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Gerstein NS, Brierley JK, Windsor J, Panikkath PV, Ram H, Gelfenbeyn KM, Jinkins LJ, Nguyen LC, Gerstein WH. Antifibrinolytic Agents in Cardiac and Noncardiac Surgery: A Comprehensive Overview and Update. J Cardiothorac Vasc Anesth 2017; 31:2183-2205. [DOI: 10.1053/j.jvca.2017.02.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Indexed: 12/19/2022]
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Abstract
Despite refinements in cardiac surgical technique, disorders of haemostasis remain a significant problem, reflecting the effects of cardiopulmonary bypass on blood cell activation and coagulation. Increased understanding of the dangers of blood and blood product transfusion have shifted the goals from blood replacement to blood conservation in cardiac surgery. Two approaches to blood conservation are used: autotransfusion and administration of pharmacological agents. These approaches may be complementary, but the latter approach- preventing or at least modifying the haemostatic disorder- may be preferable. This paper reviews some of the pharmacological agents that have been used in an attempt to conserve blood, including e-aminocaproic acid, desmopressin, prostacyclin, tranexamic acid, dipyridamole, and aprotinin. None of these agents has been able to eliminate the need for blood transfusion in all patients; aprotinin has been successful, however, in eliminating the need for transfusion in some patients and dramatically reducing the need in others.
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Choudhuri P, Biswas BK. Intraoperative Use of Epsilon Amino Caproic Acid and Tranexamic Acid in Surgeries Performed Under Cardiopulmonary Bypass: a Comparative Study To Assess Their Impact On Reopening Due To Postoperative Bleeding. Ethiop J Health Sci 2016; 25:273-8. [PMID: 26633931 PMCID: PMC4650883 DOI: 10.4314/ejhs.v25i3.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Open heart surgeries under cardiopulmonary bypass are associated with excessive perioperative bleeding that often requires reoperation. Antifibrinolytics like epsilon aminocaproic acid and tranexamic acid are widely used to control bleeding. There are limited studies primarily showing the impact of these drugs on the incidence of reopening following open heart surgical procedures. The goal of this study was to compare incidence of reopening following open heart surgeries in patients who were administered either epsilon amino caproic acid or tranexamic acid for control of perioperative bleeding. Methods A prospective, randomized, controlled trial was performed among seventy-eight patients of either sex in the age group of 18 to 65 years scheduled for open heart surgeries under cardiopulmonary bypass. They were randomly allocated into three groups where group A (n=26) received epsilon aminocaproic acid, group B (n=26) received tranexamic acid and group C (control group, n=26) received intravenous 0.9% normal saline. Patients had similar anaesthetic protocols, and were monitored for twenty-four hours postoperatively to assess reopening rates because of excessive bleeding. Results Two patients in each group receiving either tranexamic acid or epsilon aminocaproic acid had excessive bleeding requiring reopening after surgery whereas three patients in the control group had undergone reopening for excessive bleeding (p>0.05). Conclusions Epsilon aminocaproic acid and tranexamic acid exhibit similar and comparable effect to placebo on incidence of reopening for excessive bleeding following open heart surgeries under cardiopulmonary bypass
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Affiliation(s)
- Pratiti Choudhuri
- Department of Anesthesiology, ESI-Postgraduate Institute of Medical Sciences & Research, Kolkata, India
| | - Binay Kumar Biswas
- Department of Anesthesiology, ESI-Postgraduate Institute of Medical Sciences & Research, Kolkata, India
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Abstract
Perioperative bleeding in cardiac surgery is related to both surgical trauma of blood vessels and defects in the hemostatic mechanism caused, in part, by cardiopulmonary bypass. Blood transfusion therefore remains a significant risk of cardiac surgery with important health and economic consequences. Blood conservation strategies for cardiac surgery have advanced over the years and the following discussion will focus on the current practices at Toronto General Hospital.
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Affiliation(s)
- Jacek M. Karski
- Department of Anaesthesia of the Toronto General Hospital of University of Toronto, Ontario, Canada
| | - Joselito T. Balatbat
- Department of Anesthesiology of University of Louisville Hospital, Louisville, Kentucky
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Chauhan S, Bisoi AK, Rao BH, Rao MS, Saxena N, Venugopal P. Dosage of Epsilon-Aminocaproic Acid to Reduce Postoperative Blood Loss. Asian Cardiovasc Thorac Ann 2016. [DOI: 10.1177/021849230000800104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Postoperative blood loss, blood and blood-product requirements, and complications were compared for 3 commonly used doses of epsilon-aminocaproic acid in 150 patients undergoing first-time coronary artery bypass surgery. The patients were randomly assigned to one of 4 groups. Group 1 (n = 30) served as a control, group 2 (n = 30) received a single dose of 150 mg·kg−1 of epsilon-aminocaproic acid after anesthetic induction, group 3 (n = 30) received a loading dose of 150 mg·kg−1 followed by infusion of 1 g·h−1 for 6 hours, and group 4 (n = 60) received doses of 150 mg·kg−1 at induction, on bypass, and after protamine. No patients, including those who had endarterectomies, experienced any complications attributable to epsilon-aminocaproic acid administration. All patients who received epsilon-aminocaproic acid had significantly less bleeding compared to controls. Groups 3 and 4 had the least blood loss and packed-cell requirements.
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Affiliation(s)
- Sandeep Chauhan
- Department of Cardiothoracic and Vascular Surgery Cardiothoracic Sciences Centre All India Institute of Medical Sciences New Delhi, India
| | - Akshay Kumar Bisoi
- Department of Cardiothoracic and Vascular Surgery Cardiothoracic Sciences Centre All India Institute of Medical Sciences New Delhi, India
| | - Beeraka Heramba Rao
- Department of Cardiothoracic and Vascular Surgery Cardiothoracic Sciences Centre All India Institute of Medical Sciences New Delhi, India
| | - M Sanjeeva Rao
- Department of Cardiothoracic and Vascular Surgery Cardiothoracic Sciences Centre All India Institute of Medical Sciences New Delhi, India
| | - Nita Saxena
- Department of Cardiothoracic and Vascular Surgery Cardiothoracic Sciences Centre All India Institute of Medical Sciences New Delhi, India
| | - Panangipalli Venugopal
- Department of Cardiothoracic and Vascular Surgery Cardiothoracic Sciences Centre All India Institute of Medical Sciences New Delhi, India
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Pharmacokinetics of ε-Aminocaproic Acid in Neonates Undergoing Cardiac Surgery with Cardiopulmonary Bypass. Anesthesiology 2015; 122:1002-9. [PMID: 25723765 DOI: 10.1097/aln.0000000000000616] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antifibrinolytic medications such as ε-aminocaproic acid (EACA) are used in pediatric heart surgery to decrease surgical bleeding and transfusion. Dosing schemes for neonates are often based on adult regimens, or are simply empiric, in part due to the lack of neonatal pharmacokinetic information. The authors sought to determine the pharmacokinetics of EACA in neonates undergoing cardiac surgery and to devise a dosing regimen for this population. METHODS Ten neonates undergoing cardiac surgery with cardiopulmonary bypass were given EACA according to standard practice, and blood was drawn at 10 time points to determine drug concentrations. Time-concentration profiles were analyzed using nonlinear mixed effects models. Parameter estimates (standardized to a 70-kg person) were used to develop a dosing regimen intended to maintain a target concentration shown to inhibit fibrinolysis in neonatal plasma (50 mg/l). RESULTS Pharmacokinetics were described using a two-compartment model plus an additional compartment for the cardiopulmonary bypass pump. First-order elimination was described with a clearance of 5.07 l/h × (WT/70). Simulation showed a dosing regimen with a loading dose of 40 mg/kg and an infusion of 30 mg · kg · h, with a pump prime concentration of 100 mg/l maintained plasma concentrations above 50 mg/l in 90% of neonates during cardiopulmonary bypass surgery. CONCLUSIONS EACA clearance, expressed using allometry, is reduced in neonates compared with older children and adults. Loading dose and infusion dose are approximately half those required in children and adults.
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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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Fraser IS, Porte RJ, Kouides PA, Lukes AS. A benefit-risk review of systemic haemostatic agents: part 1: in major surgery. Drug Saf 2008; 31:217-30. [PMID: 18302446 DOI: 10.2165/00002018-200831030-00003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Systemic haemostatic agents play an important role in the management of blood loss during major surgery where significant blood loss is likely and their use has increased in recent times as a consequence of demand for blood products outstripping supply and the risks associated with transfusions. Their main application is as prophylaxis to reduce bleeding in major surgery, including cardiac and orthopaedic surgery and orthotopic liver transplantation. Aprotinin has been the predominant agent used in this setting; of the other antifibrinolytic agents that have been studied, tranexamic acid is the most effective and epsilon-aminocaproic acid may also have a role. Eptacog alfa (recombinant factor VIIa) has also shown promise. Tranexamic acid, epsilon-aminocaproic acid and eptacog alfa are generally well tolerated; however, when considering the methods to reduce or prevent blood loss intra- and postoperatively, the benefits of these agents need to be weighed against the risk of adverse events. Recently, concerns have been raised about the safety of aprotinin after an association between increased renal dysfunction and mortality was shown in retrospective observational studies and an increase in all-cause mortality with aprotinin relative to tranexamic acid or epsilon-aminocaproic acid was seen after a pre-planned periodic analysis of the large BART (Blood conservation using Antifibrinolytics in a Randomized Trial) study. The latter finding resulted in the trial being halted, and aprotinin has subsequently been withdrawn from the market pending detailed analysis of efficacy and safety results from the study. Part 1 of this benefit-risk review examines the efficacy and adverse effect profiles of systemic haemostatic agents commonly used in surgery, and provides individual benefit-risk profiles that may assist clinicians in selecting appropriate pharmacological therapy in this setting.
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Affiliation(s)
- Ian S Fraser
- Department of Obstetrics and Gynaecology, University of Sydney, Sydney, New South Wales, Australia.
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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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Brown JR, Birkmeyer NJO, O'Connor GT. Meta-analysis comparing the effectiveness and adverse outcomes of antifibrinolytic agents in cardiac surgery. Circulation 2007; 115:2801-13. [PMID: 17533182 DOI: 10.1161/circulationaha.106.671222] [Citation(s) in RCA: 222] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Since the 1980s, antifibrinolytic therapies have assisted surgical teams in reducing the amount of blood loss. To date, however, serious questions remain regarding the safety and effectiveness of these agents. METHODS AND RESULTS We conducted a meta-analysis to compare aprotinin, epsilon-aminocaproic acid, and tranexamic acid with placebo and head to head on 8 clinical outcomes from 138 trials. Published randomized controlled trial data were collected from OVID/PubMed. Outcomes included total blood loss, transfusion of packed red blood cells, reexploration, mortality, stroke, myocardial infarction, dialysis-dependent renal failure, and renal dysfunction (0.5-mg/dL increase in creatinine from baseline). All agents were effective in significantly reducing blood loss by 226 to 348 mL and the proportion of patients transfused with packed red blood cells over placebo. Only high-dose aprotinin reduced the rate of reexploration (relative risk, 0.49; 95% CI, 0.33 to 0.73). There were no significant risks or benefits for any agent for mortality, stroke, myocardial infarction, or renal failure. However, high-dose aprotinin significantly increased the risk of renal dysfunction (relative risk, 1.47; 95% CI, 1.12 to 1.94), 12.9% versus 8.4%. Compared head to head, high-dose aprotinin demonstrated significant reduction in total blood loss over epsilon-aminocaproic acid (-184 mL; 95% CI, -256 to -112) and tranexamic acid (-195 mL; 95% CI, -286 to -105). There were no significant differences among any agent when compared head to head on other outcomes. CONCLUSIONS All antifibrinolytic agents were effective in reducing blood loss and transfusion. There were no significant risks or benefits for mortality, stroke, myocardial infarction, or renal failure. However, high-dose aprotinin was associated with a statistically significant increased risk of renal dysfunction.
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Affiliation(s)
- Jeremiah R Brown
- Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH, USA.
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Edmunds LH, Colman RW. Thrombin During Cardiopulmonary Bypass. Ann Thorac Surg 2006; 82:2315-22. [PMID: 17126170 DOI: 10.1016/j.athoracsur.2006.06.072] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Revised: 06/28/2006] [Accepted: 06/28/2006] [Indexed: 12/30/2022]
Abstract
Cardiopulmonary bypass (CPB) ignites a massive defense reaction that stimulates all blood cells and five plasma protein systems to produce a myriad of vasoactive and cytotoxic substances, cell-signaling molecules, and upregulated cellular receptors. Thrombin is the key enzyme in the thrombotic portion of the defense reaction and is only partially suppressed by heparin. During CPB, thrombin is produced by both extrinsic and intrinsic coagulation pathways and activated platelets. The routine use of a cell saver and the eventual introduction of direct thrombin inhibitors now offer the possibility of completely suppressing thrombin production and fibrinolysis during cardiac surgery with CPB.
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Affiliation(s)
- L Henry Edmunds
- Harrison Department of Surgical Research, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Gunawan B, Runyon B. The efficacy and safety of epsilon-aminocaproic acid treatment in patients with cirrhosis and hyperfibrinolysis. Aliment Pharmacol Ther 2006; 23:115-20. [PMID: 16393288 DOI: 10.1111/j.1365-2036.2006.02730.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with decompensated cirrhosis are at risk for hyperfibrinolysis; this is potentially fatal. epsilon-aminocaproic acid has been used to treat patients with hyperfibrinolysis; however, the data about its benefit in the setting of cirrhosis are minimal. AIM To analyse the efficacy of epsilon-aminocaproic acid and its safety in cirrhotic patients with hyperfibrinolysis. METHODS All patients with an abnormal euglobin lysis time who were admitted to Rancho Los Amigos Medical Center from 1 January 2001 to 31 December 2002 were included in the study. Their medical records were reviewed and analysed. RESULTS There were 60 cirrhotic patients with shortened euglobin lysis time. Fifty-two patients received epsilon-aminocaproic acid. Of the 52 patients, seven had one or more bleeding episodes with the subcutaneous or soft tissue bleeding as the most common indication for epsilon-aminocaproic acid use. Of the 37 patients, 34 (92%) had improvement or resolution of their bleeding. Only two (3%) patients had epsilon-aminocaproic acid treatment discontinued because of minor side effects, rash and lightheadedness. There were no thromboembolic complications of treatment. CONCLUSIONS epsilon-aminocaproic acid was found to be effective and safe for treatment of hyperfibrinolysis in patients with cirrhosis.
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Affiliation(s)
- B Gunawan
- University of Southern California Liver Unit, Rancho Los Amigos Medical Center, Downey, CA 92354, USA
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Kalmadi S, Tiu R, Lowe C, Jin T, Kalaycio M. Epsilon aminocaproic acid reduces transfusion requirements in patients with thrombocytopenic hemorrhage. Cancer 2006; 107:136-40. [PMID: 16708357 DOI: 10.1002/cncr.21958] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Epsilon aminocaproic acid (EACA) is an antifibrinolytic drug that has been used to control hemorrhage by stabilizing the thrombus. It has been used in thrombocytopenic patients largely on an empiric basis. METHODS Concerns regarding side effects have limited the use of this drug. The authors reviewed their experience with EACA at the Cleveland Clinic Foundation from 1997 to 2003. RESULTS Of 77 patients with thrombocytopenic hemorrhage, 51 (66%) patients achieved a complete response and 13 (17%) patients achieved a partial response, resulting in a decrease in platelet and red blood cell transfusions. Adverse effects were manageable in this set of patients with severe underlying disease. CONCLUSIONS Based on this experience, EACA may be a valuable adjunctive therapy in the treatment of patients with thrombocytopenic hemorrhage.
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Affiliation(s)
- Sujith Kalmadi
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, Ohio 44122, USA.
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. MGM, . PEA. The Efficacy of Epsilon-aminocaproic Acid and its Timing in Reducing Blood Loss in Major Cardiac Coronary Bypass Surgery: A Randomized Double-blinded Placebo-controlled Study. INT J PHARMACOL 2005. [DOI: 10.3923/ijp.2006.131.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Whitlock R, Crowther MA, Ng HJ. Bleeding in Cardiac Surgery: Its Prevention and Treatment—an Evidence-Based Review. Crit Care Clin 2005; 21:589-610. [PMID: 15992674 DOI: 10.1016/j.ccc.2005.04.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Expected and unexpected bleeding occur frequently in patients undergoing cardiac surgery. Bleeding after cardiac surgery can be broadly divided into two groups: surgical (unrecognized bleeding vessel, anastomosis, or other suture line) or nonsurgical bleeding (caused by coagulopathy). Factors influencing both surgical and nonsurgical bleeding can be further broken down into those occurring preoperatively and those that occur intraoperatively and postoperatively. A thorough understanding of these factors is necessary to reduce bleeding. This is a desirable clinical goal, because excessive bleeding is associated with adverse outcomes.
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Affiliation(s)
- Richard Whitlock
- Department of Medicine, McMaster University, Room L208, St. Joseph's Hospital, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada
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Serna DL, Thourani VH, Puskas JD. Antifibrinolytic agents in cardiac surgery: Current controversies. Semin Thorac Cardiovasc Surg 2005; 17:52-8. [PMID: 16104361 DOI: 10.1053/j.semtcvs.2004.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Antifibrinolytic agents play a prominent role in adult cardiac surgery. This article is a review of the modern published experience of antifibrinolytic agent use in adult cardiac surgery. The use of tranexamic acid, epsilon-aminocaproic acid, and aprotinin is examined during primary cardiac surgery, deep hypothermic circulatory arrest, reoperative cardiac surgery, and off-pump coronary artery bypass surgery. In addition, the issues of vein graft patency and hypersensitivity reaction in the presence of antifibrinolytic agents are examined.
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Affiliation(s)
- Daniel L Serna
- Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA 30308, USA
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Ballen KK, Becker PS, Yeap BY, Matthews B, Henry DH, Ford PA. Autologous Stem-Cell Transplantation Can Be Performed Safely Without the Use of Blood-Product Support. J Clin Oncol 2004; 22:4087-94. [PMID: 15353543 DOI: 10.1200/jco.2004.01.144] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose Autologous stem-cell transplantation has been shown to be a curative procedure for a variety of leukemias and lymphomas. Most transplants require RBC and platelet support. We report the ability to perform autologous transplantation without blood-product support. Subjects and Methods In this study, we treated 26 patients with religious objection to blood products with autologous stem-cell support without the use of any blood products. Patients received a combination of granulocyte colony-stimulating factor (G-CSF), erythropoietin, and interleukin-11 or G-CSF alone to mobilize stem cells. Post-transplant patients received intravenous iron, erythropoietin, G-CSF, and epsilon aminocaproic acid. Results There were two major bleeding complications (8%), with two treatment-related deaths (8%). There were three minor bleeding complications (12%). The median fall in hemoglobin level was 4.7 g/dL; the median hemoglobin level 30 days after transplantation was 9.2 g/dL. The median total number of days with platelet count less than 10 × 109/L was 4 days; the median days to platelet recovery greater than 20 × 109/L was 12 days. Conclusion Autologous stem-cell transplantation can be performed safely without the use of any blood products.
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Affiliation(s)
- Karen K Ballen
- Division of Hematology/Oncology, Massachusetts General Hospital, 100 Blossom St, Cox 640, Boston, MA 02114, USA.
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20
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Green JA, Spiess BD. Current status of antifibrinolytics in cardiopulmonary bypass and elective deep hypothermic circulatory arrest. ACTA ACUST UNITED AC 2003; 21:527-51. viii. [PMID: 14562564 DOI: 10.1016/s0889-8537(03)00042-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Cardiopulmonary bypass (CPB) results in many physiologic derangements, including activation of the hemostatic and fibrinolytic pathways. Deep hypothermic circulatory arrest (DHCA) adds a further insult to the coagulation systems because it involves more extreme hypothermia and organ ischemia related to blood stasis. The abnormalities induced by CPB disrupt the checks and balances in the hemostatic and fibrinolytic systems, resulting in a pathologic state that leads to excessive bleeding and other perioperative complications. Prophylactic antifibrinolytic therapy can attenuate the response to this insult by restoring the delicate balance within these systems, potentially reducing the complication rate and improving patient outcomes.
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Affiliation(s)
- Jeffrey A Green
- Department of Anesthesiology, Virginia Commonwealth University, Medical College of Virginia Campus, 1200 East Broad Street, PO Box 980695, Richmond, VA 23209, USA.
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Abstract
This article focuses on new findings leading to improved understanding of the pathophysiology and mechanisms of potential drug interactions between anesthetic drugs or techniques and cardiovascular medications in patients scheduled for surgery. Only the most frequently used drugs are reviewed. Elective surgery provides the luxury to consider these risks and alter therapy accordingly. Under urgent circumstances, however, the increased risks associated with these agents should be anticipated with the goal to minimize adverse effects while maintaining optimal cardiovascular function in the perioperative period.
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Affiliation(s)
- Sheldon Goldstein
- Division of Cardiac Anesthesia, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Gomez D, Olshove V, Weinstein S, Davis JT. Blood Conservation During Pediatric Cardiac Surgery. ACTA ACUST UNITED AC 2002. [DOI: 10.1111/j.1778-428x.2002.tb00057.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Despotis GJ, Avidan MS, Hogue CW. Mechanisms and attenuation of hemostatic activation during extracorporeal circulation. Ann Thorac Surg 2001; 72:S1821-31. [PMID: 11722116 DOI: 10.1016/s0003-4975(01)03211-8] [Citation(s) in RCA: 200] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients undergoing cardiac surgery with cardiopulmonary bypass are at risk for excessive microvascular bleeding, which often leads to transfusion of allogeneic blood and blood components as well as reexploration in a smaller subset of patients. Excessive bleeding after cardiac surgery is generally related to a combination of several alterations in the hemostatic system pertaining to hemodilution, excessive activation of the hemostatic system, and potentially the use of newer, longer-acting antiplatelet or antithrombotic agents. Although several nonpharmacologic strategies have been proposed, this review summarizes the role of pharmacologic interventions as means to attenuate the alterations in the hemostatic system during CPB in an attempt to reduce excessive bleeding, transfusion, and reexploration. Specifically, agents that inhibit platelets, fibrinolysis, factor Xa and thrombin, as well as broad-spectrum agents, have been investigated with respect to their role in reducing consumption of clotting factors and better preservation of platelet function. Prophylactic administration of agents with antifibrinolytic, anticoagulant, and possibly antiinflammatory properties can decrease blood loss and transfusion. Although aprotinin seems to be the most effective blood conservation agent (which is most likely related to its broad-spectrum nature), agents with isolated antifibrinolytic properties may be as effective in low-risk patients. The ability to reduce blood product transfusions and to decrease operative times and reexploration rates favorably affects patient outcomes, availability of blood products, and overall health care costs.
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Affiliation(s)
- G J Despotis
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Uozaki Y, Watanabe G, Kotou K, Ueyama K, Doi Y, Misaki T. Effect of tranexamic acid on blood loss reduction after cardiopulmonary bypass. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2001; 49:273-8. [PMID: 11431944 DOI: 10.1007/bf02913132] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We evaluated the effect of tranexamic acid on blood loss in patients undergoing elective cardiopulmonary bypass for coronary artery bypass surgery. METHODS We randomly assigned 7 of 14 patients to a group receiving 50 mg/kg tranexamic acid before skin incision and after the start of cardiopulmonary bypass and the other 7 as controls. RESULTS Intraoperative and postoperative blood loss was significantly (p = 0.025) reduced in the tranexamic acid group. A similar decrease in platelet count was observed during cardiopulmonary bypass in both groups. Antithrombin III was significantly (p = 0.013) decreased in both groups during cardiopulmonary bypass. Antithrombin III and thrombin-antithrombin III complexes were significantly (p = 0.001) increased after protamine administration. A significant (p = 0.010) decrease in alpha 2-plasmin inhibitor was noted at 5 and 60 minutes after the start of cardiopulmonary bypass in the tranexamic acid group. alpha 2-plasmin inhibitor-plasmin complexes were significantly (p = 0.001) increased after the start of cardiopulmonary bypass in both groups and were significantly (p = 0.012) decreased after protamine administration. alpha 2-plasmin inhibitor-plasmin complexes in the tranexamic acid group were significantly (p = 0.030) lower than in controls 60 minutes after the start of cardiopulmonary bypass, just prior to the end of cardiopulmonary bypass, and after protamine administration. CONCLUSIONS These findings showed that tranexamic acid administration effectively prevented perioperative blood loss without thromboembolic complications and that tranexamic acid during cardiopulmonary bypass coordinates the anticoagulative effect of heparin and the antifibrinolytic effect of tranexamic acid.
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Affiliation(s)
- Y Uozaki
- First Department of Surgery, Toyama Medical and Pharmaceutical University, 2630 Sugitani, Toyama 930-0194, Japan
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Abstract
There is still no alternative that is as effective or as well tolerated as blood; nevertheless, the search for ways to conserve, and even eliminate blood transfusion, continues. Based on hemoglobin levels, practice guidelines for the use of perioperative transfusion of red blood cells in patients undergoing coronary artery bypass grafting have been formulated by the National Institutes of Health and the American Society of Anesthesiologists. However, it has been argued that more physiologic indicators of adequacy of oxygen delivery should be used to assess the need for blood transfusion. Methods used for conserving blood during surgery include autologous blood donation, acute normovolemic hemodilution and intra- and postoperative blood recovery and reinfusion. The guidelines for the use of autologous blood transfusion are controversial and it does not appear to be cost effective compared with allogeneic blood transfusion in patients undergoing cardiac surgery. Similarly, the cost effectiveness of intra- and postoperative blood recovery and reinfusion need further evaluation. Treatment with recombinant human erythropoietin (rhEPO) remains unapproved in the US for patients undergoing cardiac or vascular surgery, but it is a valuable adjunct in Jehovah's Witness patients, for whom blood is unacceptable. The characterization of darbepoetin alfa, a novel erythropoiesis stimulating protein with a 3-fold greater plasma elimination half-life compared with rhEPO, is an important advance in this field. Darbepoetin alfa appears to be effective in treating the anemia in patients with renal failure or cancer and trials in patients with surgical anemia are planned. Desmopressin has been used to effectively reduce intraoperative blood loss. Topical agents to prevent blood loss, such as fibrin glue and fibrin gel, and agents that alter platelet function, such as aspirin (acetylsalicylic acid) or dipyridamole, need further evaluation in patients undergoing cardiac surgery. Aprotinin has been shown to preserve hemostasis and reduce allogeneic blood exposure to a greater extent than the antifibrinolytic agents tranexamic acid and aminocaproic acid. Controlled clinical trials comparing the costs of these agents with clinical outcomes, along with tolerability profiles in patients at risk for substantial perioperative bleeding are needed.
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Affiliation(s)
- L T Goodnough
- Department of Medicine and Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Henry DA, Moxey AJ, Carless PA, O'Connell D, McClelland B, Henderson KM, Sly K, Laupacis A, Fergusson D. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2001:CD001886. [PMID: 11279735 DOI: 10.1002/14651858.cd001886] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Concerns regarding the safety of transfused blood have prompted re-consideration of the use of allogeneic (blood from an unrelated donor) blood transfusion. OBJECTIVES To assess the effects of the anti-fibrinolytic drugs aprotinin, tranexamic acid, and epsilon aminocaproic acid, on peri-operative red blood cell (RBC) transfusion. SEARCH STRATEGY We searched MEDLINE (to May 1998), EMBASE (to December 1997), web sites of international health technology assessment agencies (to May 1998). References in identified trials and review articles were checked and authors contacted to identify any additional studies. SELECTION CRITERIA Randomised controlled trials of anti-fibrinolytic drugs in adults scheduled for non-urgent surgery. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS We found 61 trials of aprotinin (7027 participants). Aprotinin reduced the rate of RBC transfusion by a relative 30% (RR=0.70: 95%CI: 0.64 to 0.76). The average absolute risk reduction (ARR) was 20.4% (95%CI: 15.6% to 25.3%). On average, aprotinin use saved 1.1 units of RBC (95%CI: 0.69 to 1.47) in those requiring transfusion. Aprotinin also significantly reduced the need for re-operation due to bleeding (RR=0.40: 95%CI: 0.25 to 0.66). We found 18 trials of tranexamic acid (TXA) (1,342 participants). TXA reduced the rate of RBC transfusion by a relative 34% (RR=0.66: 95%CI: 0.54 to 0.81). This represented an ARR of 17.2% (95%CI: 8.7% to 25.7%). TXA use resulted in a saving of 1.03 units of RBC (95%CI: 0.67 to 1.39) in those requiring transfusion. We found four trials of epsilon aminocaproic acid (EACA) (208 participants). EACA use resulted in a statistically non-significant reduction in RBC transfusion (RR=0.48: 95%CI: 0.19 to 1.19). Comparisons between agents Eight trials made 'head-to-head' comparisons between TXA and aprotinin. There was no significant difference between the two drugs in the rate of RBC transfusion: RR=1.21 (95%CI: 0.83 to 1.76) for TXA compared to aprotinin. Adverse Effects Aprotinin did not seem to be associated with an excess risk of adverse effects, including thrombo-embolic events (thrombosis RR=0.64: 95%CI: 0.31 to 1.31) and renal failure (RR=1.19: 95%CI: 0.79 to 1.79). Fewer data were available for TXA and EACA. REVIEWER'S CONCLUSIONS From this review it appears that aprotinin reduces the need for red cell transfusion, and the need for re-operation due to bleeding, without serious adverse effects. However, there was significant heterogeneity in trial outcomes, and some evidence of publication bias. Similar trends were seen with TXA and EACA, although the data were rather sparse. The poor evaluation of these latter drugs is unfortunate as results suggest they may be equally as effective as aprotinin, but are significantly cheaper. The evidence reviewed here supports the use of aprotinin in cardiac surgery. Further small trials of this drug are not warranted. Future trials should be large enough to compare the efficacy and cost-effectiveness of aprotinin with that of TXA and EACA.
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Affiliation(s)
- D A Henry
- Discipline of Clinical Pharmacology, Faculty of Medicine and Health Sciences, The University of Newcastle, Newcastle Mater Hospital, Edith St Waratah, Newcastle, New South Wales, Australia, 2298.
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Gruber EM, Shukla AC, Reid RW, Hickey PR, Hansen DD. Synthetic antifibrinolytics are not associated with an increased incidence of baffle fenestration closure after the modified Fontan procedure. J Cardiothorac Vasc Anesth 2000. [DOI: 10.1053/cr.2000.5859] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Levi M, Cromheecke ME, de Jonge E, Prins MH, de Mol BJ, Briët E, Büller HR. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet 1999; 354:1940-7. [PMID: 10622296 DOI: 10.1016/s0140-6736(99)01264-7] [Citation(s) in RCA: 342] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Excessive bleeding may complicate cardiac surgery, and is associated with increased morbidity and mortality. Pharmacological strategies to decrease perioperative bleeding have been investigated in a large number of controlled trials, most of which have shown a decrease in blood loss. However, most studies lacked sufficient power to detect a beneficial effect on clinically more relevant outcomes. We did a meta-analysis of all randomised, controlled trials of the three most frequently used pharmacological strategies to decrease perioperative blood loss (aprotinin, lysine analogues [aminocaproic acid and tranexamic acid], and desmopressin). METHODS Studies were included if they reported at least one clinically relevant outcome (mortality, rethoracotomy, proportion of patients receiving a transfusion, or perioperative myocardial infarction) in addition to perioperative blood loss. In addition, a separate meta-analysis was done for studies concerning complicated cardiac surgery. FINDINGS We identified 72 trials (8409 patients) that met the inclusion criteria. Treatment with aprotinin decreased mortality almost two-fold (odds ratio 0.55 [95% CI 0.34-0.90]) compared with placebo. Treatment with aprotinin and with lysine analogues decreased the frequency of surgical re-exploration (0.37 [0.25-0.55], and 0.44 [0.22-0.90], respectively). These two treatments also significantly decreased the proportion of patients receiving any allogeneic blood transfusion. By contrast, the use of desmopressin resulted in a small decrease in perioperative blood loss, but was not associated with a beneficial effect on other clinical outcomes. Aprotinin and lysine analogues did not increase the risk of perioperative myocardial infarction; however, desmopressin was associated with a 2.4-fold increase in the risk of this complication. Studies in patients undergoing complicated cardiac surgery showed similar results. INTERPRETATION Pharmacological strategies that decrease perioperative blood loss in cardiac surgery, in particular aprotinin and lysine analogues, also decrease mortality, the need for rethoracotomy, and the proportion of patients receiving a blood transfusion.
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Affiliation(s)
- M Levi
- Department of Vascular Medicine, Academic Medical Centre, University of Amsterdam, The Netherlands.
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29
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Eagle KA, Guyton RA, Davidoff R, Ewy GA, Fonger J, Gardner TJ, Gott JP, Herrmann HC, Marlow RA, Nugent WC, O'Connor GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf S, Gibbons RJ, Alpert JS, Eagle KA, Garson A, Gregoratos G, Russell RO, Smith SC. ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery). American College of Cardiology/American Heart Association. J Am Coll Cardiol 1999; 34:1262-347. [PMID: 10520819 DOI: 10.1016/s0735-1097(99)00389-7] [Citation(s) in RCA: 329] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Williams GD, Bratton SL, Riley EC, Ramamoorthy C. Efficacy of epsilon-aminocaproic acid in children undergoing cardiac surgery. J Cardiothorac Vasc Anesth 1999; 13:304-8. [PMID: 10392682 DOI: 10.1016/s1053-0770(99)90268-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To compare coagulation test results, blood loss, and blood product transfusions between patients receiving prophylactic epsilon-aminocaproic acid (EACA) and a control group matched for age, resternotomy, and surgery in children undergoing cardiac surgery. DESIGN Nested case-control study. SETTING University-affiliated, pediatric medical center. PARTICIPANTS Same study period; 70 patients in EACA group and 70 patients in control group. INTERVENTIONS Prophylactic EACA administered intravenously (load, 150 mg/kg, infusion; 30 mg/kg/h) to 70 patients at increased risk for bleeding (reoperation or Ross procedure). MEASUREMENTS AND MAIN RESULTS Coagulation test values were measured before, during, and after cardiopulmonary bypass (CPB). Intraoperative blood loss, postoperative chest tube output, and allogenic blood product transfusions were recorded. Comparison of demographic and surgical data indicated close matching of the EACA and control groups. The EACA group ([median, 25th to 75th quartile] 15.6 mL/kg; 9.2 to 26.3 mL/kg) had less intraoperative blood loss than the control group (22.2 mL/kg; 14.3 to 36.3 mL/kg; p = 0.02). Postoperative chest tube output at 6 hours (p = 0.08), 12 hours (p = 0.07), and 24 hours (p = 0.08) was not significantly different between groups. Fewer EACA group patients required reexploration for bleeding (p < 0.05). There was no difference between groups in blood products transfused (in milliliters per kilogram or allogenic exposure per patient). Thromboelastography values (maximum amplitude [MA], whole blood clot lysis index at 30 minutes after MA) during CPB were better preserved in the EACA group. CONCLUSION EACA reduced intraoperative blood loss but did not significantly decrease blood product transfusions. Lack of efficacy may be related to relative underdosing and should be further studied.
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Affiliation(s)
- G D Williams
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, USA
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Munoz JJ, Birkmeyer NJ, Birkmeyer JD, O'Connor GT, Dacey LJ. Is epsilon-aminocaproic acid as effective as aprotinin in reducing bleeding with cardiac surgery?: a meta-analysis. Circulation 1999; 99:81-9. [PMID: 9884383 DOI: 10.1161/01.cir.99.1.81] [Citation(s) in RCA: 150] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although aprotinin is known to be effective in reducing postoperative hemorrhage after cardiac surgery, epsilon-aminocaproic acid, an alternative antifibrinolytic, is considerably less expensive. Because the results of 3 small randomized clinical trials comparing these 2 agents directly were inconclusive, we performed a meta-analysis to compare the relative effectiveness and adverse-effect profile of these 2 agents against placebo. METHODS AND RESULTS Data from 52 randomized clinical trials published between 1985 and 1998 involving the use of epsilon-aminocaproic acid (n=9) or aprotinin (n=46) in patients undergoing cardiac surgery were abstracted. Our primary outcomes were total blood loss, red blood cell transfusion rates and amounts, reexploration, stroke, myocardial infarction, and mortality. The meta-analysis revealed substantial reductions in total blood loss with epsilon-aminocaproic acid and low-dose aprotinin (each with a 35% reduction versus placebo, P<0.001) and high-dose aprotinin (53% reduction, P<0.001). There were identical reductions in total postoperative transfusions with epsilon-aminocaproic acid (61% reduction versus placebo, P<0. 010) and high-dose aprotinin (62% reduction, P<0.001). The proportion of patients transfused was similarly reduced with epsilon-aminocaproic acid (OR, 0.32; 95% CI, 0.15 to 0.69) and high-dose aprotinin (OR, 0.28; 0.22 to 0.37). Although both drugs reduced rates of reexploration to similar degrees, this effect was statistically significant only with high-dose aprotinin (OR, 0.39; 0. 24 to 0.61). epsilon-Aminocaproic acid and aprotinin had no effect on risks of postoperative myocardial infarction or overall mortality. CONCLUSIONS Because the 2 antifibrinolytic agents appear to have similar efficacies, the considerably less-expensive epsilon-aminocaproic acid may be preferred over aprotinin for reducing hemorrhage with cardiac surgery.
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Affiliation(s)
- J J Munoz
- Department of Surgery, Dartmouth Medical School, Hanover, NH, USA.
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Eaton MP, Deeb GM. Aprotinin versus epsilon-aminocaproic acid for aortic surgery using deep hypothermic circulatory arrest. J Cardiothorac Vasc Anesth 1998; 12:548-52. [PMID: 9801976 DOI: 10.1016/s1053-0770(98)90099-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the relative efficacy of aprotinin and epsilon-aminocaproic acid (EACA) in decreasing blood loss and transfusion requirements after aortic surgery involving deep hypothermic circulatory arrest (DHCA). DESIGN A retrospective chart review. SETTING A university medical center. PARTICIPANTS Forty-nine patients who had undergone thoracic aortic surgery with the use of circulatory arrest. INTERVENTIONS Charts were examined for variables believed to influence postoperative blood loss, including the use of medications, and for the amount of postoperative chest tube drainage and perioperative transfusion. MEASUREMENTS AND MAIN RESULTS Median chest tube output (CTO) at 6 and 12 hours postoperatively was nearly identical in patients treated with aprotinin or EACA (660 and 1,015 v 700 and 950 mL for aprotinin and EACA at 6 and 12 hours, respectively), as were total perioperative blood transfusions. Complications were not significantly different between groups with the exception of a trend toward increased incidence of renal failure in the group receiving EACA. CONCLUSION Aprotinin and EACA appear to be equally efficacious in reducing perioperative blood loss and transfusion requirements in patients undergoing aortic surgery involving DHCA. Questions of safety remain about the use of EACA in this setting that could not be addressed by this small retrospective study. A prospective, placebo-controlled study is warranted to confirm the absolute efficacy of these agents and to better define safety issues.
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Affiliation(s)
- M P Eaton
- Department of Biostatistics, University of Rochester School of Medicine, NY 14642, USA
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34
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Affiliation(s)
- P M Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Maggiore Hospital, and the University of Milan, Italy
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Faught C, Wells P, Fergusson D, Laupacis A. Adverse effects of methods for minimizing perioperative allogeneic transfusion: a critical review of the literature. Transfus Med Rev 1998; 12:206-25. [PMID: 9673005 DOI: 10.1016/s0887-7963(98)80061-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- C Faught
- Department of Medicine, University of Ottawa, Ontario, Canada
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36
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Pelletier MP, Solymoss S, Lee A, Chiu RC. Negative reexploration for cardiac postoperative bleeding: can it be therapeutic? Ann Thorac Surg 1998; 65:999-1002. [PMID: 9564917 DOI: 10.1016/s0003-4975(98)00078-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Reexploration of the mediastinum for bleeding is required in 3% to 7% of patients after cardiac operation, with many proving to have no surgically correctable cause. In spite of a "negative exploration," the bleeding often ceases. We propose the hypothesis that such a negative exploration can be therapeutic by reducing marked fibrinolytic activity in the mediastinal cavity. METHODS Fibrinolytic activity in shed mediastinal blood was compared with that in the system blood in 5 patients after cardiac operation by measuring fibrinogen, fibrin degradation product, plasminogen activator inhibitor-1, and alpha2-antiplasmin levels. RESULTS Fibrinolytic activity in mediastinal blood was markedly increased when compared with paired systemic venous blood. This was indicated by the mediastinal blood's lower fibrinogen levels (0.47 versus 1.91 U/mL; p < 0.001), very high levels of fibrin degradation products (1,350 versus 200 ng/mL; p < 0.05), and higher levels of plasminogen activator inhibitor-1 (55.5 versus 28.1 ng/mL; p < 0.005). Decreased levels of alpha2-antiplasmin were also observed in the mediastinum (0.50 versus 0.61 U/mL; p < 0.05). CONCLUSIONS Our data confirm that fibrinolytic activity can be extremely high in the mediastinum in response to clot formation. This may explain the hemostatic effects of a negative reexploration, where irrigation and the removal of clots may reduce the fibrinolytic process; this may allow the bleeding ends of capillaries and small vessels to thrombose. Decreased levels of alpha2-antiplasmin observed suggest that lysine analogs, such as epsilon-aminocaproic acid, may have a beneficial role when locally delivered into the mediastinum.
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Affiliation(s)
- M P Pelletier
- Division of Cardiothoracic Surgery, The Montreal General Hospital, McGill University, Quebec, Canada
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Hardy JF, Bélisle S, Dupont C, Harel F, Robitaille D, Roy M, Gagnon L. Prophylactic tranexamic acid and epsilon-aminocaproic acid for primary myocardial revascularization. Ann Thorac Surg 1998; 65:371-6. [PMID: 9485231 DOI: 10.1016/s0003-4975(97)01016-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The efficacy of prophylactic epsilon-aminocaproic acid and tranexamic acid to reduce transfusions after primary myocardial revascularization was evaluated in a teaching hospital context. METHODS Patients (n = 134) received either epsilon-aminocaproic acid (15-g bolus + infusion of 1 g/h), high-dose tranexamic acid (10-g bolus + placebo infusion), or normal saline solution in a double-blind fashion. Anticoagulation and conduct of cardiopulmonary bypass were standardized. RESULTS Tranexamic acid and epsilon-aminocaproic acid produced a significant reduction in postoperative blood loss compared with placebo (median loss, 438 mL, 538 mL, and 700 mL, respectively). Transfusion of red cells was similar in all three groups. Nonetheless, the percentage of patients receiving hemostatic blood products was significantly decreased in the epsilon-aminocaproic acid group compared with the placebo group (20% versus 43%; p = 0.03). Both tranexamic acid and epsilon-aminocaproic acid significantly decreased total exposure to allogeneic blood products compared with placebo (p = 0.01 and p = 0.05, respectively), and this reduction was clinically important (median exposure, 2, 2, and 7.5 units, respectively). Fibrinolysis was inhibited significantly in both treatment groups. CONCLUSIONS We conclude that either high-dose tranexamic acid or epsilon-aminocaproic acid effectively reduces transfusions in patients undergoing primary, elective myocardial revascularization.
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Affiliation(s)
- J F Hardy
- Department of Anesthesia, Montreal Heart Institute, University of Montreal, Quebec, Canada.
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Rossi M, Storti S, Martinelli L, Varano C, Marra R, Zamparelli R, Possati G, Schiavello R. A pump-prime aprotinin dose in cardiac surgery: appraisal of its effects on the hemostatic system. J Cardiothorac Vasc Anesth 1997; 11:835-9. [PMID: 9412880 DOI: 10.1016/s1053-0770(97)90116-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To examine pump-prime aprotinin action on coagulation and fibrinolysis in patients undergoing primary coronary revascularization. DESIGN A prospective randomized study. SETTING A university hospital. PARTICIPANTS Forty-three patients were randomly assigned to either group A, 21 patients treated with 2 x 10(6) kallikrein inhibitor units (KIU) of aprotinin in the cardiopulmonary bypass (CPB) prime, or group B, 22 patients, untreated. INTERVENTIONS Patients, scheduled for elective coronary surgery, were treated with 2 x 10(6) KIU of aprotinin in the CPB prime. Markers of coagulation and fibrinolysis were evaluated. MEASUREMENTS AND MAIN RESULTS Surgical times, number of reopenings, and allogeneic blood requirements were collected for each patient. Blood samples were obtained before and after surgery for assessing coagulation (prothrombin time [PT], activated partial thromboplastin time [aPTT], ethanol test, factor VII, antithrombin III [AT III], thrombin-antithrombin III complex [TAT], fragment 1.2 of prothrombin [F1.2]) and fibrinolysis (fibrin degradation products [FOP], plasmin-antiplasmin complexes [PAP], D-dimers) markers variations. In group A surgical times were faster, there were fewer reopenings (0 v 3), and fewer blood transfusions (1 patient v 4 patients). The two groups did not differ for PT, aPTT, and fibrinogen measurements. Postoperative FDP (measurable in more patients of group B at the end of the operation), PAP, and D-dimers postoperatory levels (less increased in aprotinin group) show the antifibrinolytic properties of the drug. Regarding the coagulation markers, factor VII decreased, whereas TAT and F1.2 increased, all to a lesser extent in the aprotinin group compared with the untreated patients, at the end of operation. CONCLUSION Pump-prime aprotinin minimized, even if not completely inhibited, the activation of coagulation and fibrinolysis during CPB, possibly ensuring a less complicated and safer postoperative recovery. It seemed to allow the maintenance of a correct balance of hemostatic systems, avoiding the risk of thrombotic phenomena.
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Affiliation(s)
- M Rossi
- Department of Anesthesiology and Intensive Care, Catholic University of the Holy Heart, Rome, Italy
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Royston D. Hemostatic Drugs in Prothrombotic or Hypercoagulable States. Semin Cardiothorac Vasc Anesth 1997. [DOI: 10.1177/108925329700100410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Certain drug therapies, such as heparin, warfarin, and aspirin, are associated with prothrombotic or hypercoagulable states. If these agents that are administered to prevent thrombosis have been associated with its opposite effect, then agents that are specifically given to inhibit bleeding may produce a deleterious hypocoagulable effect. This article evaluates the risks presented by serine protease inhibitors (ie, aprotinin), lysine analog antifibrinolyics (ie, epsilon aminocaproic acid [Amicar, Wyeth-Ayerst, Philadelphia, PA] and tranexamic acid), and desmopressin acetate (DDAVP, Rhone-Poulenc Rorer, Collegeville, PA). It focuses on their mechanisms of action, particularly their effect on microvascular tone and endothelial function, coagulation factors, platelet function, and the fibrinolytic pathway. It discusses their use in the presence of known thrombin production or fibrinogen conversion and whether certain vascular beds are more prone to drug-related thrombosis.
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Affiliation(s)
- David Royston
- From the Department of Anaesthesia, Harefield Hospital, Harefield, United Kingdom
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Brown RS, Thwaites BK, Mongan PD. Tranexamic Acid Is Effective in Decreasing Postoperative Bleeding and Transfusions in Primary Coronary Artery Bypass Operations. Anesth Analg 1997. [DOI: 10.1213/00000539-199711000-00003] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Brown RS, Thwaites BK, Mongan PD. Tranexamic acid is effective in decreasing postoperative bleeding and transfusions in primary coronary artery bypass operations: a double-blind, randomized, placebo-controlled trial. Anesth Analg 1997; 85:963-70. [PMID: 9356085 DOI: 10.1097/00000539-199711000-00003] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
UNLABELLED We evaluated the effects of tranexamic acid (TA) administered before and after cardiopulmonary bypass (CPB) in a prospective, randomized, placebo-controlled, double-blind study of adult patients undergoing primary coronary artery bypass grafting surgery. Patients received placebo (n = 30) or TA 15 mg/kg before CPB, followed by a TA infusion of 1 mg x kg(-1) x h(-1) for 5 h (n = 30) or TA 15 mg/kg after CPB, followed by a TA infusion of 1 mg x kg(-1) x h(-1) for 5 h (n = 30). Demographic, medical, surgical, laboratory, mediastinal chest tube drainage (MCTD), hemoglobin loss, transfusion, and outcome data were collected. Allogenic blood product administration was tightly controlled. The demographic, medical, and surgical characteristics were similar in all three groups. The median postoperative MCTD and hemoglobin loss in the pre-CPB TA group (710 mL, 8.6 g) was significantly less (P < 0.001) compared with the control (1202 mL, 44.2 g) and post-CPB TA groups (1020 mL, 23.4 g). The percentage of patients who received no allogenic blood products was 27% for the pre-CPB TA group and 33% for the post-CPB TA group (not significant). These percentages were significantly lower than those in the placebo group (66%, P < 0.001). The median number of allogenic blood products administered to the pre-CPB TA group (0 units) was significantly less compared with the control group (4.5 units). The thromboelastogram and fibrinogen split product levels in the pre-CPB TA group indicated better platelet function and less activation of the fibrinolytic system compared with the other two groups (P < 0.05). There were no intergroup differences in reoperation, myocardial infarction, stroke, infections, or death. These data support the use of pre-CPB TA to decrease patient exposure to postcardiopulmonary bypass allogenic blood products. IMPLICATIONS In this randomized, placebo-controlled trial, we investigated the efficacy of tranexamic acid to decrease bleeding and blood transfusions after open-heart operations. Tranexamic acid administered before and during the operation was effective in decreasing both bleeding and transfusions. When tranexamic acid was administered immediately after the operation, it had a minor beneficial effect.
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Affiliation(s)
- R S Brown
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
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Affiliation(s)
- P G Loubser
- Department of Anesthesiology, Baylor College of Medicine, Methodist Hospital, Houston, TX, USA
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Abstract
Although excessive bleeding is widely recognized as a common complication of cardiac surgery, the recent success of antifibrinolytic drugs as prophylactic hemostatic agents has received little attention outside the surgical literature. The etiology of the coagulopathy following cardiac surgery is clearly multifactorial; however, the success of antifibrinolytic drugs as hemostatic agents suggests that fibrinolysis contributes to bleeding in this setting. Increasingly widespread administration of these drugs necessitates increased awareness of the risks and benefits posed by perioperative antifibrinolytic therapy. The objectives of this review are to understand the mechanisms of action of antifibrinolytic drugs in the context of the normal hemostatic response and to review evidence pertaining to the efficacy and safety of antifibrinolytic drugs as hemostatic agents during cardiac surgery.
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Affiliation(s)
- T F Slaughter
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Dryden PJ, O'Connor JP, Jamieson WR, Reid I, Ansley D, Sadeghi H, Burr LH, Munro AI, Merrick PM. Tranexamic acid reduces blood loss and transfusion in reoperative cardiac surgery. Can J Anaesth 1997; 44:934-41. [PMID: 9305556 DOI: 10.1007/bf03011964] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The objective of this study was to assess the effect of tranexamic acid (TA), a synthetic antifibrinolytic, on blood loss and the need for transfusion of blood products following repeat cardiac valve surgery. METHODS After ethics committee approval, 41 patients scheduled for reoperative valve replacement were enrolled in this randomized, double blind, placebo controlled study. Patients were randomized to receive TA (10 g in 500 ml NSaline) or placebo (NSaline) as an iv bolus over 30 min, after anaesthesia induction and prior to skin incision. Intraoperative blood loss was assessed by estimating blood volume on drapes, weighing surgical sponges, and measuring suction bottle returns. Postoperative blood loss was measured from mediastinal chest tube drainage following surgery. Blood products were transfused according to a standardized protocol. RESULTS Patient demographics were similar for age, sex, cardiopulmonary bypass pump time, cross clamp time, surgical time, preoperative haemoglobin, coagulation profile, and the number of valves replaced during surgery. Tranexamic acid administration reduced intraoperative blood loss [median (range)] from 1656 (575-6270) to 720 ml (355-5616) (P < 0.01) and postoperative blood loss from 1170 (180-4025) to 538 ml (135-1465) (Intent to Treat n = 41, P < 0.01). The total red blood cells transfused (median, range) was reduced from 1500 (0-9300) ml to 480 (0-2850) ml (P < 0.01) in the TA group. In hospital complications and mortality rates were not reduced in the TA group. CONCLUSION Tranexamic acid reduced blood loss and the need for blood product transfusion and appears to be an effective treatment for patients undergoing reoperative cardiac valvular surgery.
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Affiliation(s)
- P J Dryden
- Department of Anaesthesia, Vancouver Hospital and Health Sciences Centre, University of British Columbia, Vancouver, Canada
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Pinosky ML, Kennedy DJ, Fishman RL, Reeves ST, Alpert CC, Ecklund J, Kribbs S, Spinale FG, Kratz JM, Crawford R, Gravlee GP, Dorman BH. Tranexamic acid reduces bleeding after cardiopulmonary bypass when compared to epsilon aminocaproic acid and placebo. J Card Surg 1997; 12:330-8. [PMID: 9635271 DOI: 10.1111/j.1540-8191.1997.tb00147.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Perioperative bleeding following coronary artery bypass grafting (CABG) is associated with increased blood product usage. Although aprotonin is effective in reducing perioperative blood loss, excessive cost prohibits routine utilization. Epsilon aminocaproic acid (EACA) and tranexamic acid (TA) are inexpensive antifibrinolytic agents, which, when given prophylactically, may reduce blood loss. The present study was undertaken to compare the efficacy of TA and EACA in reducing perioperative blood loss. METHODS The study population consisted of first-time CABG patients. Patients were allocated in a prospective double-blind fashion: (1) group EACA (loading dose 15 mg/kg, continuous infusion 10 mg/kg per hour for 6 hours, N = 20); (2) group TA (loading dose 15 mg/kg, continuous infusion 1 mg/kg per hour for 6 hours, N = 20); (3) control group (infusion of normal saline for 6 hours, N = 19). RESULTS Treatment groups were similar preoperatively. No significant difference in intraoperative blood loss or perioperative use of blood products was noted. D-dimer concentration was elevated in the control group compared to the EACA and TA groups (p < 0.05). Group TA had less postoperative blood loss than the EACA and control groups at 6 and 12 hours postoperatively (p < 0.05). TA had reduced total blood loss (600 +/- 49 mL) postoperatively compared to EACA (961 +/- 148 mL) and control (1060 +/- 127 mL, p < 0.05). CONCLUSION TA and EACA effectively inhibited fibrinolytic activity intraoperatively and throughout the first 24 hours postoperatively. TA was more effective in reducing blood loss postoperatively following CABG. This suggests that TA may be beneficial as an effective and inexpensive antifibrinolytic in first-time CABG patients.
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Affiliation(s)
- M L Pinosky
- Department of Anesthesia, Medical University of South Carolina, Charleston 29425-2207, USA
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Bennett-Guerrero E, Sorohan JG, Canada AT, Ayuso L, Newman MF, Reves JG, Mythen MG. epsilon-Aminocaproic Acid Plasma Levels During Cardiopulmonary Bypass. Anesth Analg 1997. [DOI: 10.1213/00000539-199708000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bennett-Guerrero E, Sorohan JG, Canada AT, Ayuso L, Newman MF, Reves JG, Mythen MG. epsilon-Aminocaproic acid plasma levels during cardiopulmonary bypass. Anesth Analg 1997; 85:248-51. [PMID: 9249095 DOI: 10.1097/00000539-199708000-00002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
epsilon-Aminocaproic acid (EACA) concentrations achieved during cardiopulmonary bypass (CPB) have not been previously reported. It is unknown whether plasma concentrations reported to inhibit fibrinolysis in vitro (130 microg/mL) are achieved or whether differences in these levels relate to variability in postoperative bleeding. EACA (total intraoperative dose 270 mg/kg) was administered to 27 patients undergoing cardiac reoperation. The plasma EACA concentration was measured by using high-pressure liquid chromatography: 1) 30 min after initiation of drug administration (baseline); 2) 30 min (CPB + 30) after initiation of CPB; 3) 90 min after initiation of CPB. (CPB + 90); and 4) at cardiopulmonary bypass termination (end CPB). Plasma EACA concentrations (microg/mL, min - max, mean +/- SD) were 276-998, 593 +/- 154 at baseline; 147-527, 302 +/- 95 at CPB + 30; 112-500, 314 +/- 100 at CPB + 90; and 84-537, 317 +/- 100 at end CPB. Twenty-four-hour postoperative thoracic drainage and allogeneic red blood cell transfusions were not associated with plasma levels at any time. Although plasma EACA concentrations greater than 130 microg/mL were consistently achieved, we observed a marked variability (more than sixfold) in plasma concentrations and bleeding outcomes despite the use of a weight-based dosing regimen. This variability in drug levels appears to have little relevance to bleeding outcomes, possibly since mean plasma levels exceeded 130 microg/mL during CPB, and nearly all patients (26 of 27) achieved that target level.
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Affiliation(s)
- E Bennett-Guerrero
- Department of Anesthesiology, The Mount Sinai Medical Center, New York, New York 10029-6574, USA
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Janssens M, Hartstein G, David JL. Reduction in requirements for allogeneic blood products: pharmacologic methods. Ann Thorac Surg 1996; 62:1944-50. [PMID: 8957438 DOI: 10.1016/s0003-4975(96)00940-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Numerous articles describe the reduction of perioperative bleeding by the therapeutic or prophylactic administration of drugs such as prostacyclin, desmopressin, and natural or synthetic antifibrinolytics. METHODS A review of the literature was carried out to help the reader define the indications of these drugs during cardiopulmonary bypass operations, highlight the questions that remain concerning their indications and modes of action, and suggest future studies to answer these remaining questions. RESULTS Prostacyclin reduces platelet trauma induced by extracorporeal circulation but does not effectively reduce postoperative bleeding and transfusion requirements. Desmopressin acts as a "glue," improving platelet adhesion, and may be effective when postoperative bleeding is excessive, but its routine use in cardiac operations cannot be recommended. Natural and synthetic antifibrinolytics inhibit plasmin and plasmin-induced platelet dysfunction. These agents have been shown to decrease bleeding and the need for allogeneic transfusions after open heart operations. However, with antifibrinolytic drugs, the risk of thromboembolic phenomena cannot be neglected. With aprotinin, this risk appears to be minimal when the drug is used at concentrations high enough to inhibit plasma kallikrein also. CONCLUSIONS Prophylactic antifibrinolytics are efficacious, but their routine use remains controversial, both for economic reasons and for fear of thromboembolic complications.
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Affiliation(s)
- M Janssens
- Department of Anesthesia and Intensive Care Medicine, University Hospital of Liège, Belgium
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50
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Vander Salm TJ, Kaur S, Lancey RA, Okike ON, Pezzella AT, Stahl RF, Leone L, Li JM, Valeri CR, Michelson AD. Reduction of bleeding after heart operations through the prophylactic use of epsilon-aminocaproic acid. J Thorac Cardiovasc Surg 1996; 112:1098-107. [PMID: 8873738 DOI: 10.1016/s0022-5223(96)70112-5] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
UNLABELLED Excessive postoperative bleeding after heart operations continues to be a source of morbidity. This prospective double-blind study evaluated epsilon-aminocaproic acid as an agent to reduce postoperative bleeding and investigated its mode of action. One hundred three patients were randomly assigned to receive either 30 gm epsilon-aminocaproic acid (51 patients) or an equivalent volume of placebo (52 patients). In a subset of these patients (14 epsilon-aminocaproic acid, 12 placebo), tests of platelet function and fibrinolysis were performed. RESULTS By multivariate analysis, three factors were associated with decreased blood loss in the first 24 hours after operation: epsilon-aminocaproic acid versus placebo (647 ml versus 839 ml, p = 0.004), surgeon 1 versus all other surgeons (582 ml versus 978 ml, p = 0.002), and no intraaortic balloon versus intraaortic balloon pump use (664 ml versus 1410 ml, p = 0.02). No significant differences in platelet function could be demonstrated between the two groups. Inhibited fibrinolysis, as reflected by less depression of the euglobulin clot lysis and no rise in D-dimer levels, was significant in the epsilon-aminocaproic acid group compared with the placebo group. CONCLUSION The intraoperative use of epsilon-aminocaproic acid reduces postoperative cardiac surgical bleeding.
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Affiliation(s)
- T J Vander Salm
- Division of Cardiothoracic Surgery, University of Massachusetts Medical Center, Worcester 01655-0333, USA
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