Early postoperative outcomes and blood product utilization in adult cardiac surgery: the post-aprotinin era

BACKGROUND

Aprotinin was a commonly used pharmacological agent for homeostasis in cardiac surgery but was discontinued, resulting in the extensive use of lysine analogues. This study tested the hypothesis that early postoperative adverse events and blood product utilization would affected in this post-aprotinin era.

METHODS AND RESULTS

Adult patients (n=781) undergoing coronary artery bypass, valve replacement, or both from November 1, 2005, to October 31, 2008, at a single institution were included. Multiple logistic regression modeling and propensity scoring were performed on 29 preoperative and intraoperative variables in patients receiving aprotinin (n=325) or lysine analogues (n=456). The propensity-adjusted relative risk (RR) for the intraoperative use of packed red blood cells (RR, 0.75; 95% confidence interval [CI], 0.57 to 0.99), fresh frozen plasma (RR, 0.37; 95% CI, 0.21 to 0.64), and cryoprecipitate (RR:0.06; 95% CI, 0.02 to 0.22) were lower in the aprotinin versus lysine analog group (all P<0.05). The risk for mortality (RR, 0.53; 95% CI, 0.16 to 1.79) and neurological events (RR, 0.87; 95% CI, 0.35 to 2.18) remained similar between groups, whereas a trend for reduced risk for renal dysfunction was observed in the aprotinin group.

CONCLUSIONS

In the post-aprotinin era, with the exclusive use of lysine analogues, the relative risk of early postoperative outcomes such as mortality and renal dysfunction have not improved, but the risk for the intraoperative use of blood products has increased. Thus, improvements in early postoperative outcomes have not been realized with the discontinued use of aprotinin, but rather increased blood product use has occurred with the attendant costs and risks inherent with this strategy.

2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines

BACKGROUND

Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007.

METHODS

The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical 'OR' connector--Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical 'AND' connector.

RESULTS

In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management.

CONCLUSIONS

Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations.

The year in cardiothoracic and vascular anesthesia: selected highlights from 2008

The 2008 highlights in cardiovascular and thoracic anesthesia include the ultimate departure of aprotinin from clinical practice. However, a new antihypertensive drug, clevidipine, was approved for perioperative control of hypertension. There were also advances in pharmacologic myocardial conditioning with agents such as cyclosporine, sodium nitroprusside, and levosimendan. Furthermore, ischemic preconditioning appears ready for testing in large clinical trials designed to improve ischemic outcomes after cardiac surgery. With regard to transfusion, a landmark study suggests that transfused red blood cells stored for >2 weeks may significantly worsen major outcome after cardiac surgery. Furthermore, a second study suggests that relative rather than absolute hemoglobin reduction significantly determines adverse outcomes after cardiac surgery. These studies may greatly affect future transfusion guidelines. Left-sided valve replacement has been revolutionized by transcatheter technology, which progressed significantly in 2008. Important advances in percutaneous coronary intervention included drug-eluting bioabsorbable stents and further insights into the clinical consequences of platelet resistance. These 2008 themes represent a sampling of the total highlights for the year. Many of the advances not covered have been reviewed and discussed in the literature review sections of the Journal in 2008.