Large doses of aprotinin (1,000,000-2,000,000 kallikrein inhibitor units [KIU] initial dose and a 500,000 KIU/h infusion) have been used during orthotopic liver transplantation (OLT) to reduce the incidence and severity of fibrinolysis. This double-blinded study was designed to investigate whether a small-dose infusion of aprotinin (200,000 KIU/h) would control fibrinolysis. A controlled study was undertaken to compare small-dose aprotinin with a placebo in patients undergoing OLT with veno-venous bypass. Forty-four patients were randomized either to the aprotinin group (n = 21), which received an intravenous infusion of 200,000 KIU/h without an initial dose, or to a control group (n = 23), which received normal saline. Coagulation variables, thrombelastograms, and postoperative blood drainage were measured. Blood levels of fibrin degradation products (FDP) were significantly higher in the control group (95% > 20 micrograms/mL) at the end of surgery compared to the aprotinin group (53% > 20 micrograms/mL, P < 0.01). The transfusion of cryoprecipitate units was more in the control group versus the aprotinin (12.6 +/- 12.8 vs 5.7 +/- 7.5; P < 0.04), as was the number of fresh frozen plasma units (6.6 +/- 3.5 vs 3.6 +/- 6.1; P < 0.05). We conclude that an infusion of a small dose of aprotinin can safely control fibrinolysis during liver transplantation with a concomitant reduction in transfusion of blood products.
The prolongation of vecuronium-induced neuromuscular block has been reported as a predictor of hepatic allograft dysfunction. This study investigates the duration of action of rocuronium, which also relies on hepatic clearance, to examine whether it also is prolonged with allograft dysfunction. Fifty-seven patients undergoing orthotopic liver transplant were given rocuronium (0.6 mg/kg) prior to allograft placement and the recovery of contraction of the orbicularis oculi muscle to a 2-Hz train-of-four stimulus was recorded. Fifteen minutes after reperfusion of the allograft, rocuronium (0.6 mg/kg) was administered and the time to recovery of muscle contraction to a train-of-four stimulus (train-of-four time) was again recorded. The patients were divided into two groups according to posttransplant liver function. Group I consisted of 50 patients with immediate normal liver function. Group II contained 7 patients with primary dysfunctional livers. Primary dysfunction was determined by peak serum aspartate aminotransferase and alanine aminotransferase levels > 2000 U/L, and prothrombin time > 16 s. The train-of-four time in Group II was prolonged compared with Group I (P < 0.05). Immediate graft function testing using the recovery time from rocuronium of > 150 min has a positive predictive value of 100% and a negative predictive value of 96%. The sensitivity and specificity is 71% and 100%, respectively. Receiver operating characteristic analysis supports this conclusion.
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