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• W2204525311 abstract "A GROWING AMOUNT of evidence linking transfusion of allogeneic blood products with negative patient outcomes and increased cost continues to drive interest into strategies and technologies that limit patient exposure to this risk. The single largest consumer of this resource continues to be cardiac surgery, with 20% of the worldwide use of allogeneic blood products accounted for by this cohort. 1 Cobain T.J. Vamvakas E.C. Wells A. et al. A survey of the demographics of blood use. Transfus Med. 2007; 17: 1-15 Crossref PubMed Google Scholar In cardiac surgical patients, red blood cell transfusion is known to increase postoperative morbidity, incidence of infectious complications, early and late mortality, hospital length of stay, and hospital costs. 2 Murphy G.J. Reeves B.C. Rogers C.A. et al. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation. 2007; 116: 2544-2552 Crossref PubMed Scopus (1005) Google Scholar In addition to the negative impact of transfusion, there has been an independent association of massive blood loss with increased mortality in cardiac surgery, 3 Karkouti K. Wijeysundera D.N. Yau T.M. et al. The independent association of massive blood loss with mortality in cardiac surgery. Transfusion. 2004; 44: 1453-1462 Crossref PubMed Scopus (323) Google Scholar as well as an association of increased postoperative chest tube drainage with adverse outcomes. 4 Christensen M.C. Dziewior F. Kempel A. et al. Increased chest tube drainage is independently associated with adverse outcomes after cardiac surgery. J Cardiothorac Vasc Anesth. 2012; 26: 26-51 Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar Bleeding in cardiac surgery is multifactorial and impacted by patient comorbidities and medications, surgical procedures, and acquired defects in coagulation due to cardiopulmonary bypass. Activation of the fibrinolytic system during cardiopulmonary bypass leads to excessive consumption of fibrin by plasmin and an increased risk of significant blood loss in these patients. Two classes of antifibrinolytic agents that attempt to arrest this process, the serine protease inhibitor aprotinin (AP) and the lysine analogs tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), have gained widespread use in cardiac surgery as blood-sparing agents. Multiple meta-analyses 5 Henry D.A. Carless P.A. Moxey A.J. et al. Anti-fibrinolytic use for minimizing perioperative allogeneic blood transfusion. Cochrane Database of Systematic Reviews. 2011; (Art. No.: CD001886)https://doi.org/10.1002/14651858. CD001886. pub4 Crossref Google Scholar , 6 Levi M. Cromheecke M.E. de Jonge E. et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: A meta-analysis of clinically relevant endpoints. Lancet. 1999; 354: 1940-1947 Abstract Full Text Full Text PDF PubMed Scopus (457) Google Scholar , 7 Brown J.R. Birkmeyer N.J. O’Connor G.T. Meta-analysis comparing the effectiveness and adverse outcomes of antifibrinolytic agents in cardiac surgery. Circulation. 2007; 115: 2801-2813 Crossref PubMed Scopus (248) Google Scholar have demonstrated the superiority of AP as compared to TXA or EACA in reducing postoperative blood loss, rates of transfusion, and need for surgical re-exploration in cardiac surgery. However, observational studies raised concern about the safety of aprotinin, 8 Mangano D.T. Miao Y. Vuylsteke A. et al. Mortality associated with aprotinin during 5 years following coronary artery bypass graft surgery. JAMA. 2007; 297: 471-479 Crossref PubMed Scopus (330) Google Scholar , 9 Schneeweiss S. Seeger J.D. Landon J. et al. Aprotinin during coronary-artery bypass grafting and risk of death. N Engl J Med. 2008; 358: 771-783 Crossref PubMed Scopus (287) Google Scholar and the drug eventually was withdrawn from worldwide markets in 2008 after The Blood Conservation Using Antifibrinolytics in a Randomized Trial (BART) was stopped early due to an increased risk of death in high-risk cardiac surgical patients receiving aprotinin. 10 Fergusson D.A. Hébert P.C. Mazer C.D. et al. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med. 2008; 358: 2319-2331 Crossref PubMed Scopus (874) Google Scholar Since the withdrawal of AP, the lysine analogs have been the mainstay in prevention of hyperfibrinolysis in cardiac surgery. The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists have made the use of either lysine analog a class-I recommendation (level of evidence A) for the reduction of total blood loss and need for transfusion in cardiac surgery. 11 Ferraris V.A. Brown J.R. Despotis G.J. et al. 2011 update to The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011; 91: 944-982 Abstract Full Text Full Text PDF PubMed Scopus (990) Google Scholar While the most recent Cochrane Database review of antifibrinolytics found worthwhile reductions in blood loss and transfusions with the use of the lysine analogs in cardiac surgery, 5 Henry D.A. Carless P.A. Moxey A.J. et al. Anti-fibrinolytic use for minimizing perioperative allogeneic blood transfusion. Cochrane Database of Systematic Reviews. 2011; (Art. No.: CD001886)https://doi.org/10.1002/14651858. CD001886. pub4 Crossref Google Scholar their effectiveness and safety in low-risk surgical populations still are uncertain. The question remains unanswered: Is the indiscriminate use of lysine analogs in this patient cohort supported by data demonstrating their unequivocal safety and efficacy?" @default.
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• W2204525311 title "Con: Antifibrinolytics Should Not Be Used Routinely in Low-Risk Cardiac Surgery" @default.
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