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Coombs DM, Knackstedt R, Patel N. Optimizing Blood Loss and Management in Craniosynostosis Surgery: A Systematic Review of Outcomes Over the Last 40 Years. Cleft Palate Craniofac J 2023; 60:1632-1644. [PMID: 35903885 DOI: 10.1177/10556656221116007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Surgical correction of craniosynostosis can involve significant blood loss. Rates of allogenic blood transfusion have been reported to approach 100%. Multiple interventions have been described to reduce blood loss and transfusion requirements. The aim of this study was to analyze various approaches over the last 4 decades to optimize blood loss and management during craniosynostosis surgery. PRISMA guidelines for systematic reviews were followed. PubMed and Cochrane database searches identified studies analyzing approaches to minimizing blood loss or transfusion rate in craniosynostosis surgery. Primary outcomes included rate or amount of allogenic or autologous blood transfusion, estimated blood loss (EBL), postoperative hemoglobin (Hg), or hematocrit (Hct) levels. Secondary outcomes were examined when reported. Fifty-two studies met inclusion criteria. There was marked heterogeneity regarding design, inclusion criteria, surgical intervention, and endpoints. The majority of the studies were nonrandomized and noncomparative. Four studies analyzed erythropoietin (EPO), 6 analyzed various cell-saver (CS) technologies, 18 analyzed antifibrinolytics (tranexamic acid [TXA], aminocaproic acid [ACA], and aprotinin [APO]), 8 analyzed various alternatives, and 16 analyzed multimodal pathways & protocols. Some studies analyzed multiple approaches. Although the majority of studies reviewed represent level III/IV evidence, several high-quality level I studies were identified and included. Level I evidence supported an improvement in blood outcomes by utilizing EPO, CS, and TXA, individually or in concert with one another. Thus, this review suggests that a multi-prong approach may be the most effective means to optimize blood loss and transfusion outcomes in craniosynostosis surgery.
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Affiliation(s)
| | | | - Niyant Patel
- Division of Pediatric Plastic and Reconstructive Surgery, Akron Children's Hospital, Akron, OH, USA
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Ivachtchenko AV, Ivashchenko AA, Shkil DO, Ivashchenko IA. Aprotinin-Drug against Respiratory Diseases. Int J Mol Sci 2023; 24:11173. [PMID: 37446350 DOI: 10.3390/ijms241311173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
Aprotinin (APR) was discovered in 1930. APR is an effective pan-protease inhibitor, a typical "magic shotgun". Until 2007, APR was widely used as an antithrombotic and anti-inflammatory drug in cardiac and noncardiac surgeries for reduction of bleeding and thus limiting the need for blood transfusion. The ability of APR to inhibit proteolytic activation of some viruses leads to its use as an antiviral drug for the prevention and treatment of acute respiratory virus infections. However, due to incompetent interpretation of several clinical trials followed by incredible controversy in the literature, the usage of APR was nearly stopped for a decade worldwide. In 2015-2020, after re-analysis of these clinical trials' data the restrictions in APR usage were lifted worldwide. This review discusses antiviral mechanisms of APR action and summarizes current knowledge and prospective regarding the use of APR treatment for diseases caused by RNA-containing viruses, including influenza and SARS-CoV-2 viruses, or as a part of combination antiviral treatment.
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Affiliation(s)
- Alexandre V Ivachtchenko
- ChemDiv Inc., San Diego, CA 92130, USA
- ASAVI LLC, 1835 East Hallandale Blvd #442, Hallandale Beach, FL 33009, USA
| | | | - Dmitrii O Shkil
- ASAVI LLC, 1835 East Hallandale Blvd #442, Hallandale Beach, FL 33009, USA
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Recalcitrant Anaphylaxis Associated with Fibrin Sealant: Treatment with "TISSEEL-ectomy". PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3382. [PMID: 33552820 PMCID: PMC7862072 DOI: 10.1097/gox.0000000000003382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/02/2020] [Indexed: 11/25/2022]
Abstract
Here, we present the case of an adolescent male who developed a severe allergic reaction 10 minutes after application of TISSEEL fibrin sealant to control bleeding during a gynecomastia revision surgery. Conventional treatments of acute hypersensitivity were ineffective. After a "tisseel-ectomy," the patient's condition improved and symptoms resolved. Besides oral tranexamic acid, and topical and local anaesthesia, no other medications besides TISSEEL were administered preceding the allergic reaction. After TISSEEL was identified as the allergen upon its removal, his clinical status improved. The patient had been exposed to TISEEL 15 months before the anaphylactic episode. This case can aid in decision-making for surgical re-exposure to fibrin sealants in the setting of acute anaphylaxis.
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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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Mossad EB, Machado S, Apostolakis J. Bleeding Following Deep Hypothermia and Circulatory Arrest in Children. Semin Cardiothorac Vasc Anesth 2016; 11:34-46. [PMID: 17484172 DOI: 10.1177/1089253206297413] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Deep hypothermic circulatory arrest (DHCA) is a technique of extracorporeal circulation commonly used in children with complex congenital heart defects undergoing surgical repairs. The use of profound cooling (20°C) and complete cessation of circulation allow adequate exposure and correction of these complex lesions, with enhanced cerebral protection. However, the profound physiologic state of DHCA results in significant derangement of the coagulation system and a high incidence of postoperative bleeding. This review examines the impact of DHCA on bleeding and transfusion requirements in children and the pathophysiology of DHCA-induced platelet dysfunction. It also focuses on possible pharmacologic interventions to decrease bleeding following DHCA in children.
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Affiliation(s)
- Emad B Mossad
- Department of Cardiothoracic Anesthesia-G3, Cleveland Clinic, Cleveland, OH 44195, USA.
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7
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Abstract
Aprotinin is a naturally occurring serine protease inhibitor that is being used with increasing frequency in cardiac surgery and beyond to reduce blood loss and the need for perioperative blood transfusion. Through inhibition of serine proteases such as plasmin, aprotinin significantly reduces fibrinolysis, thereby aiding hemostasis during surgical procedures. In addition, aprotinin interacts with other factors in the coagulation and fibrinolytic cascade, creating a hemostatic balance, without increasing the risk of thrombosis. These proven benefits are supplemented by the anti-inflammatory properties of aprotinin, which may help curb some of the deleterious effects of cardiopulmonary bypass. This article will review the discovery of aprotinin, its mechanism of action, dosing and adverse effects, and highlight the major recent trials demonstrating its efficacy.
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Affiliation(s)
- Neel R Sodha
- Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, LMOB 9B, Boston, MA 02215, USA.
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Banerjee A, Stoica C, Walia A. Acute hyperkalemia as a complication of intravenous therapy with epsilon-aminocaproic acid. J Clin Anesth 2011; 23:565-8. [DOI: 10.1016/j.jclinane.2010.12.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Revised: 12/09/2010] [Accepted: 12/15/2010] [Indexed: 10/16/2022]
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GUNNARSSON I, HLYNSSON BÖ, ROSMUNDSSON TH, THORSTEINSSON A. Haemostatic effect of aprotinin during craniosynostotic surgery in children. Acta Anaesthesiol Scand 2011; 55:1010-4. [PMID: 22092167 DOI: 10.1111/j.1399-6576.2011.02490.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Aprotinin has been used in our hospital since the year 2003 to reduce bleeding during craniosynostotic surgery in children. The aim of this retrospective study was to investigate its effect, primarily on bleeding and secondarily on the need for transfusion. METHODS Thirteen children were treated with aprotinin from 2003 to 2008, while 39 were not treated in the period 1993-2002. Information on blood loss and need for transfusion during the operations in all 52 children was collected from their medical records. RESULTS There was a significant difference in both blood loss and need for transfusion. Estimated blood volume was used to correct for difference in the children's age and size. In the aprotinin group, blood loss was 3.9% of circulating blood volume vs. 22.0%, and the need for transfusion was 0.0% vs. 21.1%. CONCLUSION Blood loss and need for blood transfusion were significantly reduced in the aprotinin group. No allergic or other possible aprotinin-specific complications were registered in the aprotinin group.
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Affiliation(s)
- I. GUNNARSSON
- Department of Anaesthesiology and Intensive Care; Landspitali - The National University Hospital of Iceland; Reykjavik Iceland
| | | | - TH. ROSMUNDSSON
- Children's Hospital; Landspitali - The National University Hospital of Iceland; Reykjavik Iceland
| | - A. THORSTEINSSON
- Department of Anaesthesiology and Intensive Care; Landspitali - The National University Hospital of Iceland; Reykjavik Iceland
- University of Iceland; Reykjavik Iceland
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Mertes PM, Karila C, Demoly P, Auroy Y, Ponvert C, Lucas MM, Malinovsky JM. [What is the reality of anaphylactoid reactions during anaesthesia? Classification, prevalence, clinical features, drugs involved and morbidity and mortality]. ACTA ACUST UNITED AC 2011; 30:223-39. [PMID: 21353759 DOI: 10.1016/j.annfar.2011.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- P-M Mertes
- Service d'anesthésie-réanimation chirurgicale, hôpital Central, CHU de Nancy, 29 avenue de Lattre-de-Tassigny, Nancy cedex, France.
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Patel S, Rodriguez-Merchan EC, Haddad FS. The use of fibrin glue in surgery of the knee. ACTA ACUST UNITED AC 2010; 92:1325-31. [DOI: 10.1302/0301-620x.92b10.24828] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Fibrin glue, also known as fibrin sealant, is now established as a haemostatic agent in surgery, but its role in orthopaedic surgery is neither well known nor clearly defined. Although it was originally used over 100 years ago, concerns about transmission of disease meant that it fell from favour. It is also available as a slow-release drug delivery system and as a substrate for cellular growth and tissue engineering. Consequently, it has the potential to be used in a number of ways in orthopaedic surgery. The purpose of this review is to address its use in surgery of the knee in which it appears to offer great promise.
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Affiliation(s)
- S. Patel
- Department of Orthopaedics, University College Hospital, 235 Euston Road, London NW1 2BU, UK
| | - E. C. Rodriguez-Merchan
- Department of Orthopaedics, La Paz University Hospital, Paeso de la Castellana 261, 28046, Madrid, Spain
| | - F. S. Haddad
- Department of Orthopaedics, University College Hospital, 235 Euston Road, London NW1 2BU, UK
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Bryant J, Shariat-Madar Z. Human plasma kallikrein-kinin system: physiological and biochemical parameters. Cardiovasc Hematol Agents Med Chem 2009; 7:234-50. [PMID: 19689262 PMCID: PMC4905712 DOI: 10.2174/187152509789105444] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The plasma kallikrein-kinin system (KKS) plays a critical role in human physiology. The KKS encompasses coagulation factor XII (FXII), the complex of prekallikrein (PK) and high molecular weight kininogen (HK). The conversion of plasma prekallikrein to kallikrein by the activated FXII and in response to numerous different stimuli leads to the generation of bradykinin (BK) and activated HK (HKa, an antiangiogenic peptide). BK is a proinflammatory peptide, a pain mediator and potent vasodilator, leading to robust accumulation of fluid in the interstitium. Systemic production of BK, HKa with the interplay between BK bound-BK receptors and the soluble form of HKa are key to angiogenesis and hemodynamics. KKS has been implicated in the pathogenesis of inflammation, hypertension, endotoxemia, and coagulopathy. In all these cases increased BK levels is the hallmark. In some cases, the persistent production of BK due to the deficiency of the blood protein C1-inhibitor, which controls FXII, is detrimental to the survival of the patients with hereditary angioedema (HAE). In others, the inability of angiotensin converting enzyme (ACE) to degrade BK leads to elevated BK levels and edema in patients on ACE inhibitors. Thus, the mechanisms that interfere with BK liberation or degradation would lead to blood pressure dysfunction. In contrast, anti-kallikrein treatment could have adverse effects in hemodynamic changes induced by vasoconstrictor agents. Genetic models of kallikrein deficiency are needed to evaluate the quantitative role of kallikrein and to validate whether strategies designed to activate or inhibit kallikrein may be important for regulating whole-body BK sensitivity.
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Affiliation(s)
- J.W. Bryant
- Pfizer Global Research and Development, CVMED Exploratory, Groton, CT 06340
| | - z Shariat-Madar
- School of Pharmacy, Department of Pharmacology, University of Mississippi, University, MS 38677-1848
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Santos Silva F. Severe intraoperative anaphylactic reaction: aprotinin and rocuronium. J Cardiothorac Vasc Anesth 2008; 22:740-3. [PMID: 18922434 DOI: 10.1053/j.jvca.2007.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Indexed: 11/11/2022]
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Schummer C, Wirsing M, Schummer W. The Pivotal Role of Vasopressin in Refractory Anaphylactic Shock. Anesth Analg 2008; 107:620-4. [DOI: 10.1213/ane.0b013e3181770b42] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kober BJ, Scheule AM, Voth V, Deschner N, Schmid E, Ziemer G. Anaphylactic Reaction After Systemic Application of Aprotinin Triggered by Aprotinin-Containing Fibrin Sealant. Anesth Analg 2008; 107:406-9. [DOI: 10.1213/ane.0b013e31817e6043] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Liu CM, Chen J, Wang XH. Requirements for transfusion and postoperative outcomes in orthotopic liver transplantation: A meta-analysis on aprotinin. World J Gastroenterol 2008; 14:1425-9. [PMID: 18322960 PMCID: PMC2693694 DOI: 10.3748/wjg.14.1425] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the effect of aprotinin used in orthotopic liver transplantation (OLT) on the intraoperative requirement for blood products and on the incidence of laparotomy for bleeding, thrombotic events and mortality.
METHODS: A systematic review of the literature in the electronic database Medline and the Clinic Trials Registry Database was performed. Literature that did not fit our study were excluded. Patients in the reviewed studies were divided into two groups; one group used aprotinin (aprotinin group) while the other did not (control group). The data in the literature that fit our requirements were recorded. Weighted mean differences (WMD) in the requirements for blood products between the aprotinin group and the control group were tested using a fixed effect model. A Z test was performed to examine their reliability; the Fleiss method of fixed effect model was used to analyze data on postoperative events, and odds ratios (ORs) were tested and merged.
RESULTS: Seven citations were examined in our study. Among them, a requirement for blood products was reported in 4 studies including 321 patients, while postoperative events were reported in 5 studies including 477 patients. The requirement for red blood cells and fresh frozen plasma in the aprotinin group was statistically lower than that in the control group (WMD = -1.80 units, 95% CI, -3.38 to -0.22; WMD = -3.99 units, 95% CI, -6.47 to -1.50, respectively). However, no significant difference was indicated in the incidence of laparotomy for bleeding, thrombotic events and mortality between the two groups. Analysis on blood loss, anaphylactic reactions and renal function was not performed in this study due to a lack of sufficient information.
CONCLUSION: Aprotinin can reduce the intraoperative requirement for blood products in OLT, and has no significant effect on the incidence of laparotomy for bleeding, thrombotic events and mortality.
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Dietrich W, Ebell A, Busley R, Boulesteix AL. Aprotinin and anaphylaxis: analysis of 12,403 exposures to aprotinin in cardiac surgery. Ann Thorac Surg 2007; 84:1144-50. [PMID: 17888960 DOI: 10.1016/j.athoracsur.2007.05.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Revised: 05/03/2007] [Accepted: 05/04/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hypersensitivity reactions to the nonspecific proteinase inhibitor aprotinin may occur. The present study evaluates the incidence of hypersensitivity reactions to aprotinin. METHODS Data were prospectively collected as part of the institution's quality assurance program. The database was screened for anaphylactic reactions, especially those against aprotinin. The definition of an allergic reaction was predefined. A severe reaction was defined as hemodynamic instability of more than 10 minutes despite high dosages of vasopressors and inotropic medication. RESULTS Of 13,315 cardiac operations, 12,403 were done with aprotinin, with 801 reexposures in 697 patients. Eleven reactions to aprotinin (11 of 11,602; 0.09%, 95% confidence interval: 0.05% to 0.16%) were recorded after primary exposure, of which none was severe, while 12 reactions (12 of 801; 1.5%; 95% confidence interval: 0.86% to 2.6%) occurred after reexposure, of which 5 were severe. All severe reactions were in patients reexposed to aprotinin within 6 months after previous exposure. There was no reaction observed in patients reexposed to aprotinin within 3 days after the last exposure (n = 42). The incidence of hypersensitivity reactions was 4.1%, 1.9%, and 0.4% in the less than 6 months, 6 to 12 months, and more than 12 months reexposure intervals, respectively. CONCLUSIONS The risk of hypersensitivity reactions is low after primary exposure to aprotinin. This risk after reexposure reaches a maximum between the fourth day and the 30th day after previous exposure and declines considerably after 6 months. Consequently, application of aprotinin carries a high risk between the fourth and the 30th day after previous exposure, and cannot be recommended for the first 6 months, but is justifiable in previously aprotinin-exposed patients with a high risk of bleeding after this interval.
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Affiliation(s)
- Wulf Dietrich
- Department of Anesthesiology, German Heart Center Munich, Germany.
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21
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Abstract
Aprotinin is the only agent with Class A Level 1 evidence for reduction in rates of transfusion and return to operating theatre to control bleeding after heart surgery. Principal on the list of safety issues raised over the years are increased risk for: a) thrombosis; and b) renal dysfunction. With multiple administrations, hypersensitivity reactions have emerged as a further safety concern. This review discusses these issues, based on the examination of > 500 published articles. The article also specifically places in context the data presented recently from the observational McSPI database analysis. This report suggested that aprotinin should be withdrawn from human use as serious safety issues have been ignored or missed, an inference not in agreement with the majority of the human safety literature.
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Affiliation(s)
- David Royston
- Royal Brompton and Harefield NHS Trust, Department of Cardiothoracic Anaesthesia and Critical Care, Harefield Hospital, Hill End Road, Harefield, Middlesex, UB9 6JH, UK.
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Abstract
Like adults, children taking beta-blockers are at risk for serious hemodynamic instability in case of anaphylaxis. We report a case of severe bradycardia associated with anaphylactic shock after aprotinin in a beta-blocked child, which was resistant to intravenous epinephrine and vascular filling but was treated successfully with isoproterenol.
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Affiliation(s)
- Mona Momeni
- Department of Anesthesiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
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Beaulieu PL, Gandhi SD, Iqbal Z, Butler EG, Almassi GH, Pagel PS, Levy JH. Case 4—2007. J Cardiothorac Vasc Anesth 2007; 21:597-601. [PMID: 17678797 DOI: 10.1053/j.jvca.2007.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Phillip L Beaulieu
- Department of Anesthesiology, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI 53295, USA
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Chetham PM. Anesthesia for Heart or Single or Double Lung Transplantation in the Adult Patient. J Card Surg 2007. [DOI: 10.1111/j.1540-8191.2000.tb00451.x-i1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
For half a century, controlled hypotension has been used to reduce bleeding and the need for blood transfusions, and provide a satisfactory bloodless surgical field. It has been indicated in oromaxillofacial surgery (mandibular osteotomy, facial repair), endoscopic sinus or middle ear microsurgery, spinal surgery and other neurosurgery (aneurysm), major orthopaedic surgery (hip or knee replacement, spinal), prostatectomy, cardiovascular surgery and liver transplant surgery. Controlled hypotension is defined as a reduction of the systolic blood pressure to 80-90 mm Hg, a reduction of mean arterial pressure (MAP) to 50-65 mm Hg or a 30% reduction of baseline MAP. Pharmacological agents used for controlled hypotension include those agents that can be used successfully alone and those that are used adjunctively to limit dosage requirements and, therefore, the adverse effects of the other agents. Agents used successfully alone include inhalation anaesthetics, sodium nitroprusside, nitroglycerin, trimethaphan camsilate, alprostadil (prostaglandin E1), adenosine, remifentanil, and agents used in spinal anaesthesia. Agents that can be used alone or in combination include calcium channel antagonists (e.g. nicardipine), beta-adrenoceptor antagonists (beta-blockers) [e.g. propranolol, esmolol] and fenoldopam. Agents that are mainly used adjunctively include ACE inhibitors and clonidine. New agents and techniques have been recently evaluated for their ability to induce effective hypotension without impairing the perfusion of vital organs. This development has been aided by new knowledge on the physiology of peripheral microcirculatory regulation. Apart from the adverse effects of major hypotension on the perfusion of vital organs, potent hypotensive agents have their own adverse effects depending on their concentration, which can be reduced by adjuvant treatment. Care with use limits the major risks of these agents in controlled hypotension; risks that are generally less important than those of transfusion or alternatives to transfusion. New hypotensive drugs, such as fenoldopam, adenosine and alprostadil, are currently being evaluated; however, they have disadvantages and a high treatment cost that limits their development in this indication. New techniques of controlled hypotension subscribe to the use of the natural hypotensive effect of the anaesthetic drug with regard to the definition of the ideal hypotensive agent. It must be easy to administer, have a short onset time, an effect that disappears quickly when administration is discontinued, a rapid elimination without toxic metabolites, negligible effects on vital organs, and a predictable and dose-dependent effect. Inhalation agents (isoflurane, sevoflurane) provide the benefit of being hypnotic and hypotensive agents at clinical concentrations, and are used alone or in combination with adjuvant agents to limit tachycardia and rebound hypertension, for example, inhibitors of the autonomic nervous system (clonidine, beta-blockers) or ACE inhibitors. When they are used alone, inhalation anaesthetics require high concentrations for a significant reduction in bleeding that can lead to hepatic or renal injury. The greatest efficacy and ease-of-use to toxicity ratio is for techniques of anaesthesia that associate analgesia and hypotension at clinical concentrations without the need for potent hypotensive agents. The first and oldest technique is epidural anaesthesia, but depending on the surgery, it is not always appropriate. The most recent satisfactory technique is a combination treatment of remifentanil with either propofol or an inhalation agent (isoflurane, desflurane or sevoflurane) at clinical concentrations. In light of the current literature, and because of their safety and ease of use, these two techniques are preferred.
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Affiliation(s)
- Christian-Serge Degoute
- Service d'Anesthésie-réanimation, Centre Hospitalier-Universitaire Lyon-Sud, Pierre-Bénite, France.
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Ferraris VA, Ferraris SP, Saha SP, Hessel EA, Haan CK, Royston BD, Bridges CR, Higgins RSD, Despotis G, Brown JR, Spiess BD, Shore-Lesserson L, Stafford-Smith M, Mazer CD, Bennett-Guerrero E, Hill SE, Body S. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007; 83:S27-86. [PMID: 17462454 DOI: 10.1016/j.athoracsur.2007.02.099] [Citation(s) in RCA: 543] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Revised: 01/21/2007] [Accepted: 02/08/2007] [Indexed: 01/24/2023]
Abstract
BACKGROUND A minority of patients having cardiac procedures (15% to 20%) consume more than 80% of the blood products transfused at operation. Blood must be viewed as a scarce resource that carries risks and benefits. A careful review of available evidence can provide guidelines to allocate this valuable resource and improve patient outcomes. METHODS We reviewed all available published evidence related to blood conservation during cardiac operations, including randomized controlled trials, published observational information, and case reports. Conventional methods identified the level of evidence available for each of the blood conservation interventions. After considering the level of evidence, recommendations were made regarding each intervention using the American Heart Association/American College of Cardiology classification scheme. RESULTS Review of published reports identified a high-risk profile associated with increased postoperative blood transfusion. Six variables stand out as important indicators of risk: (1) advanced age, (2) low preoperative red blood cell volume (preoperative anemia or small body size), (3) preoperative antiplatelet or antithrombotic drugs, (4) reoperative or complex procedures, (5) emergency operations, and (6) noncardiac patient comorbidities. Careful review revealed preoperative and perioperative interventions that are likely to reduce bleeding and postoperative blood transfusion. Preoperative interventions that are likely to reduce blood transfusion include identification of high-risk patients who should receive all available preoperative and perioperative blood conservation interventions and limitation of antithrombotic drugs. Perioperative blood conservation interventions include use of antifibrinolytic drugs, selective use of off-pump coronary artery bypass graft surgery, routine use of a cell-saving device, and implementation of appropriate transfusion indications. An important intervention is application of a multimodality blood conservation program that is institution based, accepted by all health care providers, and that involves well thought out transfusion algorithms to guide transfusion decisions. CONCLUSIONS Based on available evidence, institution-specific protocols should screen for high-risk patients, as blood conservation interventions are likely to be most productive for this high-risk subset. Available evidence-based blood conservation techniques include (1) drugs that increase preoperative blood volume (eg, erythropoietin) or decrease postoperative bleeding (eg, antifibrinolytics), (2) devices that conserve blood (eg, intraoperative blood salvage and blood sparing interventions), (3) interventions that protect the patient's own blood from the stress of operation (eg, autologous predonation and normovolemic hemodilution), (4) consensus, institution-specific blood transfusion algorithms supplemented with point-of-care testing, and most importantly, (5) a multimodality approach to blood conservation combining all of the above.
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Abstract
According to the global study of the burden of disease, violence and accidental injury account for 12% of deaths worldwide; 30-40% of trauma mortality is attributable to haemorrhage. The highly complex haemostatic system is severely impaired as a result of haemorrhagic shock, acidosis, hypothermia, haemodilution, hyperfibrinolysis, and consumption of clotting factors. Thus it is important to prioritize the prevention of the development of coagulopathy. Timely transfusion of red blood cells and plasma products becomes essential to restore tissue oxygenation, support perfusion, and maintain the pool of active haemostatic factors. The limits to this strategy to compensate for the loss of blood and coagulation factors are discussed. In the absence of international guidelines, there is an ongoing debate about a generally accepted treatment algorithm, mass transfusion protocols, and adverse events that have been observed as a result of transfusion. Thus many recommendations are based upon expert opinion rather than on evidence. In this chapter we address key issues of transfusions of red blood cells and plasma products in the acute control of bleeding in traumatized patients.
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Affiliation(s)
- Oliver Grottke
- University Hospital Aachen, Department of Anaesthesiology, Pauwelsstrasse 30, D-52074 Aachen, Germany.
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28
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Kaddoum RN, Chidiac EJ, Zestos MM, Rajan SD, Baraka A. An Anaphylactic Reaction After Primary Exposure to an Aprotinin Test Dose in a Child With a Severe Milk Allergy. J Cardiothorac Vasc Anesth 2007; 21:243-4. [PMID: 17418739 DOI: 10.1053/j.jvca.2006.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2006] [Indexed: 11/11/2022]
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29
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Grottke O, Rossaint R. [Procedure for critical nonsurgical bleeding]. Chirurg 2007; 78:101-2, 104-9. [PMID: 17265055 DOI: 10.1007/s00104-006-1285-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The improvement of surgical and nonsurgical approaches to control bleeding offers new strategies for overcoming coagulopathy. Massive hemorrhage is usually caused by a combination of surgical and coagulopathic bleeding. Coagulopathy is multifactorial and results from the dilution and consumption of both platelets and coagulation factors and dysfunction of the coagulation system. Blood component therapy continues to be a mainstay for this coagulopathy-related bleeding. However, the transfusion of red blood cells has been shown to be associated with post-injury infection and multiple organ failure. Therefore it is crucial to develop a clear strategy for correcting coagulopathy, preventing exsanguination, and minimizing the need for blood transfusion.
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Affiliation(s)
- O Grottke
- Klinik für Anästhesiologie, Universitätsklinikum Aachen, Pauwelsstrasse 30, 52074 Aachen.
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30
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Abstract
Coagulopathy after trauma is a major cause for uncontrolled hemorrhage in trauma victims. Approximately 40% of trauma related deaths are attributed to or caused by exsanguination. Therefore the prevention of coagulopathy is regarded as the leading cause of avoidable death in these patients. Massive hemorrhage after trauma is usually caused by a combination of surgical and coagulopathic bleeding. Coagulopathic bleeding is multifactorial, including dilution and consumption of both platelets and coagulation factors, as well as dysfunction of the coagulation system. Because of the high mortality associated with hypothermia, acidosis and progressive coagulopathy, this vicious circle is often referred to as the lethal triad, potentially leading to exsanguination. To overcome this coagulopahty-related bleeding an empiric therapy is often instituted by replacing blood components. However, the use of transfusion of red blood cells has been shown to be associated with post-injury infection and multiple organ failure. In the management of mass bleeding it is therefore crucial to have a clear strategy to prevent coagulopathy and to minimize the need for blood transfusion.
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Affiliation(s)
- O Grottke
- Klinik für Anästhesiologie, Universitätklinikum, Aachen.
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31
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Body SC, Mazer CD. Pro: Aprotinin Has a Good Efficacy and Safety Profile Relative to Other Alternatives for Prevention of Bleeding in Cardiac Surgery. Anesth Analg 2006; 103:1354-9. [PMID: 17122202 DOI: 10.1213/01.ane.0000246810.88697.15] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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32
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Karkouti K, Beattie WS. The above two letters were sent to Karkouti et al.; Drs Karkouti and Beattie offered the following reply. Transfusion 2006. [DOI: 10.1111/j.1537-2995.2006.01053.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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33
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Affiliation(s)
- J H Levy
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
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34
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Affiliation(s)
- Theo H N Groenland
- Department of Anesthesiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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35
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Affiliation(s)
- Peter C Neligan
- Division of Plastic Surgery, University of Toronto, Toronto, Ontario, Canada
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36
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Robinson KL, Marasco SF, Street AM. Practical management of anticoagulation, bleeding and blood product support for cardiac surgery. Part one: bleeding and anticoagulation issues. Heart Lung Circ 2006; 10:142-53. [PMID: 16352053 DOI: 10.1046/j.1444-2892.2001.00096.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
There are many challenging problems related to bleeding and anticoagulation in cardiac surgery. Practical guidelines, which are based on available evidence, can help to direct management issues of post-bypass bleeding, perioperative anticoagulation and the use of haemostatic agents. The patient's bleeding history is the most useful preoperative screening test of haemostasis. The input of a haematologist is often valuable in a number of areas, such as preoperative assessment of patients with a significant history of bleeding, or past history of heparin-induced thrombocytopenia, a lupus anticoagulant, or recent venous thromboembolism. Cardiothoracic surgeons, anaesthetists, perfusionists and haematologists can ensure 'best practice' by being actively involved in the development of 'local' transfusion and anticoagulation guidelines, hospital transfusion committee policies, and audits.
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Affiliation(s)
- K L Robinson
- Australian Red Cross Blood Service, Adelaide, South Australia
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37
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Utilización de aprotinina como agente hemostático en la prótesis total de cadera. Rev Esp Cir Ortop Traumatol (Engl Ed) 2006. [DOI: 10.1016/s1888-4415(06)76402-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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38
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Williams GD, Ramamoorthy C. Anesthesia Considerations for Pediatric Thoracic Solid Organ Transplant. ACTA ACUST UNITED AC 2005; 23:709-31, ix. [PMID: 16310660 DOI: 10.1016/j.atc.2005.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This article discusses the indications, perioperative management, postoperative complications, and patient outcome of pediatric heart transplantation and pediatric lung transplantation. Special emphasis is placed on the anesthetic considerations relevant for children who are undergoing or have received a solid thoracic organ transplant.
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Affiliation(s)
- Glyn D Williams
- Department of Anesthesia, Stanford University, CA 94305, USA.
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39
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López-Anglada E, Paz-Aparicio J, Bertrand D, Gosálbez J, Núñez-Batalla D, Paz-Jiménez J. Influencia de la aprotinina en el sangrado postoperatorio de la artroplastia total de rodilla. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s0482-5985(05)74449-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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40
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Barcelona SL, Thompson AA, Coté CJ. Intraoperative pediatric blood transfusion therapy: a review of common issues. Part II: transfusion therapy, special considerations, and reduction of allogenic blood transfusions. Paediatr Anaesth 2005; 15:814-30. [PMID: 16176309 DOI: 10.1111/j.1460-9592.2004.01549.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Sandra L Barcelona
- Department of Anesthesiology, The Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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41
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Ray M, Hatcher S, Whitehouse SL, Crawford S, Crawford R. Aprotinin and epsilon aminocaproic acid are effective in reducing blood loss after primary total hip arthroplasty--a prospective randomized double-blind placebo-controlled study. J Thromb Haemost 2005; 3:1421-7. [PMID: 15978098 DOI: 10.1111/j.1538-7836.2005.01457.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A prospective randomized double-blind placebo-controlled study was undertaken to determine the efficacy and mechanism of action of two antifibrinolytic drugs aprotinin and epsilon aminocaproic acid (EACA) in reducing blood loss in primary unilateral total hip arthroplasty (THA). Aprotinin was administered as a bolus of 2 x 10(6) kallikrein inhibitor units (KIU) followed by 0.5 x 10(6) KIU h(-1) for 3 h, EACA was given as 10 g over 30 min followed by 5 g over 3 h. The median postoperative blood loss 24 h postoperatively was reduced from 450 mL in the placebo group to 180 mL for aprotinin (60% reduction, P < 0.001) and to 210 mL for EACA (53% reduction, P < 0.01). In this population, there was no reduction in the perioperative transfusion requirements. The mechanism of both drugs was independent of platelets as indicated by flow cytometric measurement of change of their expression of P-selectin, platelet-monocyte aggregates, V/Va and CD40 ligand. There were no thrombotic or infective complications and no adverse events were attributable to use of either drug. Infusion of either aprotinin or EACA at the doses described is a safe and effective means of reducing blood loss after THA. These therapies provide a means of reducing blood loss in THA patients.
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Affiliation(s)
- M Ray
- Northside Pathology, Queensland Health Pathology Service, Australia
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42
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Jegoux F, Goyenvalle E, Bagot D'arc M, Aguado E, Daculsi G. In vivo biological performance of composites combining micro-macroporous biphasic calcium phosphate granules and fibrin sealant. Arch Orthop Trauma Surg 2005; 125:153-9. [PMID: 15761734 DOI: 10.1007/s00402-004-0748-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2003] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Fibrin glues are currently used by surgeons and can facilitate the handling of biomaterials. Combining fibrin glue with calcium phosphate bioceramics gives a mouldable composite that cements the granules into the implantation site. In addition to the mechanical aspect of the composite, it has been suggested that the mixture also promotes wound healing. These human blood derivatives contain natural (aprotinin) or synthetic (tranexamic acid) antifibrinolytic substances. We compared the bioactivity of two composites combining calcium phosphate granules with two different types of fibrin glue, one with aprotinin and the other with tranexamic acid. MATERIALS AND METHODS The composite was composed of fibrin glue (Tissucol) and 1 to 2 mm granules of biphasic calcium phosphate granules (MBCP) with a volume ratio of 1 for 2. Bone cavities were drilled in 12 New Zealand rabbits and filled with a composite with aprotinin-fibrin glue on the right condyle and one with tranexamic acid-fibrin glue on the left condyle. The rabbits were randomized into two groups: 3 and 6 weeks of delay. Light microscopy, scanning electron microscopy and image analysis were performed. RESULTS No adverse reactions were observed in either sample. Bony ingrowth associated with bioceramic resorption by osteoclastic TRAP-positive cells was noted. No significant difference was observed between the two composites. The bony ingrowth and ceramic resorption were qualitatively and quantitatively similar with both composites. CONCLUSION This study demonstrated that the choice of a natural (aprotinin) or synthetic (tranexamic acid) antifibrinolytic agent in the fibrin sealant associated with calcium phosphate granules and used as a bone substitute had no effect on the bioactivity of the composite. It remained efficient in bone reconstruction, no adverse effects were observed, and the bony ingrowth was qualitatively and quantitatively equivalent with the two types of fibrin sealant.
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Affiliation(s)
- Franck Jegoux
- EMI 99 03, Dental Surgery Faculty, INSERM Research Center on Materials of Biological Interest, Place A. Ricordeau, 44042 Nantes Cedex, France
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43
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Beierlein W, Scheule AM, Dietrich W, Ziemer G. Forty Years of Clinical Aprotinin Use: A Review of 124 Hypersensitivity Reactions. Ann Thorac Surg 2005; 79:741-8. [PMID: 15680884 DOI: 10.1016/j.athoracsur.2004.03.072] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Since its clinical introduction, the anaphylactic potential of aprotinin has been a major concern. World wide, its use is expanding so there is an increased chance that patients have reexposure from various sources. The risk of anaphylaxis is approximately 2.8% in reexposed patients. From 1963 to 2003, 124 cases of aprotinin-induced anaphylaxis were reported in 61 publications. Eleven patients died. The reexposure interval was less than 3 months in 72% (38 of 53 patients). This review looks at the profile of patients at risk so preventive measures may be taken. Past and future exposures have to be taken into account before any aprotinin administration.
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Affiliation(s)
- Wolfram Beierlein
- Department of Thoracic, Cardiac, and Vascular Surgery, Tübingen University Hospital, Tübingen, Germany.
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44
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López-Anglada E, Paz-Aparicio J, Bertrand D, Gosálbez J, Núñez-Batalla D, Paz-Jiménez J. Influencia de la aprotinina en el sangrado postoperatorio de la artroplastia total de rodilla. Rev Esp Cir Ortop Traumatol (Engl Ed) 2005. [DOI: 10.1016/s1888-4415(05)76341-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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45
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Abstract
Cardiac transplantation is a proven, accepted mode of therapy for selected patients with end-stage heart failure, but the inadequate number of suitable donor hearts available ultimately limits its application. This chapter reviews adult cardiac transplantation, with an emphasis on the anesthetic considerations of the heart transplant operation itself.
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Affiliation(s)
- Jack Shanewise
- College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
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46
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Abstract
Skilful surgery combined with blood-saving methods and careful management of blood coagulation will all help reduce unnecessary blood loss and transfusion requirements. Excessive surgical bleeding causes hypovolaemia, haemodynamic instability, anaemia and reduced oxygen delivery to tissues, with a subsequent increase in postoperative morbidity and mortality. The role of anaesthetists in managing surgical blood loss has increased greatly in the last decade. Position of the patient during surgery and the provision of a hypotensive anaesthetic regimen were once considered the most important contributions of the anaesthetist to decreasing blood loss. Now, several pharmacological haemostatic agents are being used by anaesthetists as blood-saving agents. After a brief discussion of the physiology of haemostasis, this article will review the evidence for the role of such agents in reducing perioperative blood loss and transfusion requirements.
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Affiliation(s)
- A M Mahdy
- Academic Unit of Anaesthesia and Intensive Care, University of Aberdeen, Aberdeen, UK
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47
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Affiliation(s)
- Jerrold H Levy
- Department of Anesthesiology, Emory Healthcare, Atlanta, GA 30322, USA.
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48
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Abstract
Interest is growing in blood conservation and avoidance of transfusion in patients undergoing orthopedic surgery, especially in the field of joint replacement. Several methods have proven successful in reducing intraoperative blood loss, which can translate into lessened allogeneic and autologous transfusion requirements. Available techniques include acute normovolemic hemodilution, hypotensive anesthesia, intraoperative blood salvage, specialized cautery, topical hemostatic agents, and pharmacologic agents given in the perioperative period. The greatest potential benefit arises in operations with greater expected blood loss or in special situations such as in patients with religious issues, bilateral joint replacement, coagulation disorders, or significant preoperative anemia.
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Affiliation(s)
- Mark Tenholder
- Insall Scott Kelly Institute for Orthopaedics and Sports Medicine, New York, NY, USA
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49
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Abstract
Cardiac surgery and cardiopulmonary bypass produces bleeding and the need for allogenic blood product transfusions in many patients. Blood conservation is important in the perioperative management of patients. Aprotinin, a serine protease inhibitor isolated from bovine lung, is a complex protease inhibitor that is an antifibrinolytic, inhibits contact activation, and decreases the inflammatory response to cardiopulmonary bypass. Aprotinin reduces blood loss and transfusion requirements in adult and pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. Full-dose aprotinin significantly reduces postoperative blood loss and has been demonstrated in multiple prospective blinded studies to be safe and effective. One of the major adverse effects is anaphylaxis that occurs on re-exposure to aprotinin.
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Affiliation(s)
- Jerrold H Levy
- Department of Anesthesiology, Emory University School of Medicine, Cardiothoracic Anesthesiology and Critical Care, Emory Healthcare, Atlanta, Ga, USA
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50
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Vaporciyan AA, Putnam JB, Smythe WR. The potential role of aprotinin in the perioperative management of malignant tumors. J Am Coll Surg 2004; 198:266-78. [PMID: 14759785 DOI: 10.1016/j.jamcollsurg.2003.09.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2003] [Revised: 09/10/2003] [Accepted: 09/16/2003] [Indexed: 11/19/2022]
Affiliation(s)
- Ara A Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 445, Houston, TX 77030, USA
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