Continuous Small-Dose Aprotinin Controls Fibrinolysis During Orthotopic Liver Transplantation

Marcel, Randy J.; Stegall, William C.; Suit, C. Tracy; Arnold, John; Vera, Richard L.; Ramsay, Michael A. E.; O'donnell, M. B.; Swygert, Thomas H.; Hein, H. A. Tillmann; Whitten, Charles W.

doi:10.1213/00000539-199606000-00004

Cited by 70 publications

(41 citation statements)

References 13 publications

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“…Finally 7 citations [9,10,[13][14][15][16][17] , including 521 patients, were included in our study ( Figure 1). Of these 7 studies, one used tranexamic acid in the control group [16] ; two studies contained two aprotinin groups, a high dose group and a routine dose group [10,15] ; one study contained two control groups [17] ; and two studies used the same sample [10,15] , the size of which was calculated only once.…”

Section: Recording Of Datamentioning

confidence: 99%

“…Four citations, including 321 procedures, contained results on the requirement for blood products including RBCs and fresh frozen plasma (FFP) [10,14,16,17] . One of these studies contained two control groups [17] (C1 and C2); Neither aprotinin nor any other antifibrinolytic agent was used in either group, so we just took C2 as the control group.…”

Section: Effect Of Aprotinin On Rbc Requirementmentioning

confidence: 99%

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Requirements for transfusion and postoperative outcomes in orthotopic liver transplantation: A meta-analysis on aprotinin

Liu¹,

Chen²,

Wang³

2008

WJG

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INTRODUCTIONOrthotopic liver transplantation (OLT) has become the first choice approach for the treatment of patients with end-stage liver diseases [1] . However, despite great improvements in graft preservation, surgical skills, anesthetic techniques and perioperative management [2,3] , OLT is still associated with severe bleeding and considerable transfusion requirements, which in turn greatly contribute to the peri-operative morbidity and mortality [4] . Severe bleeding in OLT occurs for several reasons, among which hemostatic abnormalities remain a major cause [5,6] . Aprotinin, a serine protease inhibitor, is more and more commonly being used in surgeries, such as cardiac surgeries and liver transplantations, to reduce bleeding and the need for transfusions. A meta-analysis of 12 trials (n = 626) of children undergoing cardiac surgery demonstrated aprotinin reduced the proportion of children receiving b l o o d t r a n s f u s i o n s d u r i n g c a r d i a c s u r g e r y w i t h cardiopulmonary bypass, but had no significant effect on the volume of blood transfused or on the amount of chest tube drainage [7] . Similarly, a meta analysis of 13 trials (n = 506) of patients undergoing major orthopedic surgery demonstrated the pooled blood loss and the amounts of red blood cell (RBC) units (U) transfused intraoperatively and peri-operatively were significantly lower among aprotinin-treated patients than control patients. Moreover, aprotinin was not associated with an increased incidence 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.

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Section: Recording Of Datamentioning

confidence: 99%

Section: Effect Of Aprotinin On Rbc Requirementmentioning

confidence: 99%

Requirements for transfusion and postoperative outcomes in orthotopic liver transplantation: A meta-analysis on aprotinin

Liu¹,

Chen²,

Wang³

2008

WJG

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“…1 8 Interestingly, the benefits conferred by aprotinin using high doses, as employed in this case, may also be achieved with somewhat lower doses. 19 Repeated blood sampling for laboratory analysis should not be underestimated as a source of blood loss, and such analysis was kept to a minimum in this case. The avoidance of severe hypothermia prevented temperature-related coagulopathy.…”

Section: Reinfusion Of Withdrawn Blood Exposes Patientsmentioning

confidence: 99%

Liver transplantation in a Jehovah’s Witness with ankylosing spondylitis

Baldry

Backman

Metrakos

et al. 2000

Can J Anesth/J Can Anesth

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Purpose: Orthotopic liver transplantation is typically associated with large volume blood loss. Technological and pharmacological advances permit liver transplantation in patients who formerly were not candidates for this surgery because of strict limitations on blood product administration. We describe a liver transplant in a Jehovah's Witness with ankylosing spondylitis.Clinical features: A 49-yr-old Jehovah's Witness with ankylosing spondylitis and end stage liver disease secondary to sclerosing cholangitis underwent orthotopic liver transplantation. Recombinant human erythropoietin (4,000 IU sc every two days for four weeks, then 4,000 IU sc every week) established a normal hemoglobin concentration preoperatively (>140 g·L -1 compared with 120 g·L -1 baseline). Intraoperatively, strategies for reducing risk of blood product transfusion included avoidance of hypothermia (T>35°C), minimal blood sampling (four 1 ml samples), normovolemic hemodilution (two units), administration of Aprotinin (2 million units bolus dose followed by infusion of 500,000 u·hr -1 ), and return of blood (1,500 ml) scavenged from the operative field. Estimated blood loss was 2,200 ml. The preoperative and postoperative hemoglobin concentration was 147 g·L -1 (hematocrit 0.45) and 123 g·L -1 (hematocrit 0.37), respectively. No blood products were required and he was discharged three weeks postoperatively without complication.Conclusion: Technological and pharmacological advances allow patients to undergo surgery traditionally associated with large volume blood loss with reduced risk of blood product administration.Objectif : La transplantation du foie orthotopique est typiquement associée à une perte de sang importante. Les progrès technologiques et pharmacologiques permettent de réaliser une transplantation hépatique chez des patients qui n'auraient pu subir cette opération auparavant à cause de limitations rigoureuses d'administration des produits sanguins. Nous décrivons une greffe hépatique chez un témoin de Jéhovah qui présente une spondylarthrite ankylosante.Éléments cliniques : Un témoin de Jéhovah de 49 ans souffrant de spondylarthrite ankylosante et d'une maladie hépatique terminale secondaire à une cholangite sclérosante a subi une greffe hépatique. L'administration d'érythropoïétine recombinante humaine (4 000 UI sc aux deux jours pendant quatre semaines, puis 4 000 UI sc chaque semaine) a établi une concentration d'hémoglobine préopératoire normale (>140 g·L -1 comparée à 120 g·L -1 au départ). Les stratégies peropératoires adoptées pour réduire le risque lié à la transfusion de produit sanguin comprenaient l'absence d'hypothermie (T >35 o C), le prélèvement minimal de sang (quatre échantillons de 1 ml), l'hémodilution normovolémique (deux unités), l'administration d'aprotinine (des bolus de deux millions d'unités suivis de perfusion de 500 000 u·h -1 ) et le retour du sang épuré (1 500 ml) provenant du champ opéra-toire. La perte sanguine a été de 2 200 ml. La concentration préopératoire et postopératoire d'hémoglobine a ét...

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“…[12][13][14][15][16][17] This effect on blood transfusion requirements can be achieved with no side effects in most patients. 18 Other factors such as the experience of the surgeon, improvements in surgical and anesthesiological techniques, venovenous bypass, and donor graft cold ischemia time are more likely to be important factors in intraoperative and/or postoperative blood loss than in intraoperative coagulation monitoring.…”

confidence: 99%

Coagulation Techniques Are Not Important In Directing Blood Product Transfusion During Liver Transplantation

Reyle-Hahn

1997

Liver Transplantation

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Preoperative acquired clotting parameters such as prothrombin time, activated partial thromboplastin time, antithrombin III, platelet concentration, and fibrinogen show coagulopathy caused by insufficiency of the diseased liver. Intraoperative determination of clotting factors or parameters is not helpful to direct intraoperative transfusion of blood, blood components, or platelets because transfusions performed solely for correction of clotting data do not correlate with the real intraoperative requirements and increase the costs of orthotopic liver transplantation. However, the use of antihyperfibrinolytic drugs seems to reduce intraoperative blood loss. Patients with cirrhotic disorders caused by portalvenous hypertension show extensive collaterals and increased intravascular blood volume. Thus it is plausible that especially overcorrection of blood loss during the surgical preparation in the preanhepatic phase of the operation results in extensive blood loss. Therefore, to avoid blood loss we attempt to keep volume substitution to a minimum during the preanhepatic phase of the operation. In contrast, during the anhepatic and postanhepatic phases we attempt to reestablish normovolemia by transfusing red packed blood cells and fresh-frozen plasma. Strictly confined use of blood products in the preanhepatic phase, followed by later correction of intravascular blood volume, may reduce intraoperative blood loss; it also seems to ensure adequate substitution of clotting factors.

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Continuous Small-Dose Aprotinin Controls Fibrinolysis During Orthotopic Liver Transplantation

Cited by 70 publications

References 13 publications

Requirements for transfusion and postoperative outcomes in orthotopic liver transplantation: A meta-analysis on aprotinin

Requirements for transfusion and postoperative outcomes in orthotopic liver transplantation: A meta-analysis on aprotinin

Liver transplantation in a Jehovah’s Witness with ankylosing spondylitis

Coagulation Techniques Are Not Important In Directing Blood Product Transfusion During Liver Transplantation

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