Pro: Aprotinin should be used in coronary artery bypass graft surgery with cardiopulmonary bypass

Aprotinin use during cardiac surgery: recent alterations and effects on blood product utilization

OBJECTIVE

To investigate a single institution's changing use of aprotinin and subsequent effects on intraoperative blood product utilization (red blood cells/fresh frozen plasma) and postoperative clinical bleeding requiring reoperation.

DESIGN

Retrospective study.

SETTING

Single university institution (University of Chicago).

MEASUREMENTS

Data from 499 adult patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) over a two-year period (February 2005 - January 2007) were reviewed. The first 12 months (Feb 2005 - Jan 2006, Group 2005-2006) of data were compared with that from the second 12-month period (Feb 2006 - Jan 2007, Group 2006-2007). Information regarding patient demographics, surgical procedures, aprotinin use (none, half-dose, full-dose), and blood product use during CPB was retrospectively retrieved and analyzed.

MAIN RESULTS

When Group 2006-2007 data was compared with that from Group 2005-2006, full-dose aprotinin use had significantly decreased (58% to 17%, P < 0.001), non-use of aprotinin significantly increased (18% to 47%, P < 0.001), while fresh frozen plasma (FFP) utilization during CPB significantly increased (24% to 36%, P = 0.004). Red blood cell (RBC) transfusion rates remained stable (67% - 69%) yet rates of RBC and FFP transfusion during CPB significantly increased (23% to 34%, P = 0.003). There was also a trend toward increased unplanned reoperations for excessive clinical bleeding (0 pts in Group 2005-2006, three pts in Group 2006-2007).

CONCLUSIONS

As the institution's use of high-dose aprotinin has significantly decreased, the number of patients requiring FFP and FFP/RBC combinations during CPB has significantly increased. Furthermore, a trend toward increasing incidence of unplanned reoperations for excessive clinical bleeding was noted.

Cardiac anesthesia and surgery in geriatric patients

The average age of US population is steadily increasing, with more than 15 million people aged 80 and older. Coronary artery disease and degenerative cardiovascular diseases are particularly prevalent in this population. Consequently, an increasing number of elderly patients are referred for surgical intervention. Advanced age is associated with decreased physiologic reserve and significant comorbidity. Thorough preoperative assessment, identification of the risk factors for perioperative morbidity and mortality, and optimal preparation are critical in these patients. Age-related changes in comorbidities and altered pharmacokinetics and pharmacodynamics impacts anesthetic management, perioperative monitoring, postoperative care, and outcome. This article updates the age-related changes in organ subsystems relevant to cardiac anesthesia, perioperative issues, and intraoperative management. Early and late operative outcome in octogenarians undergoing cardiac surgery are reviewed. The data clearly indicate that no patient group is "too old" for cardiac surgery and that excellent outcomes can be achieved in selected group of elderly patients.