Points: Subarachnoid haemorrhage

Antifibrinolytics reduces blood loss in thoracic surgery: a systematic review and meta-analysis

BACKGROUND

The purpose of this systematic review is to evaluate the efficacy of antifibrinolytics in non-cardiac thoracic surgery.

METHODS

We searched for all randomized controlled trials on this topic. A set of strict inclusion and exclusion criteria was developed. Six studies were meta-analysed together then in subgroups of topical tranexamic acid and intravenous aprotinin. We compared postoperative chest drain output, transfusions requirements and duration of hospital stay where available to determine the efficacy of topical tranexamic acid or intravenous aprotinin in reducing blood loss.

RESULTS

The use of antifibrinolytics reduces 24-h chest drain output (-290.21 mL [-524.75, -55.66], P = 0.02, I²  = 98%), red blood cell transfusion requirements (-1.27 units [-2.24, -0.30], P = 0.01, I²  = 100%) and shortened duration of hospital stay (-1.81 days [-3.25, -0.36], P = 0.01, I²  = 96%). The subgroup analysis also supported this trend.

CONCLUSION

We conclude that the use of antifibrinolytics appears to reduce postoperative blood loss by reducing chest drain output, transfusion requirements and length of stay after thoracic surgery.

The efficacy and safety of aprotinin for hemostasis during intracranial surgery

OBJECT

The aim of this study was to determine the safety and efficacy of prophylactic high-dose intravenous aprotinin in reducing intraoperative blood loss in the neurosurgical population.

METHODS

A randomized, double-blind, placebo-controlled trial was conducted in parallel groups in two regional neurosurgical departments. One hundred patients with a preoperative diagnosis of intracranial meningioma or vestibular schwannoma subsequently confirmed on histological studies were included. All patients were older than 18 years of age, pregnancy had been excluded, there was no history of bleeding diathesis, no previous exposure to aprotinin, and no ingestion of antiplatelet or anticoagulant medications within the 2 weeks preceding surgery. Aprotinin was administered in doses of 30,000 kallikrein-inhibiting units (KIU)/kg body weight on induction of anesthesia and was continued as an infusion of 10,000 KIU/kg/hr until surgery was complete, or for a maximum of 8 hours. Intraoperative blood loss, blood transfusion, the Glasgow Outcome Scale score, and the Index of Independence were measured, and screening for deep vein thrombosis and the Mini-Mental State Examination were performed.

CONCLUSIONS

Intraoperative blood loss was reduced from 1014 ml (geometric mean) to 508 ml (p = 0.028). Although this study was not designed to evaluate the need for blood transfusion, 37 U of blood was used in 11 patients in the aprotinin group and 58 U in 13 patients in the placebo group (not significant). There were no significant differences in postoperative thrombotic risk or other outcome measures between treatment groups. Aprotinin therefore can be safely used to reduce intraoperative blood loss in patients who are not receiving anticoagulation therapy.

Aprotinin reduces postoperative bleeding and the need for blood products in thoracic surgery: results of a randomized double-blind study

OBJECTIVE

Bleeding complications have been a major concern in certain thoracic surgery operations, especially decortication and pulmonary resection for inflammatory pulmonary infection. Prevention of plasminogen activation and fibrinolysis by aprotinin administration has been shown to reduce perioperative bleeding during operations associated with high blood consumption.

METHODS

Use of blood products (packed red cells, whole blood), chest tube drainage, analgesic requirement, chest tube duration for the patients undergoing major thoracic operations were recorded. In a double blind randomized fashion, patients were assigned to two groups receiving aprotinin (n=51) at a loading dose of 10(6) kallikrein inhibitory units (KIU) followed by an infusion of the same dose during chest closure or receiving placebo (n=52). On a daily basis, red-cell percentages of total fluid from drainage bottles were recorded and using the blood hematocrit level of the patient of the day before, the corrected value for the patient's blood volume equivalent of daily drainage was calculated.

RESULTS

There was a significant reduction in perioperative use of donor blood (0.98+/-0.92 vs. 0.45+/-0.32 unit; P=0.0026), and total chest tube drainage (corrected value for the corresponding blood volume) (28.2+/-36.9 vs. 76.9+/-53.3 ml, P=0.0004) (mean+/-standard deviation) in the aprotinin group. However, aprotinin did not reduce postoperative transfusion or decrease in hematocrit level due to thoracic operations. In high transfusion-risk thoracic surgery patients (patients who underwent decortication, pulmonary resection for inflammatory lung disease and chest wall resection), the perioperative transfusion was only 0.50+/-1.08 units in aprotinin group, compared with 1.94+/-0.52 units in control group (P=0.003). Postoperative transfusion was also reduced in aprotinin administrated group (0.53+/-0.56 vs. 1.38+/-0.97 units; P=0.02). The mean total blood loss was decreased to nearly one third of the blood loss of the control group (41+/-28 ml vs. 121+/-68 ml; P=0.001).

CONCLUSION

Aprotinin significantly reduced perioperative transfusion requirement and postoperative bleeding during major thoracic operations. Aprotinin decreased perioperative transfusion needs. Moreover, patients who were at risk of greater blood loss during and after certain thoracic operations had a greater potential to benefit from prophylactic perioperative aprotinin treatment.

Reduction of acute haemorrhage with aprotinin

We describe the use of aprotinin in two patients to control life threatening haemorrhage due to coagulopathy when other therapeutic measures had failed. We review the use of aprotinin and give a rationale for its use in acute coagulopathy.