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Prophylactic Use of Antifibrinolytics During Pediatric Cardiac Surgery With Cardiopulmonary Bypass on Postoperative Bleeding and Transfusion: A Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2022; 23:e517-e529. [PMID: 35997516 DOI: 10.1097/pcc.0000000000003049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To determine the effect of intraoperative antifibrinolytics, including tranexamic acid (TXA), aminocaproic acid (EACA), or aprotinin, on bleeding in children undergoing cardiac surgery with cardiopulmonary bypass (CPB). DATA SOURCES Relevant articles were systematically searched from Ovid MEDLINE, Ovid EMBASE, CINAHL, Cochrane Library, and Web of Science to November 15, 2021. STUDY SELECTION Abstracts were screened, and full texts were reviewed using predetermined inclusion and exclusion criteria using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. DATA EXTRACTION A standardized data extraction tool was used. DATA SYNTHESIS Sixty-eight studies including 28,735 patients were analyzed. TXA compared with placebo resulted in a mean decrease in chest tube output of 9.1 mL/kg (95% CI, 6.0-12.3 mL/kg), I2 equals to 65.2%, p value of less than 0.001, platelet requirement of 2.9 mL/kg (95% CI, 0.1-5.8 mL/kg), I2 =72.5%, p value less than 0.001 and plasma requirement of 4.0 mL/kg (95% CI, 0.6-7.2 mL/kg), I2 equals to 94.5%, p value less than0.001. Aprotinin compared with placebo resulted in a mean decrease in chest tube output of 4.3 mL/kg (2.4-6.2 mL/kg), I2 equals to 66.3%, p value of less than 0.001, platelet transfusion of 4.6 mL/kg (95% CI, 0.6-8.6 mL/kg), I2 equals to 93.6%, p value of less than 0.001, and plasma transfusion of 7.7 mL/kg (95% CI, 2.1-13.2 mL/kg), I2 equals to 95.3%, p value of less than 0.001. EACA compared with placebo resulted in a mean decrease in chest tube output of 9.2 mL/kg (2.3-21.0 mL/kg), I2 equals to 96.4%, p value of less than 0.001, RBC transfusion of 7.2 mL/kg (95% CI, 2.4-12.1 mL/kg), I2 equals to 94.5%, p value equals to 0.002, and platelet transfusion of 10.7 mL/kg (95% CI, 2.9-18.5 mL/kg), I2 equals to 0%, p value of less than 0.001. No statistical difference was observed in chest tube output when TXA was compared with aprotinin. Subgroup analysis of cyanotic patients showed a significant decrease in chest tube output, platelet requirement, and plasma requirement for patients receiving aprotinin. Overall, the quality of evidence was moderate. CONCLUSIONS Antifibrinolytics are effective at decreasing blood loss and blood product requirement in children undergoing cardiac surgery with CPB although the quality of evidence is only moderate.
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Atasever AG, Eerens M, Van den Eynde R, Faraoni D, Rex S. Efficacy and safety of aprotinin in paediatric cardiac surgery: A systematic review and meta-analysis. Eur J Anaesthesiol 2022; 39:352-367. [PMID: 34783684 DOI: 10.1097/eja.0000000000001632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The relicensing of aprotinin in Europe and Canada has stimulated discussions on its usefulness in paediatric cardiac surgery. OBJECTIVE To systematically evaluate the available evidence on the efficacy and safety of aprotinin in paediatric cardiac surgery. DESIGN Systematic review of all randomised and observational studies comparing aprotinin with tranexamic acid, epsilon aminocaproic acid, placebo or no drug in paediatric cardiac surgery. Meta-analyses were performed on efficacy and safety outcomes. DATA SOURCES PubMed, Cochrane Central Register of Controlled Trials, Web of Science and Embase were searched from January 2000 to March 2021. ELIGIBILITY CRITERIA Studies that enrolled children under 18 years undergoing cardiac surgery with cardiopulmonary bypass. RESULTS Thirty-two studies enrolling a total of 63 894 paediatric cardiac procedures were included. Aprotinin significantly reduced total blood loss [mean difference -4.70 ml kg-1, 95% confidence interval (CI), -7.88 to -1.53; P = 0.004], postoperative transfusion requirements and the incidence of surgical re-exploration for bleeding [odds ratio (OR) 0.74, 95% CI, 0.56 to 0.97; P = 0.03]. Aprotinin had no effects on 30-day mortality (OR 1.02, 95% CI, 0.93 to 1.11; P = 0.73) and on other safety outcomes, except for the incidence of renal replacement therapy (RRT), which was significantly increased in patients given aprotinin (OR 1.29, 95% CI, 1.08 to 1.54; P = 0.006). Findings from observational and randomised controlled trials did not largely differ. A sub-group analysis in neonates showed that aprotinin significantly reduced packed red blood cell transfusions and the incidence of postoperative surgical re-exploration for bleeding and/or tamponade. When compared with lysine analogues, aprotinin was more effective at reducing bleeding and transfusion without increasing the risk of side effects. CONCLUSION This meta-analysis suggests that aprotinin is effective and well tolerated in paediatric cardiac surgery. Given the large heterogeneity of the results and the risk of selection bias in observational studies, large randomised controlled trials are warranted.
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Affiliation(s)
- Ayse Gulsah Atasever
- From the Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat, Leuven, Belgium (AGA, ME, RVdE, SR). Arthur S. Keats Division of Paediatric Cardiovascular Anesthesia. Department of Anesthesiology, Peri-operative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA (DF). And Department of Cardiovascular Sciences, KU Leuven, Herestraat, Leuven, Belgium (SR)
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Siemens K, Sangaran DP, Hunt BJ, Murdoch IA, Tibby SM. Antifibrinolytic Drugs for the Prevention of Bleeding in Pediatric Cardiac Surgery on Cardiopulmonary Bypass: A Systematic Review and Meta-analysis. Anesth Analg 2021; 134:987-1001. [PMID: 34633994 DOI: 10.1213/ane.0000000000005760] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Bleeding is one of the commonest complications affecting children undergoing cardiac surgery on cardiopulmonary bypass. Antifibrinolytic drugs are part of a multifaceted approach aimed at reducing bleeding, though sufficiently sized pediatric studies are sparse, and dosing algorithms are heterogeneous. Our objective was to evaluate the efficacy and safety of antifibrinolytic agents as well as the effectiveness of different dosing regimens in pediatric cardiac surgery using cardiopulmonary bypass. METHODS We performed a systematic review and meta-analysis evaluating randomized controlled trials published between 1980 and 2019, identified by searching the databases MEDLINE, EMBASE, PubMed, and CENTRAL. All studies investigating patients <18 years of age without underlying hematological disorders were included. The primary outcome was postoperative bleeding; secondary end points included blood product transfusion, mortality, and safety (thromboses, anaphylaxis, renal or neurological dysfunction, and seizures). Different dosing regimens were compared. Studies were dual appraised, outcomes were reported descriptively and, if appropriate, quantitatively using the Review Manager 5 (REVMAN 5) software (The Cochrane Collaboration). RESULTS Thirty of 209 articles were included, evaluating the following drugs versus control: aprotinin n = 14, tranexamic acid (TXA) n = 12, and epsilon-aminocaproic acid (EACA) n = 4. The number of participants per intervention group ranged from 11 to 100 (median, 25; interquartile range [IQR], 20.5) with a wide age span (mean, 13 days to 5.8 years) and weight range (mean, 3.1-26.3 kg). Methodological quality was low to moderate.All agents reduced mean 24-hour blood loss compared to control: aprotinin by 6.0 mL/kg (95% confidence interval [CI], -9.1 to -3.0; P = .0001), TXA by 9.0 mL/kg (95% CI, -11.3 to -6.8; P < .00001), and EACA by 10.5 mL/kg (95% CI, -21.1 to 0.0; P = .05). Heterogeneity was low for TXA (I2 = 29%; P = .19), moderate for aprotinin (I2 = 41%; P = .11), and high for EACA (I2 = 95%; P = <.00001). All agents also reduced 24-hour blood product transfusion. There was no clear dose-response effect for TXA nor aprotinin. Studies were underpowered to detect significant differences in mortality, thromboses, anaphylaxis, and renal or neurological dysfunction. CONCLUSIONS The available data demonstrate efficacy for all 3 antifibrinolytic drugs. Therefore, the agent with the most favorable safety profile should be used. As sufficient data are lacking, large comparative trials are warranted to assess the relative safety and appropriate dosing regimens in pediatrics.
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Affiliation(s)
- Kristina Siemens
- From the Pediatric Intensive Care, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - Dilanee P Sangaran
- From the Pediatric Intensive Care, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - Beverley J Hunt
- Department of Hematology, St Thomas' Hospital, London, United Kingdom
| | - Ian A Murdoch
- From the Pediatric Intensive Care, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - Shane M Tibby
- From the Pediatric Intensive Care, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
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Lin CY, Shuhaiber JH, Loyola H, Liu H, del Nido P, DiNardo JA, Pigula FA. The safety and efficacy of antifibrinolytic therapy in neonatal cardiac surgery. PLoS One 2015; 10:e0126514. [PMID: 25954976 PMCID: PMC4425500 DOI: 10.1371/journal.pone.0126514] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 04/02/2015] [Indexed: 11/27/2022] Open
Abstract
Background Neonates undergoing open-heart surgery are particularly at risk of postoperative bleeding requiring blood transfusion. Aprotinin has attained high efficacy in reducing the requirement for a blood transfusion following a cardiopulmonary bypass, but is seldom studied in the neonatal age group. The aim of this study was to compare the efficacy and adverse effects of aprotinin and tranexamic acid in neonates undergoing open-heart surgery at a single centre. Methods Between October 2003 and March 2008, perioperative data of 552 consecutive neonatal patients undergoing open-heart surgery in Children’s Hospital Boston were reviewed. Among them, 177 did not receive antifibrinolytic therapy (Group A); 100 were treated with tranexamic acid only (Group B); and 275 patients received aprotinin with or without tranexamic acid (Group C). Except for antifibrinolytic therapy, the anaesthesiological and surgical protocols remained identical. Postoperative complications and in-hospital mortality were the primary study endpoints. Results Body weight and Risk Adjustment for Congenital Heart Surgery (RACHS-1) scores were statistically comparable among the three groups. No statistically significant differences were observed between the duration of hospitalization, chest tube drainage, reexploration for bleeding, and kidney function impairment. In Group C, less blood was transfused within 24 hours than in GroupB. Operative mortality was similar among the three groups. Conclusion No further risk and kidney injury were observed in the use of aprotinin in neonatal cardiac surgery, aprotinin demonstrated a reduced requirement for blood transfusion compared with tranexamic acid. Our data provide reasonable evidence that aprotinin and tranexamic acid are safe and efficacious as antifibrinolytic modalities in neonatal patients undergoing cardiac surgery.
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Affiliation(s)
- Chih-Yuan Lin
- Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jeffery H. Shuhaiber
- Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Hugo Loyola
- Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Hua Liu
- Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Pedro del Nido
- Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
| | - James A. DiNardo
- Department of Anaesthesia, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Frank A. Pigula
- Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Limitations of early serum creatinine variations for the assessment of kidney injury in neonates and infants with cardiac surgery. PLoS One 2013; 8:e79308. [PMID: 24244476 PMCID: PMC3823616 DOI: 10.1371/journal.pone.0079308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 09/23/2013] [Indexed: 01/11/2023] Open
Abstract
Background Changes in kidney function, as assessed by early and even small variations in serum creatinine (ΔsCr), affect survival in adults following cardiac surgery but such associations have not been reported in infants. This raises the question of the adequate assessment of kidney function by early ΔsCr in infants undergoing cardiac surgery. Methodology The ability of ΔsCr within 2 days of surgery to assess the severity of kidney injury, accounted for by the risk of 30-day mortality, was explored retrospectively in 1019 consecutive neonates and infants. Patients aged ≤ 10 days were analyzed separately because of the physiological improvement in glomerular filtration early after birth. The Kml algorithm, an implementation of k-means for longitudinal data, was used to describe creatinine kinetics, and the receiver operating characteristic and the reclassification methodology to assess discrimination and the predictive ability of the risk of death. Results Three clusters of ΔsCr were identified: in 50% of all patients creatinine decreased, in 41.4% it increased slightly, and in 8.6% it rose abruptly. Mortality rates were not significantly different between the first and second clusters, 1.6% [0.0–4.1] vs 5.9% [1.9–10.9], respectively, in patients aged ≤ 10 days, and 1.6% [0.5–3.0] vs 3.8% [1.9–6.0] in older ones. Mortality rates were significantly higher when creatinine rose abruptly, 30.3% [15.1–46.2] in patients aged ≤ 10 days, and 15.1% [5.9–25.5] in older ones. However, only 41.3% of all patients who died had an abrupt increase in creatinine. ΔsCr improved prediction in survivors, but not in patients who died, and did not improve discrimination over a clinical mortality model. Conclusions The present results suggest that a postoperative decrease in creatinine represents the normal course in neonates and infants with cardiac surgery, and that early creatinine variations lack sensitivity for the assessment of the severity of kidney injury.
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Martin K, Gertler R, MacGuill M, Mayr N, Hapfelmeier A, Hörer J, Vogt M, Tassani P, Wiesner G. Replacement of aprotinin by ɛ-aminocaproic acid in infants undergoing cardiac surgery: consequences for blood loss and outcome. Br J Anaesth 2013; 110:615-21. [DOI: 10.1093/bja/aes430] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Fan Y, Lin R, Yang L, Ye L, Yu J, Shu Q. Retrospective cohort analysis of a single dose of aprotinin use in children undergoing cardiac surgery: a single-center experience. Paediatr Anaesth 2013. [PMID: 23189963 DOI: 10.1111/pan.12079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The great difference in side effects of aprotinin was noted in adult and pediatric fields in recent reports because aprotinin was suspended for safety reasons. The aim of this study is to describe associations between aprotinin using and red blood cells transfusion, renal injury, and mortality in pediatric with cardiac surgery. METHODS We retrospectively reviewed a cohort of 507 consecutive children who received a single dose of aprotinin (March-November 2007 before the FDA's decision for withdrawal of aprotinin) and a cohort of 494 consecutive children who did not receive aprotinin or other antifibrinolytic drugs (December 2007-August 2008). RESULTS The two groups' demographics were assessed by the Aristotle basic complexity (ABC) propensity score. Postoperative blood loss was significantly reduced in the aprotinin group [P < 0.001, 95% confidence intervals (CI): 0.00-0.00], but postoperative red blood cell transfusion was not different between two groups (P = 0.4, 95% CI: 0.393-0.412). No statistical significant differences were noted in postoperative dialysis [0.39% vs. 0.40%, P = 0.98, OR: 0.974, 95% CI: 0.137-6.944] and intra-hospital mortality (2.37% vs. 1.82%, P: 0.547, OR:1.306, 95% CI: 0.546-3.129)) and reoperations for bleeding, thrombotic, and respiratory morbidity between two groups; however, the aprotinin group had temporarily a higher rate of 1.5-fold increased creatinine (class R) in the first postoperative 72 h (22.95% vs. 13.93%, P < 0.001, OR: 1.840, 95% CI: 1.323-2.560), a longer duration of mechanical intubation [6.50 (4.50-24.00) h vs. 6.00 (4.50-22.00) h, P = 0.004, 95% CI: 0.002-0.005] and a 0.55% increased clinical mortality (although not statistically significant). More complex surgery had a higher rate of the increased creatinine (class R) in the first postoperative 72 h (ABC level 3 + 4 vs. level 1 + 2, P = 0.017, OR: 0.599, 95% CI: 0.392-0.915). The multivariate analysis showed that age (<1 year), CPB >100 min, and the larger amount of transfusion (≥14 ml·kg(-1) ) were also important risk factors for the postoperative renal dysfunction (class R). CONCLUSIONS Except reducing postoperative bleeding, we did not find other benefits of aprotinin. However, much higher postoperative creatinine levels, longer duration of mechanical ventilation, not less postoperative RBCs transfusion, and a 0.55% increased clinical mortality (although not statistically significant) were found in the aprotinin populations.
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Affiliation(s)
- Yong Fan
- Department of Thoracic and Cardiovascular Surgery, Children's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Bojan M, Vicca S, Boulat C, Gioanni S, Pouard P. Aprotinin, transfusions, and kidney injury in neonates and infants undergoing cardiac surgery. Br J Anaesth 2012; 108:830-7. [PMID: 22362670 DOI: 10.1093/bja/aes002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND A significantly increased risk of acute kidney injury (AKI) with the prophylactic use of aprotinin has been reported in adults undergoing cardiac surgery, but not in children. Blood product transfusions have also been shown to carry an independent risk of AKI. The present study assessed associations between AKI, aprotinin, and transfusions in neonates and infants undergoing cardiac surgery. METHODS All neonates and infants undergoing surgery with cardiopulmonary bypass over a 42 month period, before and after the withdrawal of aprotinin, were included retrospectively. AKI was assessed by the Acute-Kidney-Injury-Network classifications. A propensity score was used to balance treated and untreated groups. RESULTS Three hundred and ninety patients received aprotinin and 568 patients did not. Inverse probability of treatment weighting resulted in good balance between groups for baseline and surgical characteristics. Controls underwent surgery with smaller bypass circuits and fewer transfusions. After adjustment for the use of miniaturized circuits and for the year of surgery, no significant association between the incidence of AKI, dialysis, and aprotinin was noted. Red blood cell transfusions were associated with an increased risk of AKI and dialysis: odds ratios (ORs) 1.64 (1.12-2.41) and 2.07 (1.13-3.73), respectively; as were fresh frozen plasma transfusions, ORs 2.28 (1.68-3.09) and 3.11 (1.95-4.97), respectively. Platelet transfusions were associated with an increased risk of dialysis: OR 2.20 (1.21-4.01). CONCLUSIONS Blood product transfusions, but not the prophylactic use of aprotinin, are significantly associated with AKI after cardiac surgery in neonates and infants.
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Affiliation(s)
- M Bojan
- Department of Anaesthesiolgy and Intensive Care, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France.
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Tóth R, Breuer T, Cserép Z, Lex D, Fazekas L, Sápi E, Szatmári A, Gál J, Székely A. Acute kidney injury is associated with higher morbidity and resource utilization in pediatric patients undergoing heart surgery. Ann Thorac Surg 2012; 93:1984-90. [PMID: 22226235 DOI: 10.1016/j.athoracsur.2011.10.046] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 10/13/2011] [Accepted: 10/14/2011] [Indexed: 01/11/2023]
Abstract
BACKGROUND The RIFLE (risk, injury, failure, loss, and end-stage renal disease) classification system was developed to standardize the definition of acute kidney injury (AKI) in adults. We hypothesized that AKI was associated with increased mortality and morbidity. METHODS Acute kidney injury was defined as a decrease in the amount of estimated creatinine clearance based on pediatric-modified RIFLE (pRIFLE) criteria. Using propensity score analysis, 325 patients who had AKI were matched to 325 patients who did not have AKI from a database of 1,510 consecutive pediatric patients who underwent cardiac surgery between January 2004 and December 2008 at a single center. The association between AKI and outcome was analyzed after propensity score matching of perioperative variables. RESULTS Four hundred eighty-one patients (31.9%) had AKI according to the RIFLE categories. Of those 1,510, 173 (11.5%) reached pRIFLE criteria for risk; 26 (1.7%) reached the criteria for injury; and 282 (18.7%) reached the criteria for failure. Fifty-five patients (3.6%) died. The 2 matched groups were well balanced in terms of measured perioperative variables. Mortality rate was 5.2% in the AKI and 2.5% in the matched control group (p=0.09). Occurrence of low cardiac output syndrome (p=0.002), need for dialysis (p<0.001), and infection (p=0.03) were significantly higher, and duration of mechanical ventilation (p<0.001) and length of intensive care unit stay (p<0.001) were significantly longer compared with the matched control group. CONCLUSIONS Acute kidney injury was independently associated with an increased occurrence of postoperative complications but not with mortality after pediatric cardiac surgery.
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Affiliation(s)
- Roland Tóth
- School of PhD Studies, Department of Cardiovascular Surgery, Semmelweis University, Budapest, Hungary
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Martin K, Gertler R, Liermann H, Mayr N, MacGuill M, Schreiber C, Vogt M, Tassani P, Wiesner G. Switch from aprotinin to ɛ-aminocaproic acid: impact on blood loss, transfusion, and clinical outcome in neonates undergoing cardiac surgery. Br J Anaesth 2011; 107:934-9. [DOI: 10.1093/bja/aer267] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Efficacy and Safety of Aprotinin in Neonatal Congenital Heart Operations. Ann Thorac Surg 2011; 92:958-63. [DOI: 10.1016/j.athoracsur.2011.04.094] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 04/21/2011] [Accepted: 04/26/2011] [Indexed: 11/18/2022]
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Chiravuri SD, Riegger LQ, Christensen R, Butler RR, Malviya S, Tait AR, Voepel-Lewis T. Factors associated with acute kidney injury or failure in children undergoing cardiopulmonary bypass: a case-controlled study. Paediatr Anaesth 2011; 21:880-6. [PMID: 21306475 DOI: 10.1111/j.1460-9592.2011.03532.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
UNLABELLED Acute kidney injury (AKI) is a serious complication that occurs commonly following cardiopulmonary bypass (CPB) in infants and children. Underlying risk factors for AKI remain unclear, given changes in CPB practices during recent years. This retrospective, case-control study examined the relationships between patient, perioperative factors, AKI, and kidney failure in children who underwent CPB. METHODS Cohorts of children with and without AKI were identified from the cardiac perfusion and nephrology consult databases. Demographic, perioperative, and postoperative outcome data were extracted from the databases and from medical records. Children were stratified into groups based on the Acute Dialysis Quality Initiative's RIFLE definitions for acute kidney risk or injury (AKI-RI) and kidney failure. RESULTS The study groups included 308 controls (no AKI-RI or failure), 161 with AKI-RI, and 89 with failure. Young age, preoperative need for mechanical ventilation, milrinone, or gentamicin; intraoperative use of milrinone and furosemide; durations of CPB and anesthesia; multiple cross-clamp and transfusion of blood products were significantly associated with AKI or failure. Young age, perioperative use of milrinone, multiple cross-clamps, extracorporeal membrane oxygenation, cardiac failure, neurological complications, sepsis, and failure significantly increased the odds of mortality. CONCLUSION This study identified multiple perioperative risk factors for AKI-RI, failure, and mortality in children undergoing CPB. In addition to commonly known risk factors, perioperative use of milrinone, particularly in young infants, and furosemide were independently predictive of poor renal outcomes in this sample. Findings suggest a need for the development of protocols aimed at renal protection in specific at risk patients.
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Affiliation(s)
- S Devi Chiravuri
- Department of Anesthesiology, Section of Pediatric Anesthesia, C.S. Mott Children's Hospital, The University of Michigan Health Systems, Ann Arbor, MI 48109-5211, USA.
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Tae YM, Kwak JG, Kim BH, Jang IJ, Kim WH. Population Pharmacokinetic Analysis and Dosing Regimen Optimization of Aprotinin in Neonates and Young Infants Undergoing Cardiopulmonary Bypass. J Clin Pharmacol 2011; 51:1163-1176. [DOI: 10.1177/0091270010379411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Martin K, Breuer T, Gertler R, Hapfelmeier A, Schreiber C, Lange R, Hess J, Wiesner G. Tranexamic acid versus ɛ-aminocaproic acid: efficacy and safety in paediatric cardiac surgery. Eur J Cardiothorac Surg 2011; 39:892-7. [DOI: 10.1016/j.ejcts.2010.09.041] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 09/21/2010] [Accepted: 09/29/2010] [Indexed: 10/18/2022] Open
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Leyvi G, Nelson O, Yedlin A, Pasamba M, Belamarich PF, Nair S, Cohen HW. A Comparison of the Effect of Aprotinin and ε-Aminocaproic Acid on Renal Function in Children Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2011; 25:402-6. [DOI: 10.1053/j.jvca.2011.01.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Indexed: 01/11/2023]
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Hsia TY, McQuinn TC, Mukherjee R, Deardorff RL, Squires JE, Stroud RE, Crawford FA, Bradley SM, Reeves ST, Spinale FG. Effects of aprotinin or tranexamic acid on proteolytic/cytokine profiles in infants after cardiac surgery. Ann Thorac Surg 2010; 89:1843-52; discussion 1852. [PMID: 20494037 DOI: 10.1016/j.athoracsur.2010.02.069] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 02/16/2010] [Accepted: 02/18/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND After cardiopulmonary bypass (CPB), elaboration of cytokines, and subsequent induction of interstitial proteases, such as matrix metalloproteinases (MMPs), can result in a complex postoperative course. The serine protease inhibitor, aprotinin, which has been used in congenital heart surgery putatively for modulating fibrinolysis is now unavailable, necessitating the use of lysine analogues such as tranexamic acid (TXA). The present study tested the hypothesis that distinctly different plasma profiles of signaling molecules and proteases would be differentially affected after the administration of aprotinin or TXA in the context of congenital cardiac surgery and CPB. METHODS Thirty-seven patients (age, 4.8 +/- 0.3 months) undergoing corrective surgery for ventricular septal defect and tetralogy of Fallot received either aprotinin (n = 22) or TXA (n = 15). Using a high throughput multiplex suspension immunoassay, plasma was serially quantified for cytokines and MMPs: before aprotinin or TXA (baseline), after separation from CPB, and 4, 12, 24, and 48 hours post-CPB. RESULTS Tumor necrosis factor-alpha increased initially after CPB in both the aprotinin and TXA groups, but at 24 and 48 hours post-CPB was approximately 50% lower in the aprotinin group (p < 0.05). The IL-10 levels were threefold higher in the TXA group compared with the aprotinin group immediately post-CBP (p < 0.05). Plasma levels of MMP types associated with inflammation, MMP-8, and MMP-9, were twofold higher in the late post-CPB period in the TXA group when compared with the aprotinin group. CONCLUSIONS After ventricular septal defect or tetralogy of Fallot repair in children, cytokine induction occurs, which is temporally related to the emergence of a specific MMP profile. Moreover, these unique findings demonstrated differential effects between the serine protease inhibitor aprotinin and the lysine analogue TXA with respect to cytokine and MMP induction in the early postoperative period. The different cytokine-proteolytic profile between these antifibrinolytics may in turn influence biologic processes in the postoperative period.
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Affiliation(s)
- Tain-Yen Hsia
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina 29425, USA
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Deetjen P, Sinzobahamvya N, Arentz C, Reckers J, Asfour B, Schindler E. Tranexamsäure als antifibrinolytische Alternative zu Aprotinin bei kinderherzchirurgischen Eingriffen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2009. [DOI: 10.1007/s00398-009-0745-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
PURPOSE OF REVIEW Toxicity concerns and awareness during anesthesia issues continue to concern pediatric anesthesiologists. Most developmental pharmacokinetic, pharmacodynamic and pharmacogenomic changes occur within the first year of life. Understanding these early changes can improve drug use in this cohort. RECENT FINDINGS Growth and development are two major aspects of children not readily apparent in adults. Clearance in the pediatric population should be investigated using models that describe size, maturation and organ function influences. Glucuronide conjugation (hepatic phase II process) mirrors glomerular filtration maturation over the first year of life. Phase 1 processes appear more rapid, and differences attributable to single nuclear polymorphisms may be obvious by the end of the 4-week neonatal period in term infants.Pharmacodynamic differences in infancy remain poorly defined, and neonatal pharmacokinetic-pharmacodynamic analyses that might elucidate such differences are few, partly because of a paucity of effective pharmacodynamic measures. SUMMARY Mechanistic models create a framework for the study of pharmacokinetic changes in infancy. Understanding these changes allows a target concentration approach to therapy and potential for reduced toxicity. The target concentration may be undefined because of a paucity of effect measures.
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Manrique A, Jooste EH, Kuch BA, Lichtenstein SE, Morell V, Munoz R, Ellis D, Davis PJ. The Association of Renal Dysfunction and the Use of Aprotinin in Patients Undergoing Congenital Cardiac Surgery Requiring Cardiopulmonary Bypass. Anesth Analg 2009; 109:45-52. [DOI: 10.1213/ane.0b013e3181a7f00a] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Williams GD, Ramamoorthy C, Pentcheva K, Boltz MG, Kamra K, Reddy VM. A randomized, controlled trial of aprotinin in neonates undergoing open-heart surgery. Paediatr Anaesth 2008; 18:812-9. [PMID: 18768040 DOI: 10.1111/j.1460-9592.2008.02678.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Neonates undergoing open-heart surgery are especially at risk for massive bleeding and pronounced inflammation. The efficacy of aprotinin, a serine protease inhibitor, at ameliorating these adverse effects of cardiopulmonary bypass has not been clearly demonstrated in neonates. METHODS Term neonates were enrolled and randomly assigned in a blinded fashion to receive saline (group P, placebo) or high-dose aprotinin (group A). Intraoperative management was standardized: surgeon, anesthesia, cardiopulmonary bypass and hemostasis therapy. Patients were admitted postoperatively to a pediatric cardiac intensive care unit. Primary outcome measure of efficacy was duration of the postoperative mechanical ventilation. Secondary outcome measures were total volume and units of blood products transfused intraoperatively and for 24 h after surgery, duration of chest tube in situ, and intensive care and hospital stays after surgery. RESULTS Twenty-six neonates were enrolled; 13 received aprotinin and 13 received placebo. The study was halted prematurely because of US Food and Drug Administration's concerns about aprotinin's safety. Baseline patient, surgery and cardiopulmonary bypass characteristics were similar between groups. No outcome variables differed between groups (P > 0.05). Duration of postoperative ventilation was 115 +/- 139 h (group A); 126 +/- 82 h (group P); P = 0.29, and total blood product exposure was 8.2 +/- 2.6 U (group A); 8.8 +/- 1.4 U (group P); P = 0.1. Postoperative blood creatinine values did not differ between groups. In-hospital mortality rate was 4%. CONCLUSIONS Aprotinin was not shown to be efficacious in neonates undergoing open-heart surgery. It is unclear whether adult aprotinin safety data are relevant to neonates undergoing open-heart surgery.
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Affiliation(s)
- Glyn D Williams
- Department of Anesthesia, Lucile Packard Children's Hospital, Stanford University, CA 94305, USA.
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Murugesan C, Banakal SK, Garg R, Keshavamurthy S, Muralidhar K. The Efficacy of Aprotinin in Arterial Switch Operations in Infants. Anesth Analg 2008; 107:783-7. [DOI: 10.1213/ane.0b013e31817f8b2c] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- Derek J Hausenloy
- The Hatter Cardiovascular Institute, University College London Hospital and Medical School, London WC1E 6HX, UK.
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