[HSF] More Bad News About Trasylol

[Ben Bidstrup]

>Prasanna,
>   I've heard that surgeons are counseling patients preop about  aprotinin. 
>However, I still would rather use extra blood products in  exchange for not
>having the patient on dialysis.  Not being able to quote  the 
>source, I remember
>recently reading that the hospital mortality for a postop  heart requiring
>dialysis is around 30%.  I don't know if it's that high  with my patients, but
>dialysis without a doubt increases the morbidity and  mortality.  I 
>have trouble
>believing that every unit of a blood product  increases the M and M by 7%. 
>If so, both of my valve cases from yesterday  don't have a chance.  The first
>was a 22 yo girl with widespread strep  viridans SBE of the mitral valve.  She
>got an MVR, but had to go back for  coagulopathy.  I should have known she
>would be a problem, because the  anesthesiologist was complaining about the
>bleeding just from putting in the  radial A-line.  She's currently 
>extubated and
>looks fine.  The second  case was a 48 yo lady with severe MR and TR 
>with normal
>coronaries and an EF of  10-15%.  She got what seemed to be an unremarkable
>mitral and tricuspid  repair with placement of LV epicardial leads for future
>bi v pacer.  However, when I took the clamp off after repairing the 
>mitral, the
>LV  massively distended.  This was treated by venting both the PA and the LV.
>  Eventually, by TEE I figured out that she had new onset severe AI.  I 
>reclamped and examined the aortic valve.  An annular mitral suture 
>in the  left
>trigone region had nailed the noncoronary leaflet.  I replaced the 
>aortic valve.
>  She came off with an IABP.  This morning, the balloon  is out and we are
>weaning the vent.  The cardiac output on mid range  dobutamine and 
>milrinone is
>5.5.  Close call.  To my knowledge, I've  never done that, but I've certainly
>read about it.  Anyway, she got a ton  of blood products because of the long
>pump run.  So far, so good.
>Hal
>_______________________________________________
This raises several questions.
It is all about risk.
Hal,
Can you show me the data that supports the use of blood products in 
reduction of bleeding? Can you show me the safety data on blood 
products? Can you show me the data on early life saving effects of 
blood products ?
Now this needs to be in cardiac surgery patients not a general population.

Can you show me the data on the risk factors for post operative renal 
impairment and renal failure requiring dialysis? Both of these (and I 
am glad you too are human and have these problems and are willing to 
talk about them,) are at increased risk of renal failure.
We balance risks and benefits all the time - that comes with the territory.
I know that the greatest risk for problems comes when about 10 or 
more donor exposures are received.
You may consider blood to be safe, but it is like any other living 
transplant and that is what it is - a transplant not a bag of fluid 
you get down from the shelf. Be worried not about HIV but Hep C, 
which is even harder to screen for. TRALI which you can't.

I hope as we all do that both of these patients do well.



-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon