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Levy JH, Faraoni D, Almond CS, Baumann-Kreuziger L, Bembea MM, Connors JM, Dalton HJ, Davies R, Dumont LJ, Griselli M, Karkouti K, Massicotte MP, Teruya J, Thiagarajan RR, Spinella PC, Steiner ME. Consensus Statement: Hemostasis Trial Outcomes in Cardiac Surgery and Mechanical Support. Ann Thorac Surg 2022; 113:1026-1035. [PMID: 34826386 DOI: 10.1016/j.athoracsur.2021.09.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/08/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Research evaluating hemostatic agents for the treatment of clinically significant bleeding has been hampered by inconsistency and lack of standardized primary clinical trial outcomes. Clinical trials of hemostatic agents in both cardiac surgery and mechanical circulatory support, such as extracorporeal membrane oxygenation and ventricular assist devices, are examples of studies that lack implementation of universally accepted outcomes. METHODS A subgroup of experts convened by the National Heart, Lung, and Blood Institute and the US Department of Defense developed consensus recommendations for primary outcomes in cardiac surgery and mechanical circulatory support. RESULTS For cardiac surgery the primary efficacy endpoint of total allogeneic blood products (units vs mL/kg for pediatric patients) administered intraoperatively and postoperatively through day 5 or hospital discharge is recommended. For mechanical circulatory support outside the perioperative period the recommended primary outcome for extracorporeal membrane oxygenation is a 5-point ordinal score of thrombosis and bleeding severity adapted from the Common Terminology Criteria for Adverse Events version 5.0. The recommended primary endpoint for ventricular assist device is freedom from disabling stroke (Common Terminology Criteria for Adverse Events AE ≥ grade 3) through day 180. CONCLUSIONS The proposed composite risk scores could impact the design of upcoming clinical trials and enable comparability of future investigations. Harmonizing and disseminating global consensus definitions and management guidelines can also reduce patient heterogeneity that would confound standardized primary outcomes in future research.
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Affiliation(s)
- Jerrold H Levy
- Division Cardiothoracic Anesthesiology and Critical Care, Departments of Anesthesiology and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina.
| | - David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christopher S Almond
- Heart Failure Service, Cardiac Anticoagulation Service, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California
| | | | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Heidi J Dalton
- INOVA Heart and Vascular Institute; Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, Virginia
| | - Ryan Davies
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas
| | - Larry J Dumont
- Vitalant Research Institute, Denver, Colorado; Department of Pathology, University of Colorado Medical School, Denver, Colorado; Department of Pathology and Laboratory Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Massimo Griselli
- Division of Pediatric Cardiovascular Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Keyvan Karkouti
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - M Patricia Massicotte
- Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jun Teruya
- Division of Transfusion Medicine and Coagulation, Department of Pathology and Immunology, Pediatrics and Medicine, Texan Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ravi R Thiagarajan
- Cardiac Intensive Care Unit, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Marie E Steiner
- Divisions of Hematology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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2
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Song P, Holmes M, Mackensen GB. Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00031-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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3
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Spinella PC, Kassar NE, Cap AP, Kindzelski AL, Almond CS, Barkun A, Gernsheimer TB, Goldstein JN, Holcomb JB, Iorio A, Jensen DM, Key NS, Levy JH, Mayer SA, Moore EE, Stanworth SJ, Lewis RJ, Steiner ME. Recommended primary outcomes for clinical trials evaluating hemostatic blood products and agents in patients with bleeding: Proceedings of a National Heart Lung and Blood Institute and US Department of Defense Consensus Conference. J Trauma Acute Care Surg 2021; 91:S19-S25. [PMID: 34039915 PMCID: PMC9032809 DOI: 10.1097/ta.0000000000003300] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
ABSTRACT High-quality evidence guiding optimal transfusion and other supportive therapies to reduce bleeding is needed to improve outcomes for patients with either severe bleeding or hemostatic disorders that are associated with poor outcomes. Alongside challenges in performing high-quality clinical trials in patient populations who are at risk of bleeding or who are actively bleeding, the interpretation of research evaluating hemostatic agents has been limited by inconsistency in the choice of primary trial outcomes. This lack of standardization of primary endpoints or outcomes decreases the ability of clinicians to assess the validity of endpoints and compare research results across studies, impairs meta-analytic efforts, and, ultimately, delays the translation of research results into clinical practice. To address this challenge, an international panel of experts was convened by the National Heart Lung and Blood Institute and the US Department of Defense on September 23 and 24, 2019, to develop expert opinion, consensus-based recommendations for primary clinical trial outcomes for pivotal trials in pediatric and adult patients with six categories in various clinical settings. This publication documents the conference proceedings from the workshop funded by the National Heart Lung and Blood Institute and the US Department of Defense that consolidated expert opinion regarding clinically meaningful outcomes across a wide range of disciplines to provide guidance for outcomes of future trials of hemostatic products and agents for patients with active bleeding.
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Affiliation(s)
- Philip C. Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Andrew P. Cap
- US Army Institute of Surgical Research, Ft Sam Houston, TX
| | | | | | - Alan Barkun
- Division of Gastroenterology, McGill University and the McGill University Health Centre Montréal, Québec, Canada
| | | | - Joshua N. Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John B. Holcomb
- Department of Surgery, Center for Injury Science, Division of Acute Care Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Alfonso Iorio
- Division of Hematology and Thromboembolism, Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton Ontario L8S 4K Canada
| | - Dennis M. Jensen
- Division of Gastroenterology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095
| | - Nigel S. Key
- Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599
| | - Jerrold H. Levy
- Department of Anesthesiology and Critical Care, Duke University Medical Center, Durham, NC 27710 USA
| | - Stephan A. Mayer
- Departments of Neurology and Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla NY 10595
| | - Ernest E. Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Department of Surgery, University of Colorado Denver, Denver, Colorado 80204 USA
| | - Simon J. Stanworth
- Oxford University, Oxford, United Kingdom, The John Radcliffe Hospital, Oxford, GBR NHSBT, Oxford, United Kingdom
| | - Roger J. Lewis
- Berry Consultants LLC, Austin TX 78746
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles California 90095 USA
| | - Marie E. Steiner
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Division of Pediatric Critical Care Medicine, University of Minnesota Medical School, Minneapolis, MN 55455 USA
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4
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Aprotinin in adults at high risk of major blood loss during isolated CABG with cardiopulmonary bypass: a profile of its use in the EU. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-019-00690-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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5
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Coleman SR, Chen M, Patel S, Yan H, Kaye AD, Zebrower M, Gayle JA, Liu H, Urman RD. Enhanced Recovery Pathways for Cardiac Surgery. Curr Pain Headache Rep 2019; 23:28. [DOI: 10.1007/s11916-019-0764-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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6
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Jovin DG, Katlaps KG, Ellis BK, Dharmaraj B. Neuroprotection against stroke and encephalopathy after cardiac surgery. Interv Med Appl Sci 2019; 11:27-37. [PMID: 32148901 PMCID: PMC7044570 DOI: 10.1556/1646.11.2019.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Cerebral ischemia in the perioperative period is a major risk factor for stroke, encephalopathy, and cognitive decline after cardiothoracic surgery. After coronary artery bypass grafting, both stroke and encephalopathy can result in poor patient outcomes and increased mortality. Neuroprotection aims to lessen the severity and occurrence of further injury mediated by stroke and encephalopathy and to aid the recovery of conditions already present. Several pharmacological and non-pharmacological methods of neuroprotection have been investigated in experimental studies and in animal models, and, although some have shown effectiveness in protection of the central nervous system, for most, clinical research is lacking or did not show the expected results. This review summarizes the value and need for neuroprotection in the context of cardiothoracic surgery and examines the use and effectiveness of several agents and methods with an emphasis on clinical trials and clinically relevant neuroprotectants.
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Affiliation(s)
- Daniel G Jovin
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Karl G Katlaps
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Ben K Ellis
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Benita Dharmaraj
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
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Nokkari A, Abou-El-Hassan H, Mechref Y, Mondello S, Kindy MS, Jaffa AA, Kobeissy F. Implication of the Kallikrein-Kinin system in neurological disorders: Quest for potential biomarkers and mechanisms. Prog Neurobiol 2018; 165-167:26-50. [PMID: 29355711 PMCID: PMC6026079 DOI: 10.1016/j.pneurobio.2018.01.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 01/15/2018] [Indexed: 01/06/2023]
Abstract
Neurological disorders represent major health concerns in terms of comorbidity and mortality worldwide. Despite a tremendous increase in our understanding of the pathophysiological processes involved in disease progression and prevention, the accumulated knowledge so far resulted in relatively moderate translational benefits in terms of therapeutic interventions and enhanced clinical outcomes. Aiming at specific neural molecular pathways, different strategies have been geared to target the development and progression of such disorders. The kallikrein-kinin system (KKS) is among the most delineated candidate systems due to its ubiquitous roles mediating several of the pathophysiological features of these neurological disorders as well as being implicated in regulating various brain functions. Several experimental KKS models revealed that the inhibition or stimulation of the two receptors of the KKS system (B1R and B2R) can exhibit neuroprotective and/or adverse pathological outcomes. This updated review provides background details of the KKS components and their functions in different neurological disorders including temporal lobe epilepsy, traumatic brain injury, stroke, spinal cord injury, Alzheimer's disease, multiple sclerosis and glioma. Finally, this work will highlight the putative roles of the KKS components as potential neurotherapeutic targets and provide future perspectives on the possibility of translating these findings into potential clinical biomarkers in neurological disease.
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Affiliation(s)
- Amaly Nokkari
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Lebanon
| | - Hadi Abou-El-Hassan
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Yehia Mechref
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, TX, USA
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Mark S Kindy
- Department of Pharmaceutical Science, College of Pharmacy, University of South Florida, Tampa, FL, USA; James A. Haley VA Medical Center, Tampa, FL, USA
| | - Ayad A Jaffa
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Lebanon; Department of Medicine, Medical University of South, Charleston, SC, USA.
| | - Firas Kobeissy
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Lebanon; Center for Neuroproteomics & Biomarkers Research, Department of Psychiatry, McKnight Brain Institute, University of Florida, Gainesville, FL, USA.
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Levy JH, Koster A, Quinones QJ, Milling TJ, Key NS. Antifibrinolytic Therapy and Perioperative Considerations. Anesthesiology 2018; 128:657-670. [PMID: 29200009 PMCID: PMC5811331 DOI: 10.1097/aln.0000000000001997] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Fibrinolysis is a physiologic component of hemostasis that functions to limit clot formation. However, after trauma or surgery, excessive fibrinolysis may contribute to coagulopathy, bleeding, and inflammatory responses. Antifibrinolytic agents are increasingly used to reduce bleeding, allogeneic blood administration, and adverse clinical outcomes. Tranexamic acid is the agent most extensively studied and used in most countries. This review will explore the role of fibrinolysis as a pathologic mechanism, review the different pharmacologic agents used to inhibit fibrinolysis, and focus on the role of tranexamic acid as a therapeutic agent to reduce bleeding in patients after surgery and trauma.
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Affiliation(s)
- Jerrold H. Levy
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Andreas Koster
- Institute of Anesthesiology, Heart and Diabetes Center NRW, Bad Oeynhausen, Ruhr-University Bochum, Germany
| | - Quintin J. Quinones
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | | | - Nigel S. Key
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina, Chapel Hill, NC
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9
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Comparison of three methods of blood conservation in expected bleeders in OPCAB (off pump coronary artery bypass surgery). Indian J Thorac Cardiovasc Surg 2018. [DOI: 10.1007/s12055-002-0017-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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10
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Hospital-Acquired Anemia: A Contemporary Review of Etiologies and Prevention Strategies. JOURNAL OF INFUSION NURSING 2017; 38:330-8. [PMID: 26339939 DOI: 10.1097/nan.0000000000000121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Advances in medicine have significantly improved lives and life spans globally. However, these practices have come with their own set of secondary consequences. Hospital-acquired anemia is one such consequence and is conferred by new medicines, operations, procedures, and tests. In this review, the authors will explore the data on this poorly considered phenomenon and discuss the etiologies, outcomes, and prevention strategies for some of the more prolific causes of hospital-acquired anemia. This study also will review the risks and benefits of treating hospital-acquired anemia.
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11
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Fergusson D, Glass KC, Hutton B, Shapiro S. Randomized controlled trials of aprotinin in cardiac surgery: could clinical equipoise have stopped the bleeding? Clin Trials 2016; 2:218-29; discussion 229-32. [PMID: 16279145 DOI: 10.1191/1740774505cn085oa] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background Aprotinin is a serine protease inhibitor used to limit perioperative bleeding and reduce the need for donated blood transfusions during cardiac surgery. Randomized controlled trials of aprotinin evaluating its effect on the outcome of perioperative transfusion have been published since 1987, and systematic reviews were conducted in 1992 and 1997. Methods A systematic search was conducted for all RCTs of aprotinin that used placebo controls or were open-label with no active control treatment. Data collected included the primary outcome, objective of each study, whether a systematic review was cited or conducted as part of the background and/or rationale for the study and the number of previously published RCTs cited. Cumulative meta-analyses were performed. Results Sixty-four randomized, controlled trials of aprotinin were found, conducted between 1987 and 2002, reporting an endpoint of perioperative transfusion. Median trial size was 64 subjects, with a range of 20 to 1784. A cumulative meta-analysis indicated that aprotinin greatly decreased the need for perioperative transfusion, stabilizing at an odds ratio of 0.25 (p, 10 2 6) by the 12th study, published in June of 1992. The upper limit of the confidence interval never exceeded 0.65 and results were similar in all subgroups. Citation of previous RCTs was extremely low, with a median of 20% of prior trials cited. Only 7 of 44 (15%) of subsequent reports referenced the largest trial (N 1/4 1784), which was 28 times larger than the median trial size. Conclusions This study demonstrates that investigators evaluating aprotinin were not adequately citing previous research, resulting in a large number of RCTs being conducted to address efficacy questions that prior trials had already definitively answered. Institutional review boards and journals could reduce the number of redundant trials by requiring investigators to conduct adequate searches for prior evidence and conducting systematic reviews.
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Affiliation(s)
- Dean Fergusson
- Ottawa Health Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada.
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12
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Bajaj J, Mittal RS, Sharma A. Preoperative clonidine use in trans-sphenoidal pituitary adenoma surgeries - a randomized controlled trial. Br J Neurosurg 2016; 31:2-4. [PMID: 27535352 DOI: 10.1080/02688697.2016.1220501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pituitary masses are common lesions accounting for about 15-20% of all brain tumours. Oozing blood is an annoyance in microscopic sublabial trans-sphenoidal approach for these masses. There have been many ways of reducing the ooze, having their own pros and cons. OBJECTIVE To find out the efficacy and safety of clonidine in reducing blood loss in pituitary adenoma surgery through a randomized masked trial. METHODS It was a prospective randomized controlled trial done. Total 50 patients of pituitary adenomas were randomized into two groups. Group A (25 patients) was given 200 μg clonidine orally, while Group B (25 patients) was given placebo. Surgeon, anaesthesiologist and patient were blinded for the trial. Sublabial trans-septal trans-sphenoidal approach to sella and excision of mass was performed in each patient. Patients were studied for pre-, intra- and post-operative blood pressure and heart rate, pre- and post-operative imaging findings, intra-operative blood loss, bleeding grading by surgeon, surgeon's satisfaction about condition of specific part and quality of surgical field, operative time and extent of resection. RESULTS Blood loss during the surgery, operative time and bleeding grading by the surgeon were found significantly less in the clonidine group, while quality of surgical field, condition of the specific part and extent of resection were found significantly better in the clonidine group (p value <.05). There was no untoward adverse effect of the drug in the test group. CONCLUSION Clonidine is a safe and effective drug to reduce bleeding in trans-sphenoidal microscopic pituitary adenoma surgeries.
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Affiliation(s)
- Jitin Bajaj
- a Department of Neurosurgery , SMS Medical College , Jaipur , India
| | | | - Achal Sharma
- a Department of Neurosurgery , SMS Medical College , Jaipur , India
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13
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Murkin JM. Adverse Central Nervous System Outcomes After Cardiopulmonary Bypass: A Beneficial Effect of Aprotinin? Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1053/seva.2001.28175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This review considers the evidence for potential central nervous system benefits associated with use of anti- protease therapy for patients undergoing procedures involving cardiopulmonary bypass. Unfortunately, few randomized, controlled clinical trials have assessed the lysine analogue class of antifibrinolytics (ie, ∈-amino caproic acid, tranexamic acid) compared with the num ber investigating the efficacy of the enzyme-inactivator class of antifibrinolytic typified by the nonspecific serine protease inhibitors aprotinin and nafamostat.
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14
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Pifarrè R. Use of Aprotinin in the Control of Bleeding During Cardiopulmonary Bypass Surgery: Current Status. Clin Appl Thromb Hemost 2016. [DOI: 10.1177/107602969800400103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Excessive bleeding is one of the major complica tions of cardiac surgery with cardiopulmonary bypass (CPB). This complication is related to the operation and the defects in hemostasis induced by extracorporeal circulation. The system atic effects of CPB are called whole body inflammatory reac tion. Heparin, platelet dysfunctions, and fibrinolysis are the major causes of bleeding problems associated with CPB. Dif ferent pharmacological approaches have been used to reduce bleeding and the need for blood transfusions in patients under going cardiac surgery. The most effective is aprotinin, a serum protease inhibitor that is an antifibrinolytic with a platelet- preserving action. It inhibits the activation of the intrinsic co agulation system. Aprotinin therapy effectively reduces blood loss and donor blood requirements. According to most reports, it does not increase the risk of acute myocardial infarction, renal dysfunction, and mortality.
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Affiliation(s)
- Roque Pifarrè
- Loyola University Medical Center, Maywood, Illinois, U.S.A
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15
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Borenstein N, Gouni V, Behr L, Trehiou-Sechi E, Petit A, Misbach C, Raillard M, Retortillo JL, Pouchelon JL, Pierrel A, Laborde F, Chetboul V. Surgical Treatment of Cor Triatriatum Sinister in a Cat Under Cardiopulmonary Bypass. Vet Surg 2015; 44:964-9. [DOI: 10.1111/vsu.12403] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Vassiliki Gouni
- Unité de Cardiologie d'Alfort, Ecole Nationale Vétérinaire d'Alfort; Université Paris-Est; Maisons-Alfort France
| | | | - Emilie Trehiou-Sechi
- Unité de Cardiologie d'Alfort, Ecole Nationale Vétérinaire d'Alfort; Université Paris-Est; Maisons-Alfort France
| | - Amandine Petit
- Unité de Cardiologie d'Alfort, Ecole Nationale Vétérinaire d'Alfort; Université Paris-Est; Maisons-Alfort France
| | - Charlotte Misbach
- Unité de Cardiologie d'Alfort, Ecole Nationale Vétérinaire d'Alfort; Université Paris-Est; Maisons-Alfort France
| | - Mathieu Raillard
- Unité de Cardiologie d'Alfort, Ecole Nationale Vétérinaire d'Alfort; Université Paris-Est; Maisons-Alfort France
| | | | - Jean-Louis Pouchelon
- Unité de Cardiologie d'Alfort, Ecole Nationale Vétérinaire d'Alfort; Université Paris-Est; Maisons-Alfort France
- Institut National de la Santé et de la Recherche Scientifique; Créteil Cedex; France
| | | | | | - Valérie Chetboul
- Unité de Cardiologie d'Alfort, Ecole Nationale Vétérinaire d'Alfort; Université Paris-Est; Maisons-Alfort France
- Institut National de la Santé et de la Recherche Scientifique; Créteil Cedex; France
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16
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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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Mitra B, Mazur S, Cameron PA, Bernard S, Burns B, Smith A, Rashford S, Fitzgerald M, Smith K, Gruen RL. Tranexamic acid for trauma: filling the 'GAP' in evidence. Emerg Med Australas 2015; 26:194-7. [PMID: 24708011 DOI: 10.1111/1742-6723.12172] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2013] [Indexed: 11/27/2022]
Abstract
Following findings of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial, tranexamic acid (TxA) use post trauma is becoming widespread. However, issues of generalisability, applicability and predictability beyond the context of study sites remain unresolved. Internal and external validity of the CRASH-2 trial are currently lacking and therefore incorporation of TxA into routine trauma resuscitation guidelines appears premature. The Pre-hospital Antifibrinolytics for Traumatic Coagulopathy and Haemorrhage (PATCH)-Trauma study is a National Health and Medical Research Council-funded randomised controlled trial of early administration of TxA in severely injured patients likely to have acute traumatic coagulopathy. The study population chosen has high mortality and morbidity and is potentially most likely to benefit from TxA's known mechanisms of action. This and further trials involving appropriate sample populations are required before evidence based guidelines on TxA use during trauma resuscitation can be developed.
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Affiliation(s)
- Biswadev Mitra
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Zacharias M, Mugawar M, Herbison GP, Walker RJ, Hovhannisyan K, Sivalingam P, Conlon NP. Interventions for protecting renal function in the perioperative period. Cochrane Database Syst Rev 2013; 2013:CD003590. [PMID: 24027097 PMCID: PMC7154582 DOI: 10.1002/14651858.cd003590.pub4] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Various methods have been used to try to protect kidney function in patients undergoing surgery. These most often include pharmacological interventions such as dopamine and its analogues, diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, N-acetyl cysteine (NAC), atrial natriuretic peptide (ANP), sodium bicarbonate, antioxidants and erythropoietin (EPO). OBJECTIVES This review is aimed at determining the effectiveness of various measures advocated to protect patients' kidneys during the perioperative period.We considered the following questions: (1) Are any specific measures known to protect kidney function during the perioperative period? (2) Of measures used to protect the kidneys during the perioperative period, does any one method appear to be more effective than the others? (3) Of measures used to protect the kidneys during the perioperative period,does any one method appear to be safer than the others? SEARCH METHODS In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2012), MEDLINE (Ovid SP) (1966 to August 2012) and EMBASE (Ovid SP) (1988 to August 2012). We originally handsearched six journals (Anesthesia and Analgesia, Anesthesiology, Annals of Surgery, British Journal of Anaesthesia, Journal of Thoracic and Cardiovascular Surgery, and Journal of Vascular Surgery) (1985 to 2004). However, because these journals are properly indexed in MEDLINE, we decided to rely on electronic searches only without handsearching the journals from 2004 onwards. SELECTION CRITERIA We selected all randomized controlled trials in adults undergoing surgery for which a treatment measure was used for the purpose of providing renal protection during the perioperative period. DATA COLLECTION AND ANALYSIS We selected 72 studies for inclusion in this review. Two review authors extracted data from all selected studies and entered them into RevMan 5.1; then the data were appropriately analysed. We performed subgroup analyses for type of intervention, type of surgical procedure and pre-existing renal dysfunction. We undertook sensitivity analyses for studies with high and moderately good methodological quality. MAIN RESULTS The updated review included data from 72 studies, comprising a total of 4378 participants. Of these, 2291 received some form of treatment and 2087 acted as controls. The interventions consisted most often of different pharmaceutical agents, such as dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors, NAC, ANP, sodium bicarbonate, antioxidants and EPO or selected hydration fluids. Some clinical heterogeneity and varying risk of bias were noted amongst the studies, although we were able to meaningfully interpret the data. Results showed significant heterogeneity and indicated that most interventions provided no benefit.Data on perioperative mortality were reported in 41 studies and data on acute renal injury in 44 studies (all interventions combined). Because of considerable clinical heterogeneity (different clinical scenarios, as well as considerable methodological variability amongst the studies), we did not perform a meta-analysis on the combined data.Subgroup analysis of major interventions and surgical procedures showed no significant influence of interventions on reported mortality and acute renal injury. For the subgroup of participants who had pre-existing renal damage, the risk of mortality from 10 trials (959 participants) was estimated as odds ratio (OR) 0.76, 95% confidence interval (CI) 0.38 to 1.52; the risk of acute renal injury (as reported in the trials) was estimated from 11 trials (979 participants) as OR 0.43, 95% CI 0.23 to 0.80. Subgroup analysis of studies that were rated as having low risk of bias revealed that 19 studies reported mortality numbers (1604 participants); OR was 1.01, 95% CI 0.54 to 1.90. Fifteen studies reported data on acute renal injury (criteria chosen by the individual studies; 1600 participants); OR was 1.03, 95% CI 0.54 to 1.97. AUTHORS' CONCLUSIONS No reliable evidence from the available literature suggests that interventions during surgery can protect the kidneys from damage. However, the criteria used to diagnose acute renal damage varied in many of the older studies selected for inclusion in this review, many of which suffered from poor methodological quality such as insufficient participant numbers and poor definitions of end points such as acute renal failure and acute renal injury. Recent methods of detecting renal damage such as the use of specific biomarkers and better defined criteria for identifying renal damage (RIFLE (risk, injury, failure, loss of kidney function and end-stage renal failure) or AKI (acute kidney injury)) may have to be explored further to determine any possible benefit derived from interventions used to protect the kidneys during the perioperative period.
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Affiliation(s)
- Mathew Zacharias
- Dunedin HospitalDepartment of Anaesthesia & Intensive CareGreat King StreetDunedinNew ZealandPrivate Bag 192
| | - Mohan Mugawar
- St Vincent's University HospitalDepartment of Anaesthesia and Intensive Care MedicineElm ParkDublinIreland4
| | - G Peter Herbison
- Dunedin School of Medicine, University of OtagoDepartment of Preventive & Social MedicinePO Box 913DunedinNew Zealand9054
| | - Robert J Walker
- University of OtagoDepartment of MedicineDunedin School of MedicinePO Box 913DunedinNew Zealand9015
| | - Karen Hovhannisyan
- RigshospitaletThe Cochrane Anaesthesia Review GroupBlegdamsvej 9,Afsnit 5211, rum 1204CopenhagenDenmark2100
| | - Pal Sivalingam
- Princess Alexandra HospitalDepartment of AnaesthesiaIpswich RoadWoolloongabbaBrisbaneAustralia4102
| | - Niamh P Conlon
- St Vincent's University HospitalDepartment of AnaesthesiaElm ParkDublinIreland4
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Albert-Weißenberger C, Sirén AL, Kleinschnitz C. Ischemic stroke and traumatic brain injury: the role of the kallikrein-kinin system. Prog Neurobiol 2012; 101-102:65-82. [PMID: 23274649 DOI: 10.1016/j.pneurobio.2012.11.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/15/2012] [Accepted: 11/20/2012] [Indexed: 12/16/2022]
Abstract
Acute ischemic stroke and traumatic brain injury are a major cause of mortality and morbidity. Due to the paucity of therapies, there is a pressing clinical demand for new treatment options. Successful therapeutic strategies for these conditions must target multiple pathophysiological mechanisms occurring at different stages of brain injury. In this respect, the kallikrein-kinin system is an ideal target linking key pathological hallmarks of ischemic and traumatic brain damage such as edema formation, inflammation, and thrombosis. In particular, the kinin receptors, plasma kallikrein, and coagulation factor XIIa are highly attractive candidates for pharmacological development, as kinin receptor antagonists or inhibitors of plasma kallikrein and coagulation factor XIIa are neuroprotective in animal models of stroke and traumatic brain injury. Nevertheless, conflicting preclinical evaluation as well as limited and inconclusive data from clinical trials suggest caution when transferring observations made in animals into the human situation. This review summarizes current evidence on the pathological significance of the kallikrein-kinin system during ischemic and traumatic brain damage, with a particular focus on experimental data derived from animal models. Experimental findings are also compared with human data if available, and potential therapeutic implications are discussed.
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Vaislic CD, Dalibon N, Ponzio O, Ba M, Jugan E, Lagneau F, Abbas P, Olliver Y, Gaillard D, Baget F, Sportiche M, Chedid A, Chaoul G, Maribas P, Dupuy C, Robine B, Kasanin N, Michon H, Ruat JM, Habis M, Bouharaoua T. Outcomes in cardiac surgery in 500 consecutive Jehovah's Witness patients: 21 year experience. J Cardiothorac Surg 2012; 7:95. [PMID: 23013647 PMCID: PMC3487917 DOI: 10.1186/1749-8090-7-95] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 09/01/2012] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Refusal of heterogenic blood products can be for religious reasons as in Jehovah's Witnesses or otherwise or as requested by an increasing number of patients. Furthermore blood reserves are under continuous demand with increasing costs. Therefore, transfusion avoidance strategies are desirable. We describe a historic comparison and current results of blood saving protocols in Jehovah's Witnesses patients. METHODS Data on 250 Jehovah's Witness patients operated upon between 1991 and 2003 (group A) were reviewed and compared with a second population of 250 patients treated from 2003 to 2012 (group B). RESULTS In group A, mean age was 51 years of age compared to 68 years in group B. An iterative procedure was performed in 13% of patients in group B. Thirty days mortality was 3% in group A and 1% in group B despite greater operative risk factors, with more redo, and lower ejection fraction in group B. Several factors contributed to the low morbidity-mortality in group B, namely: preoperative erythropoietin to attain a minimal hemoglobin value of 14 g/dl, warm blood cardioplegia, the implementation of the Cornell University protocol and fast track extubation. CONCLUSIONS Cardiac surgery without transfusion in high-risk patients such as Jehovah Witnesses can be carried out with results equivalent to those of low risk patients. Recent advances in surgical techniques and blood conservation protocols are main contributing factors.
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Schloss B, Gulati P, Yu L, Abdel-Rasoul M, O'Brien W, Von Visger J, Awad H. Impact of aprotinin and renal function on mortality: a retrospective single center analysis. J Cardiothorac Surg 2011; 6:103. [PMID: 21878108 PMCID: PMC3178482 DOI: 10.1186/1749-8090-6-103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 08/30/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An estimated up to 7% of high-risk cardiac surgery patients return to the operating room for bleeding. Aprotinin was used extensively as an antifibrinolytic agent in cardiac surgery patients for over 15 years and it showed efficacy in reducing bleeding. Aprotinin was removed from the market by the U.S. Food and Drug Administration after a large prospective, randomized clinical trial documented an increased mortality risk associated with the drug. Further debate arose when a meta-analysis of 211 randomized controlled trials showed no risk of renal failure or death associated with aprotinin. However, only patients with normal kidney function have been studied. METHODS In this study, we look at a single center clinical trial using patients with varying degrees of baseline kidney function to answer the question: Does aprotinin increase odds of death given varying levels of preoperative kidney dysfunction? RESULTS Based on our model, aprotinin use was associated with a 3.8-fold increase in odds of death one year later compared to no aprotinin use with p-value = 0.0018, regardless of level of preoperative kidney dysfunction after adjusting for other perioperative variables. CONCLUSIONS Lessons learned from our experience using aprotinin in the perioperative setting as an antifibrinolytic during open cardiac surgery should guide us in testing future antifibrinolytic drugs for not only efficacy of preventing bleeding, but for overall safety to the whole organism using long-term clinical outcome studies, including those with varying degree of baseline kidney function.
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Affiliation(s)
- Brian Schloss
- Department of Anesthesiology, The Ohio State University Medical Center, (410 West 10th Avenue), Columbus, (43210), USA
| | - Parul Gulati
- Center for Biostatistics, The Ohio State University Medical Center, (2012 Kenny Road), Columbus, (43210), USA
| | - Lianbo Yu
- Center for Biostatistics, The Ohio State University Medical Center, (2012 Kenny Road), Columbus, (43210), USA
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, The Ohio State University Medical Center, (2012 Kenny Road), Columbus, (43210), USA
| | - William O'Brien
- Perfusion Services, The Ohio State University Medical Center, (452 W. 10th Avenue), Columbus, (43210), USA
| | - Jon Von Visger
- Department of Nephrology, The Ohio State University Medical Center, (395 West 12th Avenue), Columbus, 43210, USA
| | - Hamdy Awad
- Department of Anesthesiology, The Ohio State University Medical Center, (410 West 10th Avenue), Columbus, (43210), USA
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Henry DA, Carless PA, Moxey AJ, O'Connell D, Stokes BJ, Fergusson DA, Ker K. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2011; 2011:CD001886. [PMID: 21412876 PMCID: PMC4234031 DOI: 10.1002/14651858.cd001886.pub4] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Concerns regarding the safety of transfused blood have led to the development of a range of interventions to minimise blood loss during major surgery. Anti-fibrinolytic drugs are widely used, particularly in cardiac surgery, and previous reviews have found them to be effective in reducing blood loss, the need for transfusion, and the need for re-operation due to continued or recurrent bleeding. In the last few years questions have been raised regarding the comparative performance of the drugs. The safety of the most popular agent, aprotinin, has been challenged, and it was withdrawn from world markets in May 2008 because of concerns that it increased the risk of cardiovascular complications and death. OBJECTIVES To assess the comparative effects of the anti-fibrinolytic drugs aprotinin, tranexamic acid (TXA), and epsilon aminocaproic acid (EACA) on blood loss during surgery, the need for red blood cell (RBC) transfusion, and adverse events, particularly vascular occlusion, renal dysfunction, and death. SEARCH STRATEGY We searched: the Cochrane Injuries Group's Specialised Register (July 2010), Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 3), MEDLINE (Ovid SP) 1950 to July 2010, EMBASE (Ovid SP) 1980 to July 2010. References in identified trials and review articles were checked and trial authors were contacted to identify any additional studies. The searches were last updated in July 2010. SELECTION CRITERIA Randomised controlled trials (RCTs) of anti-fibrinolytic drugs in adults scheduled for non-urgent surgery. Eligible trials compared anti-fibrinolytic drugs with placebo (or no treatment), or with each other. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. This version of the review includes a sensitivity analysis excluding trials authored by Prof. Joachim Boldt. MAIN RESULTS This review summarises data from 252 RCTs that recruited over 25,000 participants. Data from the head-to-head trials suggest an advantage of aprotinin over the lysine analogues TXA and EACA in terms of reducing perioperative blood loss, but the differences were small. Compared to control, aprotinin reduced the probability of requiring RBC transfusion by a relative 34% (relative risk [RR] 0.66, 95% confidence interval [CI] 0.60 to 0.72). The RR for RBC transfusion with TXA was 0.61 (95% CI 0.53 to 0.70) and was 0.81 (95% CI 0.67 to 0.99) with EACA. When the pooled estimates from the head-to-head trials of the two lysine analogues were combined and compared to aprotinin alone, aprotinin appeared more effective in reducing the need for RBC transfusion (RR 0.90; 95% CI 0.81 to 0.99).Aprotinin reduced the need for re-operation due to bleeding by a relative 54% (RR 0.46, 95% CI 0.34 to 0.62). This translates into an absolute risk reduction of 2% and a number needed-to-treat (NNT) of 50 (95% CI 33 to 100). A similar trend was seen with EACA (RR 0.32, 95% CI 0.11 to 0.99) but not TXA (RR 0.80, 95% CI 0.55 to 1.17). The blood transfusion data were heterogeneous and funnel plots indicate that trials of aprotinin and the lysine analogues may be subject to publication bias.When compared with no treatment aprotinin did not increase the risk of myocardial infarction (RR 0.87, 95% CI 0.69 to 1.11), stroke (RR 0.82, 95% CI 0.44 to 1.52), renal dysfunction (RR 1.10, 95% CI 0.79 to 1.54) or overall mortality (RR 0.81, 95% CI 0.63 to 1.06). Similar trends were seen with the lysine analogues, but data were sparse. These data conflict with the results of recently published non-randomised studies, which found increased risk of cardiovascular complications and death with aprotinin. There are concerns about the adequacy of reporting of uncommon events in the small clinical trials included in this review.When aprotinin was compared directly with either, or both, of the two lysine analogues it resulted in a significant increase in the risk of death (RR 1.39, 95% CI 1.02, 1.89), and a non-significant increase in the risk of myocardial infarction (RR 1.11 95% CI 0.82, 1.50). Most of the data contributing to this added risk came from a single study - the BART trial (2008). AUTHORS' CONCLUSIONS Anti-fibrinolytic drugs provide worthwhile reductions in blood loss and the receipt of allogeneic red cell transfusion. Aprotinin appears to be slightly more effective than the lysine analogues in reducing blood loss and the receipt of blood transfusion. However, head to head comparisons show a lower risk of death with lysine analogues when compared with aprotinin. The lysine analogues are effective in reducing blood loss during and after surgery, and appear to be free of serious adverse effects.
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Affiliation(s)
- David A Henry
- Institute of Clinical Evaluative Sciences2075 Bayview AvenueG1 06TorontoOntarioCanadaM4N 3M5
| | - Paul A Carless
- Faculty of Health, University of NewcastleDiscipline of Clinical PharmacologyLevel 5, Clinical Sciences Building, Newcastle Mater HospitalEdith Street, WaratahNewcastleNew South WalesAustralia2298
| | - Annette J Moxey
- Faculty of Health, University of NewcastleResearch Centre for Gender, Health & AgeingLevel 2, David Maddison BuildingCnr King & Watt StreetsNewcastleNew South WalesAustralia2300
| | - Dianne O'Connell
- Cancer CouncilCancer Epidemiology Research UnitPO Box 572Kings CrossSydneyNSWAustralia1340
| | - Barrie J Stokes
- Faculty of Health, University of NewcastleDiscipline of Clinical PharmacologyLevel 5, Clinical Sciences Building, Newcastle Mater HospitalEdith Street, WaratahNewcastleNew South WalesAustralia2298
| | - Dean A Fergusson
- University of Ottawa Centre for Transfusion ResearchOttawa Health Research Institute501 Smyth RoadOttawaOntarioCanadaK1H 8L6
| | - Katharine Ker
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupRoom 135Keppel StreetLondonUKWC1E 7HT
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Henry DA, Carless PA, Moxey AJ, O'Connell D, Stokes BJ, Fergusson DA, Ker K. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2011:CD001886. [PMID: 21249650 DOI: 10.1002/14651858.cd001886.pub3] [Citation(s) in RCA: 192] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Concerns regarding the safety of transfused blood have led to the development of a range of interventions to minimise blood loss during major surgery. Anti-fibrinolytic drugs are widely used, particularly in cardiac surgery, and previous reviews have found them to be effective in reducing blood loss, the need for transfusion, and the need for re-operation due to continued or recurrent bleeding. In the last few years questions have been raised regarding the comparative performance of the drugs. The safety of the most popular agent, aprotinin, has been challenged, and it was withdrawn from world markets in May 2008 because of concerns that it increased the risk of cardiovascular complications and death. OBJECTIVES To assess the comparative effects of the anti-fibrinolytic drugs aprotinin, tranexamic acid (TXA), and epsilon aminocaproic acid (EACA) on blood loss during surgery, the need for red blood cell (RBC) transfusion, and adverse events, particularly vascular occlusion, renal dysfunction, and death. SEARCH STRATEGY We searched: the Cochrane Injuries Group's Specialised Register (July 2010), Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 3), MEDLINE (Ovid SP) 1950 to July 2010, EMBASE (Ovid SP) 1980 to July 2010. References in identified trials and review articles were checked and trial authors were contacted to identify any additional studies. The searches were last updated in July 2010. SELECTION CRITERIA Randomised controlled trials (RCTs) of anti-fibrinolytic drugs in adults scheduled for non-urgent surgery. Eligible trials compared anti-fibrinolytic drugs with placebo (or no treatment), or with each other. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. MAIN RESULTS This review summarises data from 252 RCTs that recruited over 25,000 participants. Data from the head-to-head trials suggest an advantage of aprotinin over the lysine analogues TXA and EACA in terms of reducing perioperative blood loss, but the differences were small. Compared to control, aprotinin reduced the probability of requiring RBC transfusion by a relative 34% (relative risk [RR] 0.66, 95% confidence interval [CI] 0.60 to 0.72). The RR for RBC transfusion with TXA was 0.61 (95% CI 0.53 to 0.70) and was 0.81 (95% CI 0.67 to 0.99) with EACA. When the pooled estimates from the head-to-head trials of the two lysine analogues were combined and compared to aprotinin alone, aprotinin appeared more effective in reducing the need for RBC transfusion (RR 0.90; 95% CI 0.81 to 0.99).Aprotinin reduced the need for re-operation due to bleeding by a relative 54% (RR 0.46, 95% CI 0.34 to 0.62). This translates into an absolute risk reduction of 2% and a number needed-to-treat (NNT) of 50 (95% CI 33 to 100). A similar trend was seen with EACA (RR 0.32, 95% CI 0.11 to 0.99) but not TXA (RR 0.80, 95% CI 0.55 to 1.17). The blood transfusion data were heterogeneous and funnel plots indicate that trials of aprotinin and the lysine analogues may be subject to publication bias.When compared with no treatment aprotinin did not increase the risk of myocardial infarction (RR 0.87, 95% CI 0.69 to 1.11), stroke (RR 0.82, 95% CI 0.44 to 1.52), renal dysfunction (RR 1.10, 95% CI 0.79 to 1.54) or overall mortality (RR 0.81, 95% CI 0.63 to 1.06). Similar trends were seen with the lysine analogues, but data were sparse. These data conflict with the results of recently published non-randomised studies, which found increased risk of cardiovascular complications and death with aprotinin. There are concerns about the adequacy of reporting of uncommon events in the small clinical trials included in this review.When aprotinin was compared directly with either, or both, of the two lysine analogues it resulted in a significant increase in the risk of death (RR 1.39, 95% CI 1.02, 1.89), and a non-significant increase in the risk of myocardial infarction (RR 1.11 95% CI 0.82, 1.50). Most of the data contributing to this added risk came from a single study - the BART trial (2008). AUTHORS' CONCLUSIONS Anti-fibrinolytic drugs provide worthwhile reductions in blood loss and the receipt of allogeneic red cell transfusion. Aprotinin appears to be slightly more effective than the lysine analogues in reducing blood loss and the receipt of blood transfusion. However, head to head comparisons show a lower risk of death with lysine analogues when compared with aprotinin. The lysine analogues are effective in reducing blood loss during and after surgery, and appear to be free of serious adverse effects.
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Affiliation(s)
- David A Henry
- Institute of Clinical Evaluative Sciences, 2075 Bayview Avenue, G1 06, Toronto, Ontario, Canada, M4N 3M5
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Homi HM, Sheng H, Arepally GM, Mackensen GB, Grocott HP. Aprotinin Improves Functional Outcome but Not Cerebral Infarct Size in an Experimental Model of Stroke During Cardiopulmonary Bypass. Anesth Analg 2010; 111:38-45. [DOI: 10.1213/ane.0b013e3181e0549f] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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van den Bergh WM. Is There a Future for Neuroprotective Agents in Cardiac Surgery? Semin Cardiothorac Vasc Anesth 2010; 14:123-35. [DOI: 10.1177/1089253210370624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article gives an overview of neuroprotective drugs that were recently tested in clinical trials in cardiac surgery. Also, recommendations are given for successful translational research and considerations for management during cardiac surgery.
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26
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Edmunds LH. Managing fibrinolysis without aprotinin. Ann Thorac Surg 2010; 89:324-31. [PMID: 20103278 DOI: 10.1016/j.athoracsur.2009.10.043] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Revised: 10/12/2009] [Accepted: 10/12/2009] [Indexed: 01/10/2023]
Abstract
Cardiopulmonary bypass increases perioperative bleeding and produces a consumptive coagulopathy, which is defined as the simultaneous production of thrombin and fibrinolysis. Thrombin formation and fibrinolysis primarily occur in the surgical wound and peak at the time heparin is reversed by protamine. Neither aprotinin nor lysine analogs successfully control bleeding in many complex procedures, reoperations, aortic resections, or in implantations of mechanical circulatory devices. This analysis reviews the mechanisms involved and current treatment protocols, with the conclusion that changes in treatment protocols rather than use of a specific anti-fibrinolytic drug may provide better control of bleeding in these patients.
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Affiliation(s)
- L Henry Edmunds
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104-3325, USA.
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Iwata Y, Okamura T, Ishibashi N, Zurakowski D, Lidov HGW, Jonas RA. Optimal dose of aprotinin for neuroprotection and renal function in a piglet survival model. J Thorac Cardiovasc Surg 2009; 137:1521-9; discussion 1529. [PMID: 19464474 DOI: 10.1016/j.jtcvs.2008.06.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2008] [Accepted: 06/10/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The efficacy of aprotinin in reducing blood loss after cardiopulmonary bypass is well established, although its neuroprotective potential is less well known. Furthermore, there is controversy regarding optimal dosing and possible renal complications. METHODS Fifty-four piglets were randomized to one of 3 cardiopulmonary bypass groups designed to carry the risk of postoperative cerebral and renal dysfunction: circulatory arrest at 25 degrees C and ultra-low flow bypass (10 mL x kg(-1) x min(-1)) at either 25 degrees C or 34 degrees C. Animals were randomized to the following groups: control (no aprotinin), low dose (30,000 KIU/kg into prime only), standard full dose (30,000 KIU/kg bolus administered intravenously into prime plus 10,000 KIU/kg infusion), and double full dose. The tissue oxygenation index was monitored by means of near-infrared spectroscopy. Neurologic functional and histologic scores and creatinine and blood urea nitrogen values were outcomes of interest. RESULTS Aprotinin significantly improved neurologic scores on postoperative day 1 after ultra-low-flow bypass at 25 degrees C or 34 degrees C (P < .01) but not after hypothermic circulatory arrest (P = .57). Linear regression indicated a strong dose-response relationship, with higher aprotinin doses having the best neurologic scores. During low-flow bypass, a higher tissue oxygenation index was correlated with a higher aprotinin dose (P < .05). Aprotinin dose had no significant effect on creatinine or blood urea nitrogen values on day 1. Low body weight was the only predictor of high blood urea nitrogen values (r = -0.39, P < .01). CONCLUSION Aprotinin significantly improves neurologic recovery without compromising renal function in the young piglet.
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Affiliation(s)
- Yusuke Iwata
- Division of Cardiac Surgery, Children's National Medical Center, Washington, DC 20010, USA
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Sun HY, Szlam F, Levy JH, Csete ME, Tanaka KA. Antifibrinolytic agents reduce tissue plasminogen activator-mediated neuronal toxicity in vitro. Acta Anaesthesiol Scand 2009; 53:325-31. [PMID: 19243318 DOI: 10.1111/j.1399-6576.2008.01858.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Serine proteases and their inhibitors play an important role in physiological homeostasis including neuronal activity, hemostasis, and wound healing. Tissue plasminogen activator (tPA) is involved in normal neuronal plasticity and memory formation but can also be neurotoxic. We hypothesized that the serine protease inhibitor aprotinin confers neuronal protection by inhibiting tPA activity. METHODS Using cultured rat dopaminergic neuroblasts (N27 line), tPA-induced cytotoxicity was quantitated by an MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay and flow cytometry using propidium iodide DNA staining. The anti-apoptotic effects of aprotinin and other protease inhibitors were also evaluated using these systems. RESULTS Treatment of cultured neuroblasts with tPA (10-20 microg/ml) caused a dose-dependent decrease in cell viability (71.3+/-2.4 at 10 microg/ml down to 52.7+/-2.5% at 20 microg/m tPA, 24-h treatment), which was potentiated in the absence of serum in the culture medium (59.5+/-6.3% at 10 microg/ml down to 47.9+/-4.7% at 20 microg/ml). Aprotinin was effective in ameliorating cell death when administered 30 min before tPA exposure as shown by increased cell viability (91.8+/-0.6% at tPA at 20 microg/ml), but this protection was significantly reduced when aprotinin was administered after tPA. The efficacy of aprotinin as a neuroprotectant was equivalent or superior to other direct tPA antagonist peptides Glu-Gly-Arg-chlormethylketone (EGRck) and Phe-Pro-Arg-chlormethylketone (FPRck) in this setting. CONCLUSION These data suggest that one of the mechanisms of neuroprotection afforded by aprotinin may be inhibition of tPA-mediated neurotoxicity.
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Affiliation(s)
- H-Y Sun
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA
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Guzzetta NA, Evans FM, Rosenberg ES, Fazlollah TM, Baker MJ, Wilson EC, Kaiser AM, Tosone SR, Miller BE. The impact of aprotinin on postoperative renal dysfunction in neonates undergoing cardiopulmonary bypass: a retrospective analysis. Anesth Analg 2009; 108:448-55. [PMID: 19151271 DOI: 10.1213/ane.0b013e318194007a] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recent concern about the safety of aprotinin administration to adults has led to its suspension from worldwide markets. However, few studies have examined its safety in pediatric patients. Studies in children evaluating aprotinin's safety have been hindered by the heterogeneity of pediatric patients and the inconsistency of clinical protocols. In this investigation, we retrospectively reviewed 200 neonatal cardiac surgical cases performed at our institution to examine the safety of aprotinin, focusing on postoperative renal dysfunction, using a consistent aprotinin dosing protocol. METHODS Two-hundred consecutive neonates scheduled for palliative or corrective congenital cardiac surgery requiring cardiopulmonary bypass (CPB) from January 1, 2005 through February 28, 2007 were included in this retrospective investigation. Preoperative, intraoperative and postoperative data were collected and analyzed. Markers of safety included 72-h postoperative renal dysfunction, need for dialysis (peritoneal or hemodialysis), thrombosis and in-hospital mortality. RESULTS Neonates were divided into those who received aprotinin (aprotinin group; n = 156) and those who did not (no aprotinin group; n = 44). Twenty-four and 72-h postoperative serum creatinine levels were significantly greater than baseline levels in both groups. The degree of change in creatinine levels was highly significant and similar between the two groups. A larger percentage of neonates in the aprotinin group developed renal dysfunction, although this difference was not statistically significant. Stepwise logistic regression, assessing the impact on renal dysfunction of all variables that indicated significance between neonates who did or did not receive aprotinin and between neonates who did or did not develop renal dysfunction, identified CPB time and age as significant predictors of postoperative renal dysfunction. All neonates who developed postoperative renal dysfunction had a CPB time of more than 100 min regardless of the use of aprotinin. Additionally, using this subset, similar percentages of renal dysfunction occurred in both groups. A second multivariable regression analysis to simultaneously account for the predictors of CPB time, age and aprotinin administration found CPB time to be the only significant predictor of renal dysfunction. Incidences of postoperative dialysis, postoperative thrombosis and in-hospital mortality were not statistically significantly different between the aprotinin and the no aprotinin groups. CONCLUSION The occurrence of postoperative renal dysfunction in neonates was more significantly predicted by the duration of CPB than by the intraoperative administration of aprotinin. CPB times of more than 100 min appeared to be a critical marker for the development of postoperative renal dysfunction. Randomized prospective trials are needed to confirm the validity of our retrospective findings.
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Affiliation(s)
- Nina A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA 30322, USA.
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Abstract
Aprotinin is a polypeptide serine protease inhibitor used to prevent bleeding and need for transfusions in patients having heart surgery. A recent analysis of an observational study data set suggested the use of aprotinin was associated with an increased risk of developing renal failure. The present article reviews the data from basic science studies in tissues, animals and man together with the data from observational studies and randomised controlled trials. The interpretation of the data is hampered owing to the use of different endpoints to describe mild/moderate renal impairment. Nonetheless, the evidence points to aprotinin use being associated with a transient small rise in plasma creatinine concentration in certain patients. There is no evidence for an increased risk of developing new renal failure requiring dialysis/renal replacement therapy.
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Affiliation(s)
- Marie Bosman
- Royal Brompton and Harefield NHS Trust, Harefield Hospital, Hill End Road, Harefield, UB9 6JH, UK
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Ngaage DL, Cale AR, Cowen ME, Griffin S, Guvendik L. Aprotinin in primary cardiac surgery: operative outcome of propensity score-matched study. Ann Thorac Surg 2008; 86:1195-202. [PMID: 18805159 DOI: 10.1016/j.athoracsur.2008.06.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Revised: 06/06/2008] [Accepted: 06/09/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Some recent multicenter series have questioned the safety of aprotinin in primary cardiac operations. We report a large, single-center experience with aprotinin therapy in primary cardiac operations and discuss the limitations and potential confounders of current treatment strategies. METHODS We compared myocardial infarction, neurologic events, renal insufficiency, and operative death after first-time coronary or valve procedures, or both, in 3334 patients treated with full-dose aprotinin with 3417 patients not treated with aprotinin who underwent operation between March 1998 and January 2007. Further analysis was performed for 341 propensity score-matched pairs. RESULTS There were substantial differences between the groups. Aprotinin patients were higher risk on account of older age, unstable symptoms, poor ejection fraction, preoperative hemodynamic support, emergency/urgent operations, and combined coronary/valve operations. Postoperative bleeding and blood product transfusion were considerably reduced in aprotinin patients, as was median duration of mechanical ventilation. Aprotinin was neither a predictor of postoperative myocardial infarction, renal insufficiency, neurologic dysfunction, or operative death. Achieving parity between the groups by propensity score matching eliminated the elevated rates of postoperative renal insufficiency, neurologic dysfunction, and operative death observed in aprotinin patients in the unmatched comparison. These adverse outcomes were evenly distributed between matched groups. Conversely, blood transfusion had univariate associations with all adverse outcome measures. CONCLUSIONS Full-dose aprotinin use was not associated with myocardial infarction, neurologic dysfunction, renal insufficiency, or death after coronary or valve operations. We observed less postoperative bleeding and blood product transfusion, and early extubation with the use of aprotinin.
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Affiliation(s)
- Dumbor L Ngaage
- Castle Hill Hospital, Kingston-Upon-Hull, East Yorkshire, United Kingdom.
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Zacharias M, Conlon NP, Herbison GP, Sivalingam P, Walker RJ, Hovhannisyan K. Interventions for protecting renal function in the perioperative period. Cochrane Database Syst Rev 2008:CD003590. [PMID: 18843647 DOI: 10.1002/14651858.cd003590.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND A number of methods have been used to try to protect kidney function in patients undergoing surgery. These include the administration of dopamine and its analogues, diuretics, calcium channel blockers, angiotensin converting enzyme inhibitors and hydration fluids. OBJECTIVES For this review, we selected randomized controlled trials which employed different methods to protect renal function during the perioperative period. In examining these trials, we looked at outcomes that included renal failure and mortality as well as changes in renal function tests, such as urine output, creatinine clearance, free water clearance, fractional excretion of sodium and renal plasma flow. SEARCH STRATEGY We searched the Cochrane Central register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to June, 2007), and EMBASE (1988 to June, 2007); and handsearched six journals (Anesthesia and Analgesia, Anesthesiology, Annals of Surgery, British Journal of Anaesthesia, Journal of Thoracic and Cardiovascular Surgery, and Journal of Vascular Surgery). SELECTION CRITERIA We selected all randomized controlled trials in adults undergoing surgery where a treatment measure was used for the purpose of renal protection in the perioperative period. DATA COLLECTION AND ANALYSIS We selected 53 studies for inclusion in this review. As well as data analysis from all the studies, we performed subgroup analysis for type of intervention, type of surgical procedure, and pre-existing renal dysfunction. We undertook sensitivity analysis on studies with high and moderately good methodological quality. MAIN RESULTS The review included data from 53 studies, comprising a total of 2327 participants. Of these, 1293 received some form of treatment and 1034 acted as controls. The interventions mostly consisted of different pharmaceutical agents, such as dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors, or selected hydration fluids. The results indicated that certain interventions showed minimal benefits. All the results suffered from significant heterogeneity. Hence we cannot draw conclusions about the effectiveness of these interventions in protecting patients' kidneys during surgery. AUTHORS' CONCLUSIONS There is no reliable evidence from the available literature to suggest that interventions during surgery can protect the kidneys from damage. There is a need for more studies with high methodological quality. One particular area for further study may be patients with pre-existing renal dysfunction undergoing surgery.
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Affiliation(s)
- Mathew Zacharias
- Department of Anaesthesia & Intensive Care, Dunedin Hospital, Great King Street, Dunedin, Otago, New Zealand, Private Bag 192.
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Jeong DS, Kim KH, Kim CY, Kim JS. Efficacy of a High-Dose Aprotinin Regimen for Reducing Transfusion Requirements and Inflammatory Responses in Adult Cardiac Surgery. J Int Med Res 2008; 36:1039-48. [DOI: 10.1177/147323000803600522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study evaluated and compared the risks and effects to the inflammatory response of low- and high-dose aprotinin regimens. Between January and June 2006, patients scheduled for cardiac surgery using cardiopulmonary bypass were enrolled and randomly allocated to either low- ( n = 15) or high-dose ( n = 13) aprotinin groups. The incidences of mortality and adverse events were comparable in both groups. Post-operative creatinine levels and blood loss were not significantly different between the two groups. With the exception of platelets, the counts of transfused allogenic blood products were not significantly different between the groups. Interleukin (IL)-6, IL-10, soluble tumour necrosis factor II receptor, and interferon-γ levels increased in both groups compared with baseline, but no significant intergroup differences were detected. In conclusion, high- and low-dose aprotinin had similar effects in the reduction of mediastinal bleeding and attenuation of systemic inflammatory responses, and high-dose aprotinin therapy could be used without any increased adverse effects.
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Affiliation(s)
- DS Jeong
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Chongno-gu, Seoul, Korea
| | - K-H Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Chongno-gu, Seoul, Korea
| | - CY Kim
- Department of Thoracic and Cardiovascular Surgery, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi Province, Korea
| | - JS Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Chongno-gu, Seoul, Korea
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Despotis G, Eby C, Lublin DM. A review of transfusion risks and optimal management of perioperative bleeding with cardiac surgery. Transfusion 2008; 48:2S-30S. [PMID: 18302579 DOI: 10.1111/j.1537-2995.2007.01573.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- George Despotis
- Departments of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri 63110, USA.
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Evans BJ, Haskard DO, Finch JR, Hambleton IR, Landis RC, Taylor KM. The inflammatory effect of cardiopulmonary bypass on leukocyte extravasation in vivo. J Thorac Cardiovasc Surg 2008; 135:999-1006. [PMID: 18455576 DOI: 10.1016/j.jtcvs.2007.08.071] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Revised: 08/22/2007] [Accepted: 08/30/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Extravascular trafficking of leukocytes into organs is thought to play a major role in the pathophysiologic mechanisms of the inflammatory response to cardiopulmonary bypass, yet leukocyte extravasation is difficult to study clinically. Here we have tested the hypothesis that leukocyte emigration into skin blisters can provide a way to monitor the inflammatory effect of cardiopulmonary bypass that allows testing of anti-inflammatory interventions (exemplified by aprotinin). METHODS Patients undergoing primary elective coronary artery bypass grafting (n = 14) were randomized into 2 equal groups to receive saline infusion during cardiopulmonary bypass (control group) or high-dose aprotinin. Experimental skin blisters (in duplicate) were induced on the forearm by means of topical application of the vesicant cantharidin, and blister fluid was sampled at 5 hours postoperatively. Inflammatory leukocyte subsets in blister fluid were analyzed by means of flow cytometry by using expression of CD11b and CD62L as a phenotypic marker of activation. RESULTS In the control group of patients, cardiopulmonary bypass surgery triggered a 381% increase in leukocyte extravasation into the skin compared with reference blisters carried out before surgical intervention, with neutrophil (P = .014), monocyte (P = .014), and eosinophil (P = .009) levels all statistically significantly increased. In the aprotinin group there was no statistically significant increase during cardiopulmonary bypass surgery in any inflammatory leukocyte subset. The activation phenotype of extravascular leukocytes was not significantly altered between surgical groups. CONCLUSIONS This study introduces the cantharidin blister technique as a powerful new research tool for analyzing the inflammatory effect of cardiopulmonary bypass in vivo. It has provided detailed molecular insight into the extravascular leukocyte population during cardiopulmonary bypass. Although aprotinin blocked cardiopulmonary bypass-dependent extravasation of leukocytes, there was no change in their CD11b/CD62L activation status. The cantharidin skin test thus represents a novel research tool for evaluating future anti-inflammatory interventions in cardiothoracic surgery.
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Affiliation(s)
- B J Evans
- British Heart Foundation, Cardiothoracic Surgery Unit, Imperial College Faculty of Medicine, Hammersmith Hospital, London, United Kingdom
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Abstract
Cardiac surgery continues to be associated with significant adverse cerebral outcomes, ranging from stroke to cognitive decline. The underlying mechanism of the associated cerebral injury is incompletely understood but is believed to be primarily caused by cerebral embolism and hypoperfusion, exacerbated by ischemia/reperfusion injury. Extensive research has been undertaken in an attempt to minimize the incidence of perioperative cerebral injury, and both pharmacological and nonpharmacological strategies have been investigated. Although many agents demonstrated promise in preclinical studies, there is currently insufficient evidence from clinical trials to recommend the routine administration of any pharmacological agents for neuroprotection during cardiac surgery. The nonpharmacological strategies that can be recommended on the basis of evidence include transesophageal echocardiography and epiaortic ultrasound-guided assessment of the atheromatous ascending aorta with appropriate modification of cannulation, clamping or anastomotic technique and optimal temperature management. Large-scale randomized controlled trials are still required to address further the issues of optimal pH management, glycemic control, blood pressure management and hematocrit during cardiopulmonary bypass. Past, present and future directions in the field of neuroprotection in cardiac surgery will be discussed.
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Affiliation(s)
- Niamh Conlon
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Bittner HB, Lemke J, Lange M, Rastan A, Mohr FW. The Impact of Aprotinin on Blood Loss and Blood Transfusion in Off-Pump Coronary Artery Bypass Grafting. Ann Thorac Surg 2008; 85:1662-8. [DOI: 10.1016/j.athoracsur.2008.01.087] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Revised: 01/10/2008] [Accepted: 01/11/2008] [Indexed: 11/30/2022]
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Jámbor C, Bremerich D, Moritz A, Seifried E, Zwissler B. Gerinnungsmanagement bei Eingriffen mit extrakorporaler Zirkulation. Anaesthesist 2008; 57:374-81. [DOI: 10.1007/s00101-008-1336-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mouton R, Finch D, Davies I, Binks A, Zacharowski K. Effect of aprotinin on renal dysfunction in patients undergoing on-pump and off-pump cardiac surgery: a retrospective observational study. Lancet 2008; 371:475-82. [PMID: 18262039 DOI: 10.1016/s0140-6736(08)60237-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Aprotinin is used during cardiac surgery for its blood-saving effects. However, reports suggest a possible association between use of this drug and increased renal dysfunction and mortality. We investigated the effect of aprotinin on renal dysfunction in cardiac surgery, considering the cofactors on-pump versus off-pump surgery and co-medication with angiotensin-converting enzyme (ACE) inhibitors. METHODS Our analysis included 9875 patients undergoing on-pump or off-pump cardiac surgery from Jan 1, 2000, to Sept 30, 2007. Of these patients, 9106 were included in the retrospective observational study analysis. With propensity-adjusted, multivariate staged logistic regression, we analysed separately the incidence of renal dysfunction in patients receiving aprotinin, tranexamic acid, or no antifibrinolytic treatment in the presence or absence of preoperative ACE inhibitor treatment, for both on-pump and off-pump surgical techniques. FINDINGS In 5434 patients undergoing on-pump cardiac surgery, the odds ratio (OR) between aprotinin and an increased risk of renal dysfunction without ACE inhibitor was 1.81 (95% CI 0.79-4.13, p=0.162) and with ACE inhibitor 1.73 (0.56-5.32, p=0.342). In the 848 patients taking ACE inhibitors and undergoing off-pump cardiac surgery, aprotinin was associated with a greater than two-fold increase in the risk of renal dysfunction after off-pump cardiac surgery (OR 2.87 [1.25-6.58], p=0.013). INTERPRETATION Our results have shown that aprotinin seems to be safe during on-pump cardiac surgery. However, the combination of aprotinin and ACE inhibitors during off-pump cardiac surgery is associated with a significant risk of postoperative renal dysfunction.
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Affiliation(s)
- Ronelle Mouton
- Department of Anaesthesia, Bristol Royal Infirmary, Bristol, UK.
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Kristeller JL, Roslund BP, Stahl RF. Benefits and Risks of Aprotinin Use During Cardiac Surgery. Pharmacotherapy 2008; 28:112-24. [PMID: 18154481 DOI: 10.1592/phco.28.1.112] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Judith L Kristeller
- Department of Pharmacy Practice, Wilkes University, Wilkes-Barre, Pennsylvania 18766, USA
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Backer CL, Kelle AM, Stewart RD, Suresh SC, Ali FN, Cohn RA, Seshadri R, Mavroudis C. Aprotinin is safe in pediatric patients undergoing cardiac surgery. J Thorac Cardiovasc Surg 2007; 134:1421-6; discussion 1426-8. [DOI: 10.1016/j.jtcvs.2007.08.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 07/19/2007] [Accepted: 08/07/2007] [Indexed: 10/22/2022]
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Abstract
Aprotinin is the only agent with Class A Level 1 evidence for reduction in rates of transfusion and return to operating theatre to control bleeding after heart surgery. Principal on the list of safety issues raised over the years are increased risk for: a) thrombosis; and b) renal dysfunction. With multiple administrations, hypersensitivity reactions have emerged as a further safety concern. This review discusses these issues, based on the examination of > 500 published articles. The article also specifically places in context the data presented recently from the observational McSPI database analysis. This report suggested that aprotinin should be withdrawn from human use as serious safety issues have been ignored or missed, an inference not in agreement with the majority of the human safety literature.
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Affiliation(s)
- David Royston
- Royal Brompton and Harefield NHS Trust, Department of Cardiothoracic Anaesthesia and Critical Care, Harefield Hospital, Hill End Road, Harefield, Middlesex, UB9 6JH, UK.
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Henry DA, Carless PA, Moxey AJ, O'Connell D, Stokes BJ, McClelland B, Laupacis A, Fergusson D. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2007:CD001886. [PMID: 17943760 DOI: 10.1002/14651858.cd001886.pub2] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Concerns regarding the safety of transfused blood have led to the development of a range of interventions to minimise blood loss during major surgery. Anti-fibrinolytic drugs are widely used, particularly in cardiac surgery and previous reviews have found them to be effective in reducing blood loss and the need for transfusion. Recently, questions have been raised regarding the comparative performance of the drugs and the safety of the most popular agent, aprotinin. OBJECTIVES To assess the comparative effects of the anti-fibrinolytic drugs aprotinin, tranexamic acid (TXA), and epsilon aminocaproic acid (EACA) on blood loss during surgery, the need for red blood (RBC) transfusion, and adverse events, particularly vascular occlusion, renal dysfunction, and death. SEARCH STRATEGY We searched CENTRAL, MEDLINE, EMBASE, and the internet. References in identified trials and review articles were checked and trial authors were contacted to identify any additional studies. The searches were last updated in July 2006. SELECTION CRITERIA Randomised controlled trials (RCTs) of anti-fibrinolytic drugs in adults scheduled for non-urgent surgery. Eligible trials compared anti-fibrinolytic drugs with placebo (or no treatment), or with each other. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. MAIN RESULTS This review summarises data from 211 RCTs that recruited 20,781 participants. Data from placebo/inactive controlled trials, and from head-to-head trials suggest an advantage of aprotinin over the lysine analogues TXA and EACA in terms of operative blood loss, but the differences were small. Aprotinin reduced the probability of requiring RBC transfusion by a relative 34% (relative risk [RR] 0.66, 95% confidence interval [CI] 0.61 to 0.71). The RR for RBC transfusion with TXA was 0.61 (95% CI 0.54 to 0.69) and it was 0.75 (95% CI 0.58 to 0.96) with EACA. When the pooled estimates from the head-to-head trials of the two lysine analogues were combined and compared to aprotinin alone, aprotinin appeared superior in reducing the need for RBC transfusion: RR 0.83 (95% CI 0.69 to 0.99). Aprotinin reduced the need for re-operation due to bleeding: RR 0.48 (95% CI 0.35 to 0.68). This translates into an absolute risk reduction of just under 3% and a number needed-to-treat (NNT) of 37 (95% CI 27 to 56). Similar trends were seen with TXA and EACA, but the data were sparse and the differences failed to reach statistical significance. The blood transfusion data were heterogeneous and funnel plots indicate that trials of aprotinin and the lysine analogues may be subject to publication bias. Evidence of publication bias was not observed in trials reporting re-operation rates. Adjustment for these effects reduced the magnitude of estimated benefits but did not negate treatment effects. However, the apparent advantage of aprotinin over the lysine analogues was small and may be explained by publication bias and non-equivalent drug doses. Aprotinin did not increase the risk of myocardial infarction (RR 0.92, 95% CI 0.72 to 1.18), stroke (RR 0.76, 95% CI 0.35 to 1.64) renal dysfunction (RR 1.16, 95% CI 0.79 to 1.70) or overall mortality (RR 0.90, 95% CI 0.67 to 1.20). The analyses of myocardial infarction and death included data from the majority of subjects recruited into the clinical trials of aprotinin. However, under-reporting of renal events could explain the lack of effect seen with aprotinin. Similar trends were seen with the lysine analogues but data were sparse. These results conflict with the results of recently published non-randomised studies. AUTHORS' CONCLUSIONS Anti-fibrinolytic drugs provide worthwhile reductions in blood loss and the need for allogeneic red cell transfusion. Based on the results of randomised trials their efficacy does not appear to be offset by serious adverse effects. In most circumstances the lysine analogues are probably as effective as aprotinin and are cheaper; the evidence is stronger for tranexamic acid than for aminocaproic acid. In high risk cardiac surgery, where there is a substantial probability of serious blood loss, aprotinin may be preferred over tranexamic acid. Aprotinin does not appear to be associated with an increased risk of vascular occlusion and death, but the data do not exclude an increased risk of renal failure. There is no need for further placebo-controlled trials of aprotinin or lysine analogues in cardiac surgery. The principal need is for large comparative trials to assess the relative efficacy, safety and cost-effectiveness of anti-fibrinolytic drugs in different surgical procedures.
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Affiliation(s)
- D A Henry
- University of Newcastle, Faculty of Health, Level 5, Clinical Sciences Building, Newcastle Mater Hospital, Waratah, NSW, Australia, 2298.
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Levy JH, Tanaka KA. The anticoagulated patient: Strategies for effective blood loss management. Surgery 2007; 142:S71-7. [DOI: 10.1016/j.surg.2007.06.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McEvoy MD, Reeves ST, Reves JG, Spinale FG. Aprotinin in Cardiac Surgery: A Review of Conventional and Novel Mechanisms of Action. Anesth Analg 2007; 105:949-62. [PMID: 17898372 DOI: 10.1213/01.ane.0000281936.04102.9f] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Induction of the coagulation and inflammatory cascades can cause multiorgan dysfunction after cardiopulmonary bypass (CPB). In light of these observations, strategies that can stabilize the coagulation process as well as attenuate the inflammatory response during and after cardiac surgery are important. Aprotinin has effects on hemostasis. In addition, aprotinin may exert multiple biologically relevant effects in the context of cardiac surgery and CPB. For example, it decreases neutrophil and macrophage activation and chemotaxis, attenuates release and activation of proinflammatory cytokines, and reduces oxidative stress. Despite these perceived benefits, the routine use of aprotinin in cardiac surgery with CPB has been called into question. In this review, we examined this controversial drug by discussing the classical and novel pathways in which aprotinin may be operative in the context of cardiac surgery.
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Affiliation(s)
- Matthew D McEvoy
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.
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Bakaeen F, Rice D, Correa AM, Walsh GL, Vaporciyan AA, Putnam JB, Swisher SG, Roth JA, Huh J, Chu D, Smythe WR. Use of aprotinin in extrapleural pneumonectomy: effect on hemostasis and incidence of complications. Ann Thorac Surg 2007; 84:982-6. [PMID: 17720413 DOI: 10.1016/j.athoracsur.2007.03.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2006] [Revised: 03/12/2007] [Accepted: 03/19/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND The purpose of this study was to examine the effect of aprotinin on blood loss in extrapleural pneumonectomy and to identify potential treatment-related complications. METHODS Between March 1, 1999, and July 1, 2004, 27 (52%) of 52 patients who underwent extrapleural pneumonectomy received half-dose aprotinin (1 million kallikrein inhibition units load; 250,000 kallikrein inhibition units per hour infusion). A retrospective data review and analysis were performed. RESULTS The mean age was 59.8 +/- 11 years, and 45 of 52 patients (87%) were male. Indications for extrapleural pneumonectomy were malignant pleural mesothelioma (n = 50) and pleural-based sarcoma (n = 2). The administration of aprotinin had no significant effect on intraoperative blood loss (1,010 +/- 599 versus 1,182 +/- 688 mL; p = 0.34) or units of packed red blood cells transfused intraoperatively (2.0 +/- 1.7 versus 1.9 +/- 1.7 units; p = 0.86). None of the patients who received aprotinin required the use of non-packed red blood cells blood products, but 4 patients (16%) who did not receive aprotinin required such transfusion (p < 0.05). Postoperative chest tube output at 12 and 24 hours was lower in the aprotinin group (381 +/- 195 and 867 +/- 313 mL, respectively) compared with the control group (725 +/- 527 and 1,221 +/- 442 mL, respectively; p < 0.03). There was no significant difference in incidence of postoperative thromboembolic events between the aprotinin and the control group (5 versus 4 patients; p = 1.0), and 2 patients in each group experienced renal insufficiency (p = 1.0). CONCLUSIONS Half-dose aprotinin did not decrease intraoperative blood loss or packed red blood cells transfusion in extrapleural pneumonectomy. However, use of aprotinin was associated with decreased use of non-packed red blood cells blood products and lower postoperative chest tube output. Aprotinin administration was not associated with an increase in incidence of postoperative complications.
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Affiliation(s)
- Faisal Bakaeen
- The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.
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Abstract
Like adults, children taking beta-blockers are at risk for serious hemodynamic instability in case of anaphylaxis. We report a case of severe bradycardia associated with anaphylactic shock after aprotinin in a beta-blocked child, which was resistant to intravenous epinephrine and vascular filling but was treated successfully with isoproterenol.
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Affiliation(s)
- Mona Momeni
- Department of Anesthesiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
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Beaulieu PL, Gandhi SD, Iqbal Z, Butler EG, Almassi GH, Pagel PS, Levy JH. Case 4—2007. J Cardiothorac Vasc Anesth 2007; 21:597-601. [PMID: 17678797 DOI: 10.1053/j.jvca.2007.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Phillip L Beaulieu
- Department of Anesthesiology, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI 53295, USA
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