[HSF] Aprotinin

Mon Nov 20 12:40:40 EST 2006

I agree with you. I have used Trasylol
indiscriminately for my last 400 or so cases, and have
had only 1 patient needing dialysis, and that was a
patient whose cardiac failure did not improve post
CABG.

We have been always aware of the renal problem, and
have omitted the drug if the creatinine is above 180
mmol/l. 

We are careful to monitor patients` renal function
after their angio`s, and if there is the not uncommon
peak a the next day, the surgery is delayed until the
creat returns to normal. Most of our cases are on
Plavix, if they are not some other complex case, so we
generally wait 2 days for the Plavix to work out. This
is sufficient time if you give aprotinin, and run the
ACT around 350 to 400. We must remember that
haemorrhagic stroke is not uncommon. Maybe this is
even more common if we mistakenly allow the ACT to go
too high.

We routinely do not let the mean pressure fall below
65mmHg on pump, routinely give inotropes postop to all
patients in order to maintain urine output, not
necessarily for cardiac support, and diurese them the
next day. We aggressively flog the kidneys for the
next 2 days if there is a slight dip in output, and
the worse problems we have had are transient rises in
creatinine on day 2 to 3. If patients have a marginal
rise in creatinine pre-op, less than 160, we will load
them with saline and diurese them, and like to see a
near normal creatinine if possible. There was a time
when we were even giving IM diclofenac day 1 if the
urine output was fine, and we never had any problems.

So in our practice, we see no reason to stop using
Trasylol, as our take back rate for bleeding has been
only 2 cases in the last 400, and 1 dialysis
(excluding 5 cases who were already on elective
haemodialysis).
--- Ani Anyanwu <anianyanwu at hotmail.com> wrote:

> Prasanna
> 
> Well many would I suspect call it unbridled. 
> 
> The following would generally receive aprotinin in
> my institution
> 1) reoperations
> 2) operations on the aortic arch or descending aorta
> 3) transplant and VAD procedures
> 4) operations on patients on clopidogrel
> 5) combined valvular and CABG
> 6) Patients with renal impairment
> 7) Patients where ability to tolerate transfusion or
> bleeding complications is thought to be marginal
> including - most patients aged 70 or above, patients
> with severe lung disease, poor LV function, severe
> pulmonary hypertension, multiple comorbidity etc.
> Certainly almost all octogenrians would get
> aprotinin - even for CABG.
> 8) Paradoxically, young patients in their 20s or 30s
> (where avoidance of blood transfusion should be the
> goal in all patients)
> 9) Multiple valvular procedures (excluding tricuspid
> valve)
> 10) cases with anticipated bypass run more than 3
> hours (including complex mitral repairs)
> 
> As you can see there is not much left - so maybe it
> is unbridled! As you implied we obviously would not
> use it for an ASD or isolated AVR, but these
> constitute a small minority of our procedures.
> Personally I would use it for practically every
> operation - including all CABGs - but that is a
> personal opinion as I believe there are
> non-hematological benefits of the drug and like you
> strongly believe in blood conservation. I do not
> have any interests or links to industry.
> 
> Actually Ben brought up something that I had never
> thought of - correct me if I am wrong but Aprotinin
> is the only agent licensed as a blood conservation
> agent for heart surgery?
> 
> Ani
>   ----- Original Message ----- 
>   From: psimha<mailto:prasannasimha at gmail.com> 
>   To:
>
OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
> 
>   Sent: Sunday, November 19, 2006 12:00 AM
>   Subject: Re: [HSF] Aprotinin
> 
> 
>   Ani - are you really using it "unbridled" or
> liberally ? Do you use it 
>   for an ASD or for a straight forward valve
> replacement ? or any other 
>   case with a short bypass run ?
>   I did not say I will not use it in a redo - in
> fact if you note my 
>   original post I said I did use it in redo's ?
>   And Yes , I believe very strongly in blood
> conservation and believe that 
>   Aprotinin is one (and not the only ) cog in the
> wheel.
>   Prasanna
> 
>   Ani Anyanwu wrote:
>   > Prasanna
>   >
>   > We use aprotinin in an unbridled way and are
> certainly yet to see this price.
>   > - we have no more an incidence of renal failure
> than other institutions have (this we know because
> incidence of dialysis postop in all New York
> Hospitals is tracked by the State Department of
> Health)
>   > - we have no suggestion of an increase in early
> vein graft thrombosis (this should transform into
> higher periop MI and mortality, our CABG mortality
> rate has remained around 1.5% last 3 years)
>   > - we have not experienced any adverse events
> that caused us to be concerned about its use, except
> fatal thrombosis in 2 patients with Factor V Lieden
> deficiency having circulatory arrest so we now
> routinely screen for this defect in all circulatory
> arrest cases.
>   >
>   > The price we are paying is a low incidence of
> transfusion of blood products and a low
> re-exploration rate (<2% last 2 years even with 18%
> being redos and almost 20% aortic cases). Maybe
> there are other unknown adverse effects which will
> catch up with us, but for know they are unknown (and
> we wont be responsible; remember it is the drug
> companies not doctors being sued for COX2
> inhibitors).
>   >
>   > Maybe when Mangano is bored he might do another
> study, and then what will you do? For those who use
> Amicar, how do we really know it is any safer - the
> drug is not even licensed for human use in many
> European countries. Perhaps even his next study will
> be on morbidity of plasma and platelet
> transfusions....then what will we do?
>   >
>   > Ani
>   >   ----- Original Message ----- 
>   >   From:
>
prasannasimha<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmail.com>>
> 
>   >   To:
>
OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>>
> 
>   >   Sent: Saturday, November 18, 2006 9:37 PM
>   >   Subject: Re: [HSF] Aprotinin
>   >
>   >
>   >   The thing I want to say is that be it Vioxx /
> Aprotinin/blood/Oxygen - 
>   >   they are all drugs and have effects and side
> effects. The present mess 
>   >   that the pharmacological companies are in is
> just because of their 
>   >   unbridled enthusiasm (or greed) to ,make a
> quick buck and it backfires 
>   >   on them. COX2 Inhibitors have a specific role
> unfortunately I even saw 
>   >   my dentist prescribing it for tooth pain !!
> Who marketed it to him as a 
>   >   good NSAID  ? I told him about the literature
> and my concerns (this was 
>   >   prior to Vioxx) . They were trying to market
> Valdecoxib for post cardiac 
>   >   surgery pain !!_ and I told them you should
> not be doing that - but did 
>   >   they listen ? and bang in a few months a
> controversy breaks out. The 
>   >   wife of colleague of mine was taking
> valdecoxib sample (she is a Doctor 
>   >   too) as the sample was around and the
> premenopausal lady ended up with a 
>   >   coronary thrombosis !!
>   >   Every drug has a role and an indication based
> on good clinical judgment 
>   >   - unfortunately we pay the price when its use
> is unbridled.
>   >   Prasanna
>   >  
>
hgrmd at aol.com<mailto:hgrmd at aol.com<mailto:hgrmd at aol.com<mailto:hgrmd at aol.com>>
> wrote:
>   >   > Prasanna and Ajit,
>   >   >   At the risk of great bodily harm from Ben,
> Ani, and others, I again think the use of aprotinin
> should be limited as much as possible.  I know there
> are cases where the benefit seemingly outweighs the
> risk.  However, the mounting literature against it
> is becoming increasingly compelling.  In addition,
> my own impression, made years before any of this
> came out, was that the drug increased the risk of
> ATN.  I'm also convinced that this has the potential
> to be the Vioxx of cardiac surgery.  All I can say
> is you guys who continue to indiscriminantly use it
> have got some really big ones.
>   >   > Hal 
>   >   >  
>   >   >  
>   >   > -----Original Message-----
>   >   > From:
>
prasannasimha at gmail.com<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmail.com>>
>   >   > To:
>
OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>>
>   >   > Sent: Sat, 18 Nov 2006 1:00 PM
>   >   > Subject: Re: [HSF] Aprotinin
>   >   >
>   >   >
>   >   > Very Sorry used Aprotinin on my redo - can't
> help using it selectively !! 
>   >   > Prasanna 
>   >   >  
>   >   > Ajit Damle wrote: 
>   >   >   
>   >   >> Journal club critique > 
>   >   >> A disheartening story: Aprotinin in cardiac
> surgery > 
>   >   >> Lien M, Milbrandt E 
>   >   >>
>   >   >> Critical Care, 2006 10:317 ( 8 November
> 2006 ) 
>   >   >>
>   >   >>     
>   >   >> Journal club critique 
>   >   >>
>   >   >>     
>   >   >> A disheartening story: Aprotinin in cardiac
> surgery 
>   >   >>
>   >   >> Marcus Lien1 and Eric B Milbrandt2 > 
>   >   >> 1Clinical Fellow, Department of Critical
> Care Medicine, University of 
>   >   >> Pittsburgh School of Medicine, Pittsburgh,
> Pennsylvania, 
=== message truncated ===

Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon        
Suite A2                                
Tygerberg Hospital, 7505       
Cape Town, South Africa.            
Tel +27-21-9762347             
Fax +27-21-9761157      Mobile +27-83-3309587

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