Low dose Aprotinin as blood saver in open heart surgery

Abstract

Bleeding after open heart surgery is still a great concern for the surgeon, especially when the surgical field has been revised accurately and hemostatic stitches and electrical cauterization have been used extensively. Among non-surgical adjuncts, aprotinin has been reported as very effective in reducing complications. At the time we started using this drug, we intended to test two different dosages lower than those reported in the literature. We evaluated three groups of 18 patients: the first (A) received about 350 mg of aprotinin from the start of anesthesia up to the end of operation (140 mg in the priming of cardio-pulmonary bypass and 70 mg/h i.v. during the procedure; the second (A/2) received half that dose (i.e. 70 mg and 35 mg, respectively), and the third (C) did not receive aprotinin. We compared in these groups: postoperative bleeding, blood transfusions, red blood cells, hemoglobin, hematocrit, platelets. The results were good only in the A group: bleeding was reduced and few transfusions were required. The patients in the A/2 and C groups did not show significant differences. From our observations we conclude that aprotinin is a useful adjunct, but has to be given in the proper dose.

Can ε-Aminocaproic Acid Balance the Off-Pump Bleeding Advantage?

“…Our results, with the use of aprotinin, were quite satisfactory [1] but as Aprotinin is a serine protease inhibitor originating from the bovine lung, the Italian Ministry of Health halted its use in 1998. Therefore, in an effort to reduce bleeding and transfusions, we began using EACA which derives its antifibrinolitic action by forming a complex with plasminogen through lysine-binding sites, thus blocking their adhesion to fibrin [6].…”

“…In 1989 we started using aprotinin for all patients operated on with the use of extracorporeal circulation (EEC) and a statistically significant reduction in postoperative bleeding was noted [1]. But in 1998, because of the risk of bovine spongiform encephalopathy (BSE), the Italian Ministry of Health halted the use of aprotinin.…”

Blood Conservation Strategies in Cardiac Surgery

“…68 Different modifications in aprotinin dosing protocols were attempted to lower the intravenous and priming fluid doses but showed conflicting results. [69][70][71] Recently, Nuttall et al proposed a weight-based aprotinin dosing regimen that would result in a more stable plasma apro- tinin concentration near the targeted level throughout the CPB.72 Levy et al also described the pharmacokinetics of aprotinin in cardiac surgery patients and suggested a different dosing regimen. 73 Tatar reported significant reduction in postoperative blood loss and transfusion in patients treated with 140 mg of aprotinin poured into the pericardial cavity before sternotomy closure;74 however, the safety and efficacy of topical aprotinin is still debatable.75-77 The celite-activated clotting time (ACT) should be used with caution in monitoring anticoagulation during CPB.…”