High-dose aprotinin: hemostatic effects in open heart operations

Two groups of patients were prospectively studied to evaluate the hemostatic effects of high-dose aprotinin in open heart operations. Group A patients (n = 22) received aprotinin during the entire surgical procedure. Group B patients (n = 12) served as controls. The groups were homogeneous for base variables and for cardiopulmonary bypass duration. Postoperative bleeding was lower in group A (mean, 486 mL) than in group B (830 mL) (p less than 0.01). The need for banked blood decreased by approximately half in the aprotinin patients (mean: group A, 213 mL; group B, 409 mL). Hemoglobin levels were similar in the two groups (postoperative day 7: group A, 11.29 g/100 mL; group B, 11.26 g/100 mL; NS). Platelet count decreased at the end of operation in both groups (99,000 and 95,000/mL, respectively; NS) and then increased beyond baseline levels before discharge. No complications were observed that could be attributed to aprotinin. In conclusion, we believe that the use of high-dose aprotinin is safe and effective. It decreases blood loss and reduces the need for banked blood in cardiac operations, particularly in select groups of patients (eg, those undergoing reoperation, Jehovah's Witnesses, those with renal failure).     

Comparison of the effects of epsilon-aminocaproic acid and aprotinin on intra- and postoperative bleeding in heart surgery]

Excessive bleeding during and after cardiac surgery with cardiopulmonary bypass is a real problem in this kind of surgery. The use of prophylactic high doses of aprotinin (APROT) reduces blood loss in this context but this treatment is expensive. Some investigators have advocated that epsilon-aminocaproic acid (EACA), a cheaper antifibrinolytic drug, could reduce blood loss in cardiac surgery. The goal of this prospective study was to determine if EACA is as effective as APROT for this clinical condition. Sixty patients undergoing elective surgery for cardiac disease were randomly allocated to one of the two groups. Drugs were administered after induction of anesthesia at a dose of 2.10(6) UIK in the APROT group or 5 g in the EACA group. The same dose was added to the priming of the cardiopulmonary bypass circuit. Until the skin closure the patients received 5.10(5) UIK/h of APROT or 2 g/h of EACA. Bleeding during and after surgery was not different between the two groups. No complication, directly due to the treatment administered, was observed. EACA seems to be as effective as APROT to reduce intra and post cardiac surgery blood loss. EACA has the advantage of being cheaper (treatment is approximately 200 times cheaper), therefore allowing a wider use.     

Tranexamic acid reduces bleeding and the need for blood transfusion in primary myocardial revascularization

BACKGROUND: The objective of this study was to study the effect of low-dose tranexamic acid (TA) on postoperative bleeding and coagulation variables after coronary artery bypass grafting operation. METHODS: Fifty patients undergoing primary coronary artery bypass grafting were randomly assigned to receive either placebo (0.9% NaCl; n = 25) or 10 mg/kg TA followed by infusion of 1 mg/kg per hour during the operation (n = 25). Data measured included blood loss, transfusion, reoperation, fibrinogen level, fibrinogen split products, platelet size, and platelet function. Measurements were made after induction of anesthesia, after heparin administration, during patient warming, after skin closure, and 24 hours after operation. RESULTS: Patients in the TA study group weighed less. Other demographic characteristics were similar between groups. Postoperative bleeding was less in the TA group (194 +/- 135 mL versus 488 +/- 238 mL, p < 0.001), whereas blood requirement was higher in the control group (1.68 +/- 1 versus 0.52 +/- 0.9 U of packed cells per patient, p < 0.001). The percent of patients exposed to blood products was significantly less in the TA group (36% versus 100%, p < 0.001). Fibrinogen split products were lower in the TA group during bypass (p < 0.001). Fibrinogen levels fell in both groups during cardiopulmonary bypass. Platelet number and function were reduced equally in both groups by cardiopulmonary bypass. Other test results were not different between groups. CONCLUSIONS: The use of low-dose TA during coronary artery bypass grafting significantly reduced the coagulopathy-induced postoperative bleeding and allogeneic blood products requirement. The low levels of fibrinogen split products during bypass in the study group reflect the inhibiting effect of TA in fibrinolysis. Tranexamic acid had no effect on platelet function during cardiopulmonary bypass.     

Comparative evaluation of the effects of tranexamic acid and low-dose aprotinin on post-valvular heart surgery bleeding and allogenic transfusion

Bleeding diathesis and allogenic transfusion after complex heart surgery, such as heart valve surgery, may result in complications such as transfusion reaction, viral infection, postoperative infection, haemodynamic disturbance, prolonged stay in the intensive care unit and hospital, renal and respiratory failure and mortality. In this prospective, double-blind, randomized, placebo-controlled clinical trial, 90 patients were randomly divided into three groups: aprotinin, tranexamic acid and control. Chest-tube drainage, transfusion requirements and renal and neurological complications were evaluated. We found that chest-tube drainage during the first (P < 0.0001) and second 24 h (P = 0.001) after admission to the intensive care unit were significantly lower in the aprotinin group. The amounts of transfused packed red blood cells (P < 0.0001) and platelets (P = 0.02) were significantly lower in the aprotinin and tranexamic acid groups. The quantity of transfused fresh frozen plasma (P = 0.034) was significantly lower in the aprotinin group only. We did not find any neurological complications or renal failure in the three groups. Our data suggest that in valvular heart surgery, low-dose aprotinin is significantly better than tranexamic acid or a placebo for reduction of postoperative bleeding and allogenic transfusion, without increasing adverse outcomes.     

Tranexamic acid for reducing blood transfusions in arthroplasty interventions: a cost-effective practice

Background

Tranexamic acid (TXA) administered during arthroplasty intervention can prevent blood loss and blood transfusions. The purpose of the present study is to evaluate the benefit of TXA administration on blood transfusion rates in patients undergoing joint arthroplasty, and to perform cost-benefit analysis.

Methods

The study population included 100 patients admitted for arthroplasty intervention between 1st June 2008 and 31st October 2008 who did not receive TXA, and 98 patients admitted between 1st June 2009 and 31st October 2009 receiving TXA during the intervention. Blood transfusion was the main outcome. Risk factors for transfusion were evaluated in logistic regression models. Costs of autologous blood donation, TXA administration, autotransfusion and homologous blood transfusion were used to perform a cost-benefit evaluation.

Results

In the multivariate adjusted analysis, high preoperative haemoglobin level and TXA administration were significantly associated with a reduced risk of transfusion. Seventy-five percent of patients not receiving TXA required at least one transfusion versus 40.8 % of patients receiving TXA, with a reduction of 45.6 %. The mean number of blood units transfused was reduced of 26 %. The reduction in transfusions was higher in hip arthroplasty. Among patients receiving TXA, the reduction in Hb level was lower both at days 1 and 2 after the intervention. The mean saving related to TXA administration was of €138 per patient.

Conclusions

The administration of TXA during arthroplasty intervention reduces the need of transfusion among patients undertaking arthroplasty interventions and can be considered a cost-effective practice for the National Health System.     

Tranexamic acid reduces blood loss and blood transfusions in primary total hip arthroplasty: a prospective randomized double-blind study in 40 patients

INTRODUCTION: We performed a prospective, randomized, double-blind study on 40 patients scheduled for primary total hip arthroplasty due to arthrosis or osteonecrosis to determine the effect of tranexamic acid on per- and postoperative blood losses and on the number of blood transfusions needed. PATIENTS AND METHODS: 40 patients were randomized to tranexamic acid (10 mg/kg given as a bolus intravenous injection, followed by a continuous infusion of 1 mg/kg/hour for 10 hours) or placebo (20 mL saline given intravenously) 15 minutes before the incision. We recorded the peroperative and postoperative blood losses at removal of the drain 24 hours after the operation and the number of blood transfusions. RESULTS: Patients receiving tranexamic acid had a mean peroperative blood loss of 480 mL versus 622 mL in patients receiving placebo (p = 0.3), a postoperative blood loss of 334 mL versus 609 mL (p = 0.001), a total blood loss of 814 mL versus 1231 mL (p = 0.001) and a total need for 4 blood transfusions versus 25 (p = 0.04). No patient in either group had symptoms of deep venous thrombosis, pulmonary embolism or prolonged wound drainage. INTERPRETATION: Transemic acid is effective in reducing the postoperative blood loss, the total blood loss and the need for blood transfusion in primary total hip arthroplasty.     

Tranexamic acid reduces blood loss and blood transfusions in primary total hip arthroplastyA prospective randomized double-blind study in 40 patients

Introduction: We performed a prospective, randomized, double-blind study on 40 patients scheduled for primary total hip arthroplasty due to arthrosis or osteonecrosis to determine the effect of tranexamic acid on per- and postoperative blood losses and on the number of blood transfusions needed. Patients and methods: 40 patients were randomized to tranexamic acid (10 mg/kg given as a bolus intravenous injection, followed by a continuous infusion of 1 mg/kg/hour for 10 hours) or placebo (20 mL saline given intravenously) 15 minutes before the incision. We recorded the peroperative and postoperative blood losses at removal of the drain 24 hours after the operation and the number of blood transfusions. Results: Patients receiving tranexamic acid had a mean peroperative blood loss of 480 mL versus 622 mL in patients receiving placebo (p= 0.3), a postoperative blood loss of 334 mL versus 609 mL (p= 0.001), a total blood loss of 814 mL versus 1231 mL (p= 0.001) and a total need for 4 blood transfusions versus 25 (p= 0.04). No patient in either group had symptoms of deep venous thrombosis, pulmonary embolism or prolonged wound drainage. Interpretation: Transemic acid is effective in reducing the postoperative blood loss, the total blood loss and the need for blood transfusion in primary total hip arthroplasty.     

Blood transfusions in elective operations: comparison of whole blood versus packed red cells.

For some years the use of packed red cells in elective operations has been encouraged on an empirical basis. From the clinical and laboratory information gathered in this prospective, randomized, but unblined study of 294 patients subjected to elective general, thoracic, or gynecologic operations, the use of packed cells in such situations appears rational. Such practices minimize demand upon a unique human resource, may give patients fewer undersirable elements in blood transfusions, and do not increase the morbidity or mortality of patients receiving transfusion.     

Association of perioperative allogeneic blood transfusions and prognosis of patients with gastric cancer after curative gastrectomy

Background

The relationship between perioperative allogeneic blood transfusions (PABTs) and prognosis in patients with gastric cancer remains controversial.

Methods

Six hundred five consecutive patients with gastric cancer who underwent curative gastrectomy from a single center were enrolled in this retrospective study. Clinical and pathologic variables were prospectively collected. The effect of PABT on the long-term survival of patients with gastric cancer after curative gastrectomy was evaluated by univariate and multivariate analyses.

Results

The overall 5-year survival rate was 65.0%. On univariate analyses, PABT had a statistically significant negative impact on 3-year and 5-year survival rates (66.3% vs 80.5% [P = .005] and 38.7% vs 76.4% [P < .001], respectively). However, multivariate analyses revealed that duration of operation (P = .009), tumor size (P = .001), and tumor stage (P < .001), instead of PABT, were independent prognostic factors.

Conclusions

Our study indicates that PABT is not an independent prognostic factor for long-term survival in patients with gastric cancer after curative gastrectomy.     

Tranexamic acid in primary CABG surgery: high vs low dose

AIM: Prophylactic administration of tranexamic acid decreases bleeding and transfusions after cardiac procedures but it is still unclear what the best dose and the most appropriate timing to get the best results are. METHODS: We enrolled 250 patients scheduled for elective, primary coronary revascularization. They were randomly divided into 2 groups. Group H received tranexamic 30 mg x kg(-1) soon after the induction of anaesthesia and a further same dose was added to the prime solution of cardiopulmonary bypass (CPB). Group L received tranexamic acid 15 mg x kg(-1) after systemic heparinization followed by an infusion of 1 mg x kg(-1) h(-1) till the end of the operation. Transfusions of bank blood products, bleeding in the postoperative period and coagulation profile were recorded. RESULTS: We did not find any difference between the groups either with respect to transfusion requirements or with respect to blood loss. CONCLUSION: For elective, first time coronary artery bypass surgery, both dosages of tranexamic acid are equally effective. Theoretically, it seems safer to administer it when patients are protected from thrombus formation by full heparinization.     

Hemostatic effects of aprotinin, tranexamic acid and ε-aminocaproic acid in primary cardiac surgery

Background. The effects of ε-aminocaproic acid (EACA) and tranexamic acid (TA) on bleeding and allogeneic transfusions, and the cost of pharmacological and transfusional treatment were compared to aprotinin (AP).

Methods. We randomized 210 patients subjected to elective cardiac surgery. Of these, 68 patients received EACA (a bolus of 5 g, an infusion of 2 g/h, and 2.5 g in the priming), 72 patients received TA (a bolus of 1 g, an infusion of 400 mg/h, and 500 mg in the priming), and 70 patients received AP (a bolus of 280 mg, an infusion of 70 mg/h, and 280 mg in the priming). Postoperative blood loss and homologous transfusions were collected and the cost of pharmacological treatment and homologous transfusions were calculated.

Results. Bleeding but not allogeneic transfusions was significantly higher in the EACA group (467 ± 234 versus TA, 311 ± 231 versus AP, 283 ± 233; p < 0.001). Costs of pharmacological and transfusional treatment were significantly lower in the TA group ($58.10 ± $105.10) versus the EACA group ($100.70 ± $158.60) versus the AP group ($432.60 ± $118.70) (p < 0.0001).

Conclusions. Compared to AP, TA has the same effects on bleeding and transfusions, but with a significant reduction of costs. Patients treated with EACA showed a significantly higher postoperative bleeding with an increased trend of transfusion requirement.     

Prophylactic single-dose fosfomycin and metronidazole compared with neomycin, bacitracin, metronidazole and ampicillin in elective colorectal operations

Two antibiotic regimens for the prophylaxis of infection after colorectal operations were compared in a prospective, double blind, randomised controlled trial in 244 patients. Ninety-five patients (39%) were either excluded before randomisation or withdrawn, leaving 149 for analysis. Group 1 (n = 72) received a single infusion of 8 g fosfomycin and 1 g metronidazole at the induction of anaesthesia. Group 2 (n = 77) received bacitracin 250 mg plus neomycin 250 mg (as four tablets on three occasions over two days), metronidazole 500 mg tablets three times a day for one day, and ampicillin 1 g intravenously at induction of anaesthesia. Nine patients in group 1 (13%), 95% confidence interval (CI) 6.9 to 22.4, developed infective complications, compared with 8 in group 2 (10%), 95% CI 4.6 to 19.4. The overall infection rate was 17 of 149 evaluable patients (11%), 95% CI 6.8 to 17.7. Seven patients died (five in group 1 and 2 in group 2), two of whom (one in each group) died as a direct result of infective complications. Long operations and obesity were the most important risk factors, and may indicate a need for longer prophylaxis. Fosfomycin, which is mainly active against aerobic bacteria, was both safe and useful when combined with metronidazole.