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Antifibrinolytics Are Not Associated With Reduced Blood Loss in Minimally-Invasive Endoscopic-Assisted Craniectomy for Repair of Single-Suture Craniosynostosis. J Craniofac Surg 2021; 33:1312-1316. [PMID: 34759255 DOI: 10.1097/scs.0000000000008378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 10/31/2021] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Minimally-invasive endoscopic-assisted craniectomy (EAC) achieves similar functional and cosmetic outcomes, whereas reducing morbidity risk that is often associated with complex cranial vault reconstruction. Antifibrinolytics (AF) usage to limit blood loss and transfusion requirements during complex cranial vault reconstruction has been studied extensively; however, studies are limited for AF therapy in EAC. The aim of this single-center retrospective observational cohort pilot study was to evaluate whether the use of AF was associated with reduced blood loss in infants undergoing EAC. The authors hypothesized that there would be no difference in blood loss between patients who received AF and those that did not receive AF during EAC. Non-syndromic patients who underwent single-suture EAC were retrospectively evaluated. Primary outcome measure was intraoperative calculated blood loss (mL/kg). Secondary outcome measures included perioperative red blood cells transfusion volumes, number of blood donor exposures, and pediatric intensive care unit and total hospital length of stay. Study cohort demographic and outcome data were analyzed; Fisher exact test was used for categorical data, Student t test was used for continuous data. A P value of < 0.05 was considered statistically significant. Forty-nine EAC patients were included in the study with 34 patients in the AF cohort and 15 patients in the non-AF cohort. There were no significant differences in demographics between the 2 groups. Additionally, there was no significant difference in intraoperative calculated blood loss or any secondary outcome measure. In our single-suture EAC study cohorts, AF administration was not associated with a decrease in blood loss when compared to those that did not receive AF therapy.
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Vadivel K, Zaiss AK, Kumar Y, Fabian FM, Ismail AEA, Arbing MA, Buchholz WG, Velander WH, Bajaj SP. Enhanced Antifibrinolytic Efficacy of a Plasmin-Specific Kunitz-Inhibitor (60-Residue Y11T/L17R with C-Terminal IEK) of Human Tissue Factor Pathway Inhibitor Type-2 Domain1. J Clin Med 2020; 9:E3684. [PMID: 33212896 PMCID: PMC7698382 DOI: 10.3390/jcm9113684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 10/21/2020] [Indexed: 12/13/2022] Open
Abstract
Current antifibrinolytic agents reduce blood loss by inhibiting plasmin active sites (e.g., aprotinin) or by preventing plasminogen/tissue plasminogen activator (tPA) binding to fibrin clots (e.g., ε-aminocaproic acid and tranexamic acid); however, they have adverse side effects. Here, we expressed 60-residue (NH2NAE…IEKCOOH) Kunitz domain1 (KD1) mutants of human tissue factor pathway inhibitor type-2 that inhibit plasmin as well as plasminogen activation. A single (KD1-L17R-KCOOH) and a double mutant (KD1-Y11T/L17R- KCOOH) were expressed in Escherichia coli as His-tagged constructs, each with enterokinase cleavage sites. KD1-Y11T/L17R-KCOOH was also expressed in Pichia pastoris. KD1-Y11T/L17R-KCOOH inhibited plasmin comparably to aprotinin and bound to the kringle domains of plasminogen/plasmin and tPA with Kd of ~50 nM and ~35 nM, respectively. Importantly, compared to aprotinin, KD1-L17R-KCOOH and KD1-Y11T/L17R-KCOOH did not inhibit kallikrein. Moreover, the antifibrinolytic potential of KD1-Y11T/L17R-KCOOH was better than that of KD1-L17R-KCOOH and similar to that of aprotinin in plasma clot-lysis assays. In thromboelastography experiments, KD1-Y11T/L17R-KCOOH was shown to inhibit fibrinolysis in a dose dependent manner and was comparable to aprotinin at a higher concentration. Further, KD1-Y11T/L17R-KCOOH did not induce cytotoxicity in primary human endothelial cells or fibroblasts. We conclude that KD1-Y11T/L17R-KCOOH is comparable to aprotinin, the most potent known inhibitor of plasmin and can be produced in large amounts using Pichia.
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Affiliation(s)
- Kanagasabai Vadivel
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (K.V.); (A.K.Z.); (Y.K.)
| | - Anne K. Zaiss
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (K.V.); (A.K.Z.); (Y.K.)
| | - Yogesh Kumar
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (K.V.); (A.K.Z.); (Y.K.)
| | - Frank M. Fabian
- Department of Chemical and Biomolecular Engineering, University of Nebraska, Lincoln, NE 68588, USA; (F.M.F.); (A.E.A.I.); (W.G.B.); (W.H.V.)
- Chemistry Department, Walla Walla University, College Place, WA 99324, USA
| | - Ayman E. A. Ismail
- Department of Chemical and Biomolecular Engineering, University of Nebraska, Lincoln, NE 68588, USA; (F.M.F.); (A.E.A.I.); (W.G.B.); (W.H.V.)
| | - Mark A. Arbing
- Protein Expression Technology Center, UCLA-DOE Institute, University of California, Los Angeles, CA 90095, USA;
| | - Wallace G. Buchholz
- Department of Chemical and Biomolecular Engineering, University of Nebraska, Lincoln, NE 68588, USA; (F.M.F.); (A.E.A.I.); (W.G.B.); (W.H.V.)
| | - William H. Velander
- Department of Chemical and Biomolecular Engineering, University of Nebraska, Lincoln, NE 68588, USA; (F.M.F.); (A.E.A.I.); (W.G.B.); (W.H.V.)
| | - S. Paul Bajaj
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (K.V.); (A.K.Z.); (Y.K.)
- Molecular Biology Institute, University of California, Los Angeles, CA 90095, USA
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Strauss ER, Dahmane E, Judd M, Guo D, Williams B, Meyer M, Gammie JS, Taylor B, Mazzeffi MA, Gobburu JVS, Tanaka KA. A Pharmacokinetic and Pharmacodynamic Investigation of an ε-Aminocaproic Acid Regimen Designed for Cardiac Surgery With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2020; 35:406-417. [PMID: 32811752 DOI: 10.1053/j.jvca.2020.07.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate the pharmacokinetics and pharmacodynamics of an ε-aminocaproic acid (EACA) regimen designed for cardiac surgery with cardiopulmonary bypass (CPB). DESIGN Prospective observational study requiring blood sampling to measure EACA concentrations and fibrinolysis markers (fibrinogen, D-dimer, α2-antiplasmin, and tissue plasminogen activator-plasminogen activator inhibitor [tPA-PAI-1] complex). SETTING Single-center, tertiary medical center. PARTICIPANTS Patients who underwent cardiac surgery with CPB between 2018 and 2019 for aortic or mitral valve replacement/repair or coronary artery bypass grafting. Previous sternotomy patients were included. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The pharmacokinetics of EACA, during CPB, were described by a 3-compartment disposition model. EACA concentrations were greater than 130 mg/L in all patients after CPB and in most patients during CPB. The D-dimer level trended up and reached a peak median level of 1.35 mg/L of fibrinogen equivalence units (FEU) at 15 minutes after protamine administration. The median change in D-dimer (ΔD-dimer) from baseline to 15 minutes after protamine was 0.34 (-0.48 to 3.81) mg/L FEU. ΔD-dimer did not correlate with EACA concentration intraoperatively, urine output, body weight, glomerular filtration rate, cell salvage volume, and ultrafiltration volume. The median 24-hour chest tube output was 445 (180-1,011) mL. CONCLUSION This regimen provided maximum EACA concentrations near the time of protamine administration, with a total perioperative dose of 15 g. Most patients had EACA concentrations greater than the target during CPB. ΔD-dimer did not correlate with EACA concentration. The median 24-hour chest tube output compared well to similar studies that used higher doses of EACA.
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Affiliation(s)
- Erik R Strauss
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
| | - Elyes Dahmane
- Department of Pharmacy Practice and Science, Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD
| | - Miranda Judd
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Dong Guo
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, MD
| | - Brittney Williams
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | | | - James S Gammie
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Bradley Taylor
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Michael A Mazzeffi
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Jogarao V S Gobburu
- Department of Pharmacy Practice and Science, Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD
| | - Kenichi A Tanaka
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
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Antifibrinolytic Use in the Perioperative Setting: Aminocaproic Acid and Tranexamic Acid. J Perianesth Nurs 2015; 30:560-563. [DOI: 10.1016/j.jopan.2015.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 09/22/2015] [Indexed: 11/21/2022]
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Stricker PA, Gastonguay MR, Singh D, Fiadjoe JE, Sussman EM, Pruitt EY, Goebel TK, Zuppa AF. Population pharmacokinetics of ϵ-aminocaproic acid in adolescents undergoing posterior spinal fusion surgery. Br J Anaesth 2015; 114:689-99. [PMID: 25586726 DOI: 10.1093/bja/aeu459] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Despite demonstrated efficacy of ϵ-aminocaproic acid (EACA) in reducing blood loss in adolescents undergoing spinal fusion, there are no population-specific pharmacokinetic data to guide dosing. The aim of this study was to determine the pharmacokinetics of EACA in adolescents undergoing spinal fusion surgery and make dosing recommendations. METHODS Twenty children ages 12-17 years were enrolled, with 10 children in each of two groups based on diagnosis (idiopathic scoliosis or non-idiopathic scoliosis). Previously reported data from infants undergoing craniofacial surgery were included in the model to enable dosing recommendations over a wide range of weights, ages, and diagnoses. A population non-linear mixed effects modelling approach was used to characterize EACA pharmacokinetics. RESULTS Population pharmacokinetic parameters were estimated using a two-compartment disposition model with allometrically scaled weight and an age effect on clearance. Pharmacokinetic parameters for the typical patient were a plasma clearance of 153 ml min(-1) 70 kg(-1) (6.32 ml min(-1) kg(-0.75)), intercompartmental clearance of 200 ml min(-1) 70 kg(-1) (8.26 ml min(-1) kg(-0.75)), central volume of distribution of 8.78 litre 70 kg(-1) (0.13 litre kg(-1)), and peripheral volume of distribution of 15.8 litre 70 kg(-1) (0.23 litre kg(-1)). Scoliosis aetiology did not have a clinically significant effect on drug pharmacokinetics. CONCLUSIONS The following dosing schemes are recommended according to patient weight: weight <25 kg, 100 mg kg(-1) loading dose and 40 mg kg(-1) h(-1) infusion; weight ≤25 kg-<50 kg, 100 mg kg(-1) loading dose and 35 mg kg(-1) h(-1) infusion; and weight ≥50 kg, 100 mg kg(-1) loading dose and 30 mg kg(-1) h(-1) infusion. An efficacy trial employing this dosing strategy is warranted. CLINICAL TRIAL REGISTRATION NCT01408823.
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Affiliation(s)
- P A Stricker
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - D Singh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - J E Fiadjoe
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - E M Sussman
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - E Y Pruitt
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - T K Goebel
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - A F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Department of Pediatrics, Division of Clinical Pharmacology and Therapeutics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Fletcher DJ, Brainard BM, Epstein K, Radcliffe R, Divers T. Therapeutic plasma concentrations of epsilon aminocaproic acid and tranexamic acid in horses. J Vet Intern Med 2013; 27:1589-95. [PMID: 24118238 DOI: 10.1111/jvim.12202] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 06/17/2013] [Accepted: 08/20/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Antifibrinolytic drugs such as epsilon aminocaproic acid (EACA) and tranexamic acid (TEA) are used to treat various bleeding disorders in horses. Although horses are hypofibrinolytic compared to humans, dosing schemes have been derived from pharmacokinetic studies targeting plasma concentrations in humans. HYPOTHESIS/OBJECTIVES We hypothesized therapeutic plasma concentrations of antifibrinolytic drugs in horses would be significantly lower than in humans. Our objective was to use thromboleastography (TEG) and an in vitro model of hyperfibrinolysis to predict therapeutic concentrations of EACA and TEA in horses and humans. ANIMALS Citrated plasma collected from 24 random source clinically healthy research horses. Commercial pooled human citrated plasma with normal coagulation parameters was purchased. METHODS Minimum tissue plasminogen activator (tPA) concentration to induce complete fibrinolysis within 10 minutes was determined using serial dilutions of tPA in equine plasma. Results used to create an in vitro hyperfibrinolysis model with equine and human citrated plasma, and the minimum concentrations of EACA and TEA required to completely inhibit fibrinolysis for 30 minutes (estimated therapeutic concentrations) determined using serial dilutions of the drugs. RESULTS Estimated therapeutic concentrations of EACA and TEA were significantly lower in horses (5.82; 95% CI 3.77-7.86 μg/mL and 0.512; 95% CI 0.277-0.748 μg/mL) than in humans (113.2; 95% CI 95.8-130.6 μg/mL and 11.4; 95% CI 8.62-14.1 μg/mL). CONCLUSIONS AND CLINICAL IMPORTANCE Current dosing schemes for EACA and TEA in horses may be as much as 20× higher than necessary, potentially increasing cost of treatment and risk of adverse effects.
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Affiliation(s)
- D J Fletcher
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, NY
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Stricker PA, Zuppa AF, Fiadjoe JE, Maxwell LG, Sussman EM, Pruitt EY, Goebel TK, Gastonguay MR, Taylor JA, Bartlett SP, Schreiner MS. Population pharmacokinetics of epsilon-aminocaproic acid in infants undergoing craniofacial reconstruction surgery. Br J Anaesth 2013; 110:788-99. [PMID: 23353035 DOI: 10.1093/bja/aes507] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Understanding the clinical pharmacology of the antifibrinolytic epsilon-aminocaproic acid (EACA) is necessary for rational drug administration in children. The aim of this study is to determine the pharmacokinetics (PKs) of EACA in infants aged 6-24 months undergoing craniofacial reconstruction surgery. METHODS Cohorts of six infants were enrolled sequentially to one of the three escalating loading dose-continuous i.v. infusion (CIVI) regimens: 25 mg kg(-1), 10 mg kg(-1) h(-1); 50 mg kg(-1), 20 mg kg(-1) h(-1); 100 mg kg(-1), 40 mg kg(-1) h(-1). Plasma EACA concentrations were determined using a validated high-performance liquid chromatography-tandem mass spectrometry assay. A population non-linear mixed effects modelling approach was used to characterize EACA PKs. RESULTS Population PK parameters of EACA were estimated using a two-compartment disposition model with weight expressed as an allometric covariate and an age effect. The typical patient in this study had an age of 38.71 weeks and a weight of 8.82 kg. PK parameters for this typical patient were: pre-/postoperative plasma drug clearance of 32 ml min(-1) (3.6 ml kg(-1) min(-1)), inter-compartmental clearance of 42.4 ml min(-1) (4.8 ml min(-1) kg(-1)), central volume of distribution of 1.27 litre (0.14 litre kg(-1)), and peripheral volume of distribution of 2.53 litre (0.29 litre kg(-1)). Intra-operative clearance and central volume of distribution were 89% and 80% of the pre-/postoperative value, respectively. CONCLUSIONS EACA clearance increased with weight and age. The dependence of clearance on body weight supports weight-based dosing. Based on this study, a loading dose of 100 mg kg(-1) followed by a CIVI of 40 mg kg(-1) h(-1) is appropriate to maintain target plasma EACA concentrations in children aged 6-24 months undergoing these procedures.
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Affiliation(s)
- P A Stricker
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104-4399, USA
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Martin K, Breuer T, Gertler R, Hapfelmeier A, Schreiber C, Lange R, Hess J, Wiesner G. Tranexamic acid versus ɛ-aminocaproic acid: efficacy and safety in paediatric cardiac surgery. Eur J Cardiothorac Surg 2011; 39:892-7. [DOI: 10.1016/j.ejcts.2010.09.041] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 09/21/2010] [Accepted: 09/29/2010] [Indexed: 10/18/2022] Open
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Yurka HG, Wissler RN, Zanghi CN, Liu X, Tu X, Eaton MP. The Effective Concentration of Epsilon-Aminocaproic Acid for Inhibition of Fibrinolysis in Neonatal Plasma in Vitro. Anesth Analg 2010; 111:180-4. [DOI: 10.1213/ane.0b013e3181e19cec] [Citation(s) in RCA: 25] [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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Mutter WP, Stillman IE, Dahl NK. Thrombotic Microangiopathy and Renal Failure Exacerbated by ε-Aminocaproic Acid. Am J Kidney Dis 2009; 53:346-50. [DOI: 10.1053/j.ajkd.2008.07.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Accepted: 07/28/2008] [Indexed: 11/11/2022]
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Ross J, Dallap BL, Dolente BA, Sweeney RW. Pharmacokinetics and pharmacodynamics of ε-aminocaproic acid in horses. Am J Vet Res 2007; 68:1016-21. [PMID: 17764418 DOI: 10.2460/ajvr.68.9.1016] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the pharmacokinetics and pharmacodynamics of epsilon-aminocaproic acid (EACA), including the effects of EACA on coagulation and fibrinolysis in healthy horses. ANIMALS 6 adult horses. PROCEDURES Each horse received 3.5 mg of EACA/kg/min for 20 minutes, i.v. Plasma EACA concentration was measured before (time 0), during, and after infusion. Coagulation variables and plasma alpha(2)-antiplasmin activity were evaluated at time 0 and 4 hours after infusion; viscoelastic properties of clot formation were assessed at time 0 and 0.5, 1, and 4 hours after infusion. Plasma concentration versus time data were evaluated by use of a pharmacokinetic analysis computer program. RESULTS Drug disposition was best described by a 2-compartment model with a rapid distribution phase, an elimination half-life of 2.3 hours, and mean residence time of 2.5 +/- 0.5 hours. Peak plasma EACA concentration was 462.9 +/- 70.1 microg/mL; after the end of the infusion, EACA concentration remained greater than the proposed therapeutic concentration (130 microg/mL) for 1 hour. Compared with findings at 0 minutes, EACA administration resulted in no significant change in plasma alpha(2)-antiplasmin activity at 1 or 4 hours after infusion. Thirty minutes after infusion, platelet function was significantly different from that at time 0 and 1 and 4 hours after infusion. The continuous rate infusion that would maintain proposed therapeutic plasma concentrations of EACA was predicted (ie, 3.5 mg/kg/min for 15 minutes, then 0.25 mg/kg/min). CONCLUSIONS AND CLINICAL RELEVANCE Results suggest that EACA has potential clinical use in horses for which improved clot maintenance is desired.
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Affiliation(s)
- Julie Ross
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA 19348, USA
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Hall RI. Cardiopulmonary bypass and the systemic inflammatory response: effects on drug action. J Cardiothorac Vasc Anesth 2002; 16:83-98. [PMID: 11854886 DOI: 10.1053/jcan.2002.29690] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Richard I Hall
- Departments of Anesthesia, Pharmacology, and Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
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Ririe DG, James RL, O’Brien JJ, Lin YA, Bennett J, Barclay D, Hines MH, Butterworth JF. The Pharmacokinetics of ε-Aminocaproic Acid in Children Undergoing Surgical Repair of Congenital Heart Defects. Anesth Analg 2002. [DOI: 10.1213/00000539-200201000-00008] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ririe DG, James RL, O'Brien JJ, Lin YA, Bennett J, Barclay D, Hines MH, Butterworth JF. The pharmacokinetics of epsilon-aminocaproic acid in children undergoing surgical repair of congenital heart defects. Anesth Analg 2002; 94:44-9, table of contents. [PMID: 11772798 DOI: 10.1097/00000539-200201000-00008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
UNLABELLED epsilon-Aminocaproic acid (epsilonACA) is often administered to children undergoing cardiac surgery by using empiric dosing techniques. We hypothesized that children would have different pharmacokinetic variables and require a dosing scheme different from adults to maintain stable and effective serum epsilonACA concentrations. Eight patients were enrolled in our study. epsilonACA 50 mg/kg was administered three times IV: before, during, and after cardiopulmonary bypass (CPB). Nine serum samples were obtained. epsilonACA plasma concentrations were measured by using high-performance liquid chromatography, and pharmacokinetic modeling was done by using NONMEM. The best fit was seen with a two-compartment model with volume of distribution (V(1)) adjusted for weight and CPB. Compared with published results in adults, modeling suggests that weight-adjusted V(1) is larger in children than in adults before, during, and after CPB. Clearance from the central compartment (k(10)) was also greater in children than adults, and declined during CPB. Redistribution rates from the central compartment, k(12) and k(21), were greater in children and not affected by CPB. We modeled several different dosing regimens for epsilonACA based on the larger V(1), and higher redistribution and clearance variables. We conclude that, because of the developmental differences in pharmacokinetic variables of epsilonACA, when compared with adult patients, a larger initial dose and faster infusion rate as well as an addi-tional dose on CPB are needed to maintain similar concentrations. IMPLICATIONS Pharmacokinetic modeling of epsilon-aminocaproic acid in children undergoing cardiac surgery suggests that there are developmental differences in pharmacokinetic variables. Based on these data, a dosing modification in children is suggested which may better maintain serum concentrations in children when compared with adults.
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Affiliation(s)
- Douglas G Ririe
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1009, USA.
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Budris WA, Roxe DM, Duvel JM. High anion gap metabolic acidosis associated with aminocaproic acid. Ann Pharmacother 1999; 33:308-11. [PMID: 10200855 DOI: 10.1345/aph.18029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report a case of high anion gap metabolic acidosis related to infusion of aminocaproic acid (ACA) that temporarily corrected during hemodialysis and resolved upon ACA discontinuation. CASE SUMMARY A 65-year-old white woman with staphylococcal sepsis complicated by acute renal failure was treated with ACA to control a hemorrhagic coagulopathy. After receiving an initial 5-g bolus of ACA, she received a continuous intravenous infusion of 500 mg/h for just over 5 days, then 250 mg/h for a final 12 hours. Immediately after beginning ACA therapy, she developed a severe anion gap metabolic acidosis that briefly improved after hemodialysis. The condition resolved completely only after the discontinuation of ACA and therapy with a systemic alkalinizer. DISCUSSION ACA is not among the previously identified causes of high anion gap metabolic acidosis. The temporal profile relating anion gap to ACA initiation, hemodialysis treatment, and ACA discontinuation supports causality in this case. The magnitude of increase in the anion gap appears to have been proportional to the dose of ACA. CONCLUSIONS In patients with renal impairment, ACA administration may produce a dose-related, high anion gap metabolic acidosis that might be reversible during hemodialysis. Insufficient data are available, but when ACA must be used in such patients, a more conservative dosing of ACA should be coupled with close monitoring.
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Affiliation(s)
- W A Budris
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL 60611, USA
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Krishnamurti C, Vukelja SJ, Alving BM. Inhibitory effects of lysine analogues on t-PA induced whole blood clot lysis. Thromb Res 1994; 73:419-30. [PMID: 8073394 DOI: 10.1016/0049-3848(94)90043-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The lysine analogues epsilon-aminocaproic acid (EACA) and trans-4-amino-methyl cyclohexane carboxylic acid (AMCA) are used to prevent excessive bleeding in patients with coagulopathies, such as hemophilia and thrombocytopenia, or in those who have received tissue plasminogen activator (t-PA). However, their relative efficacy in inhibiting lysis of clots that have been formed in the presence of exogenous t-PA or that have been formed and then exposed to exogenous t-PA has not been well characterized. The present study utilized blood from normal volunteers and 125I-fibrinogen in a dilute whole blood clot assay to determine the relative concentrations of lysine analogues required for inhibition of clot lysis induced by exogenous t-PA. AMCA (0.06 mM) and EACA (0.6 mM) were effective in prolonging clot lysis if (1) whole blood clots were formed and then exposed to a lysine analogue and exogenous t-PA or if (2) whole blood clots were formed in the presence of exogenous t-PA and a lysine analogue. However, their inhibitory effect was markedly reduced if clots were formed in the presence of t-PA and then exposed to either of the lysine analogues. The analogues did not inhibit the initial binding of t-PA to fibrin. They did inhibit binding of plasminogen to fibrin as well as the activation of plasminogen by t-PA in the absence of fibrin. The data suggest that lysine analogues, even at low concentrations, reduce the rate of t-PA induced whole blood clot lysis by several mechanisms.
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Affiliation(s)
- C Krishnamurti
- Walter Reed Army Institute of Research, Washington, DC 20307-5100
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Distribution and pharmacokinetics of active recombinant plasminogen activator inhibitor-1 in the rat and rabbit. ACTA ACUST UNITED AC 1992. [DOI: 10.1016/0268-9499(92)90059-q] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Haug MT, Mauro VF, Davis HH. Effect of renal failure and hemodialysis on aminocaproic acid plasma concentrations. DICP : THE ANNALS OF PHARMACOTHERAPY 1989; 23:922-3. [PMID: 2596137 DOI: 10.1177/106002808902301116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Palmer DJ, Goldberg MF, Frenkel M, Fiscella R, Anderson RJ. A comparison of two dose regimens of epsilon aminocaproic acid in the prevention and management of secondary traumatic hyphemas. Ophthalmology 1986; 93:102-8. [PMID: 3951807 DOI: 10.1016/s0161-6420(86)33784-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Fifty-nine patients who sustained hyphema following blunt trauma were randomly assigned prospectively to either of two dose regimens of epsilon aminocaproic acid (Amicar). Twenty-six took an oral dosage of 50 mg/kg ("half dose") every four hours for five days, up to a maximum of 30 g/day, and 33 patients received 100 mg/kg ("full-dose") every four hours up to a maximum of 30 g/day. Five patients in the full-dose group experienced dizziness, hypotension, and syncope. Half-dose Amicar substantially reduced such serious side effects (P = 0.063), had no adverse effect on the reduced rate of recurrent hemorrhages (P = 0.22), and was more cost effective than the full-dose regimen. When the two patients in the half-dose group receiving 30 g/day of Amicar were deleted, however, the comparison of dizziness and hypotension in the two groups became more significant (P = 0.050). The incidence of nausea and vomiting was approximately the same in both groups (P = 0.52). Serum Amicar levels were within the range of plasminogen inhibition at both dose levels. Prior aspirin ingestion appeared to have no influence on the rate of rebleeding (P = 0.58).
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