risk of anaphylaxis is approximately 2.8% in reexposed patients. From 1963 to 2003, 124 cases of aprotinin-induced anaphylaxis were reported in 61 publications. Eleven patients died. The reexposure interval was less than 3 months in 72% (38 of 53 patients). This review looks at the profile of patients at risk so preventive measures may be taken. Past and future exposures have to be taken into account before any aprotinin administration.

Aprotinin and major orthopedic surgery

Aprotinin is a potent pharmacological agent that reduces bleeding and limits blood transfusion requirements in current surgical practice. Many studies have been conducted in orthopedic surgery. In several trials performed in total hip replacement (THR) and total knee replacement (TKN) patients, aprotinin only moderately decreased blood-loss-replacement requirements. Conversely, when aprotinin was used in patients at high risk for bleeding (cancer, sepsis, redone surgery), it developed a potent hemostatic activity and decreased blood transfusion significantly. No increase in deep vein thrombosis and pulmonary embolism was observed. The only major side effect could be the potential occurrence of an anaphylactoid reaction. Prophylactic administration of aprotinin should be considered in extensive spine surgery and in high-risk major orthopedic operations. The decision to use aprotinin should be guided by a risk/benefit analysis.

A direct antifibrinolytic agent in major orthopedic surgery

Aprotinin is a potent pharmacological agent that reduces bleeding. In current surgical practices, the rate of blood transfusions has decreased with the use of aprotinin. Recently, studies using aprotinin have been conducted in orthopedic surgery. Several trials have been performed in patients undergoing total hip replacement and total knee replacement. Aprotinin moderately decreased blood loss in these patients. When aprotinin was used in patients with a high-risk of bleeding (ie, patients with cancer, sepsis, or undergoing reoperation), potent hemostatic activity occurred and the rate of blood transfusions significantly decreased. No increase in deep vein thrombosis and pulmonary embolism was observed. One adverse effect was the potential occurrence of an anaphylactoid reaction. Prophylactic administration of aprotinin should be considered in extensive spine surgery and in high-risk orthopedic operations. The decision to use aprotinin can be guided by a risk/benefit analysis.

Aprotinin: a pharmacologic overview

Aprotinin is a polypeptide with serine protease inhibitory activity of key enzymes associated with inflammatory, fibrinolytic, and hemostatic pathways. The drug binds directly to the fibrinolytic plasmin at the lower plasmin-inhibiting dose (plasma concentration, 137 KIU/mL), and the inflammatory mediator, kallikrein, using the higher kallikrein-inhibiting dose (plasma concentration, >250 KIU/mL). Aprotinin inhibits platelet glycoprotein loss (GpIb and GpIIb/IIIa receptors) associated with cardiopulmonary bypass and has been described as platelet sparing. Current literature supports direct anti-inflammatory effects through modulation of neutrophil activation, attachment, and transmigration, with resultant blunting in the rise of proinflammatory cytokine levels and deleterious tissue damaging enzymes. The pharmacologic properties of aprotinin may lead clinicians to consider this therapy for use as a hemostatic and anti-inflammatory agent in surgeries beyond its established use in coronary artery bypass graft surgery.

Aprotinin versus placebo in major orthopedic surgery: a randomized, double-blinded, dose-ranging study

We conducted a prospective, multicenter, double-blinded, dose-ranging study to compare the risk/benefit ratio of large- and small-dose aprotinin with placebo after major orthopedic surgery. Fifty-eight patients were randomized into three groups: Large-Dose Aprotinin (4 M kallikrein inactivator unit [KIU] bolus before surgery followed by a continuous infusion of 1 M KIU/h until the end of surgery), Small-Dose Aprotinin (2 M KIU bolus plus 0.5 M KIU/h), and Placebo. Bleeding was measured and calculated. Bilateral ascending venography was systematically performed on the third postoperative day. Measured and calculated blood loss decreased in the Large-Dose Aprotinin group (calculated bleeding, whole blood, hematocrit 30%, median [range], 2,023 mL [633-4,113] as compared with placebo, 3,577 mL [1,670-21,758 mL]). The total number of homologous and autologous units was also significantly decreased in the Large-Dose Aprotinin group (2 U [0-5 U] as compared with placebo, 4 U [0-42 U]). No increase in deep vein thrombosis or pulmonary embolism was observed in the aprotinin groups. Large-dose aprotinin was safe and effective in dramatically reducing the measured and calculated bleeding and the amount of transfused red blood cell units after major orthopedic surgery.

IMPLICATIONS

Large doses of aprotinin decrease blood loss and transfusion amount in major orthopedic surgery.

Suture support: is it advantageous?

Sutures have been used to facilitate and enhance wound closure and healing throughout the course of medical history. Suturing is still the most common method of wound closure, but in some surgical situations suture support can improve clinical outcomes. Sutures provide mechanical support to a wound and help create the optimal environment for wound healing. However, suturing can give rise to such complications as bleeding from suture holes and air and fluid leakage. In the last 25 years, fibrin sealants have been used increasingly in the clinical setting to assist in the sealing of surgical wounds and to give additional mechanical support to a range of wounds during the early phases of wound healing. The use of fibrin sealants in addition to sutures has a direct effect on hemostasis and blood loss. Fibrin sealants also reduce the volume of fluid drained and air leakage postoperatively in head, neck, and thoracic surgery, in some cases resulting in a reduced length of hospital stay. The use of fibrin sealant as suture support can also reduce the number of sutures and the length of operations for intricate or complex procedures. The aim of this article is to provide an overview of how fibrin sealants acting as an adjunct to sutures affect surgical outcomes.

Aprotinin Use in Pediatric Cardiac Surgery

Aprotinin is a serine protease inhibitor that inhibits kal likrein and plasmin. Aprotinin's plasmin inhibition accounts for its antifibrinolytic and platelet-sparing effects, which are important factors for its homeostatic efficacy. The kallikrein inhibition occurs at higher plasma levels and is the mecha nism accounting for its anti-inflammatory actions. Aprotinin has relatively large acquisition costs, but these costs are offset by potential reductions in transfusions and intensive care costs. This review summarizes the pediatric literature and develops generalized recommendations for the effica cious use of aprotinin.

[Anaphylactic reactions to aprotinin: intradermal diagnostic tests]

A 66-year-old patient, undergoing heart surgery, developed an anaphylactic reaction following the first administration of a test-dose of aprotinin. Skin tests were performed six months later. Prick-tests with 10(-2) and 10(-1) aprotinin dilutions were negative but intradermal reaction with a 10(-3) dilution was clearly positive. The level of aprotinin specific IgE was high, both in the serum obtained before surgery and in the one sampled on the day of the testing. As no reaction was observed during the tests, skin-testing and specific IgE appear to be an interesting alternative to a potentially dangerous test-dose, but they both need further evaluation.

Anesthesia for heart or single or double lung transplantation in the adult patient

Providing an anesthetic for patients undergoing heart or a single or double lung transplantation may represent a challenge even to the most experienced anesthesiologist. Patients with end-stage cardiac dysfunction have an impaired response to beta-agonist due to receptor downregulation. These patient will have isolated left ventricular dysfunction secondary to ischemic heart disease or present with biventricular failure with or without significant pulmonary hypertension. Increasingly, more patients have undergone prior major cardiac procedures and are at risk for significant perioperative bleeding. Patients undergoing single or double lung are particularly challenging because most of these procedures are performed without the aid of cardiopulmonary bypass. The anesthesiologist must be proficient at the management of one-lung ventilation techniques and have a rational physiologic approach to the management of intraoperative hypoxemia and auto-PEEP.

An immediate, allergic skin reaction to aprotinin after reexposure to fibrin sealant

BACKGROUND

The safety of fibrin tissue adhesives has been a concern since they entered wide clinical application. Most commercially available kits contain the proteolytic inhibitor, aprotinin, to stabilize the fibrin clot. A bovine protein, this substance has an allergenic potency.

CASE REPORT

This case report presents a patient who had a generalized allergic skin reaction, probably triggered by aprotinin upon reexposure to fibrin sealant injected subgaleally to achieve closure of a liquor fistula after neurosurgical treatment. The serologic investigation revealed aprotinin-specific IgE and IgG. From 1990 through 1998, reports of five allergic reactions following 1 million exposures to fibrin sealant were made to the manufacturer. The clinical relevance of allergic reactions to aprotinin contained in fibrin sealants and measures to avoid them are discussed.

CONCLUSION

These hypersensitivity reactions are extremely rare (incidence, 0.5/100,000 for all reactions and 0.3/100,000 for serious reactions), but they must be kept in mind as possible adverse events after repeated applications of fibrin sealants within a few weeks.

[Allergic risk of aprotinin]

OBJECTIVE

To analyse the risk of anaphylactic reaction with the administration of aprotinin, either by i.v. route or as a biological sealant application and to propose updated guidelines in accordance with current data of the literature.

DATA SOURCES

Search in the Medline data base of articles in French, English and German, published since 1960, using following key words: aprotinin, allergy, anaphylaxis.

STUDY SELECTION

All categories of articles on this topic have been selected.

DATA EXTRACTION

Articles have been analysed for history, incidence and mechanisms of anaphylactic reactions, symptomatology, factors of risk, diagnosis and precautions of use.

DATA SYNTHESIS

Aprotinin is widely used for decreasing preoperative bleeding, especially in cardiac and orthopaedic surgery. This heterologue protein can cause anaphylactic reactions in 0.5 to 5.8% of patients, depending of the inclusion criteria. They are mediated by IgG and IgE antibodies. Aprotinin has also a direct, non specific, histaminoliberation effect. The clinical presentation includes various degrees of severity, up to cardiac arrest. Documented factors of risk are a previous parotinin administration, 15 days to 6 months before, and intolerance to beef meat, white of egg, cheese and milk. The immediate biological diagnosis is obtained on assessing the degranulation of basophiles (histamine) and mastocytes (tryptase), as well as the concentration of anti-aprotinin antibodies (RAST IgE), with a test of inhibition. The secondary assessment, six weeks later, includes prick-tests and intradermoreactions if the former are negative. The mean precaution consists to search factors of risk at preanaesthetic assessment. The predictive value of systematic prick-tests has not yet been validated. Anti H1 and anti H2 premedication is inefficient. A test dose can trigger a severe reaction.

CONCLUSION

Considering a significant anaphylactic risk, aprotinin administration becomes only licit after a careful evaluation of the benefit-risk ratio.

Cardiac surgery and the coagulation system

This review focuses on the activation of the haemostatic system during cardiopulmonary bypass. The interaction of different cascade systems are examined, in particular the relation of inflammation with haemostasis. Novel strategies to supplement or replace heparin for anticoagulation during cardiopulmonary bypass have recently been described. Drug approaches to reduce activation of haemostasis reported during the review period are already well established. Their influence on the inflammatory response may offer interesting perspectives for the future.

[Anaphylactic shock after a test-dose of aprotinin in pediatric orthopedic surgery]

A case of severe anaphylactic shock in a 28-month-old child following a testing-dose of aprotinin during major orthopaedic surgery is reported. Two months earlier, aprotinin had been administered during a similar controlateral surgical procedure. The grade III anaphylactic accident required a 48 h treatment in an intensive care unit. The outcome was favourable. The pin-prick tests were positive for aprotinin, substantiating the diagnosis of anaphylactic shock, whereas the test with specific IgE was negative. The value of current diagnostic tools for aprotinin allergy is discussed. The administration of a testing-dose in a patient previously treated with aprotinin cannot be recommended. Considering the risk for allergy, aprotinin should only be administered for recognized indications such as major orthopaedic surgery. Before any readministration of this agent an assessment by an allergist-anaesthetist is essential for determination of the risk-benefit ratio.

Blood transfusion support in pediatric cardiovascular surgery

The majority of children who undergo open-heart surgery with cardiopulmonary bypass (CPB) require perioperative blood transfusion. Blood product requirements are affected by factors such as patient age, underlying cardiac disease, complexity of the surgical procedure, and hemostatic alterations induced by CPB. Transfusion support may include the use of whole blood and/or individual blood components with transfusion practices varying widely based on individual preferences and blood product availability. Approaches to limit allogeneic blood exposure include the use of modified ultrafiltration and smaller bypass circuits, preoperative autologous blood donation and intraoperative blood salvage, and adjunctive antifibrinolytic agents. Potential advantages and disadvantages of the different blood products and pharmacological agents must be considered in managing the pediatric cardiac surgery patient.