[HSF] More Bad News About Trasylol

[Tea Acuff]

Maybe we should recommend that all CABG be done "off pump" since they clearly bleed less, and likely have less renal failure by whatever criteria.
 
On the other hand if aprotonin patients actually require say 25% less transfusion ( I am sure Ben can come up with a "real" number) does that follow that all patients of such class deserve aprotonin?  Do all patients with an EF <35% need an ICD? Do all patients with proximal LAD over 50% need a LIMA? Several years ago I heard a talk by a MD/JD who said that all guidelines were for lawyers, not patients and doctors. It is a rope that we give the lawyers with instructions on how to hang us. I actually think that guidelines are developed consciously with that factor in mind. I know that I do think that way because that is how the game is now played and why letting the ACC give the guidelines for surgeons and the patients we see is totally inexcusable if we think surgeons should be involved in any thinking whatsoever.
 
The dissonance between evidence and practice is deafening in this thread, and we need to come to real terms with this problem as we as surgeons have a foot planted actually each in evidence and in practice. This problem is not a religious or philosophical society discussion. First we need to stop lying to ourselves with this politically correct talk that we have true answers and guidelines to protect all from harm. Then we need to stop promoting the consequences of this lie to the public and our political bodies that regulate us to seek their special dispensation. There are very many consequences that we intuit but fail to formally examine and act upon, eg the FDA, lawyers, credentials, etc. Lastly (and perhaps also firstly) we need to get as real as possible with each patient that we face, not to scare them, but to let them know their options as best as the can from what we know. 
 
I know that I am hard to follow philosophically sometimes, but that is not all my fault as we prefer to look right past these issues as if they don't really exist. We do this at a great peril to ourselves collectively and to our patients.
 
Disclosure: I take a Bayer aspirin every day.
 
Tea Acuff


 
----- Original Message ----
From: Ben Bidstrup <benjamin.bidstrup at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, October 1, 2006 9:12:46 PM
Subject: Re: [HSF] More Bad News About Trasylol


>Hal
>
>I use aprotinin in almost all cases (especially circ arrest) given the
>complexity of the cases I do and our incidence of renal failure 
>requiring dialysis
>is no different. The incidence of "renal insufficiency" defined by a 50% rise
>in creatinine is higher, however, what most people don't realize is that
>aprotinin competes with creatinine for renal excretion and you will 
>see a  transient
>rise in creatinine based on this competition.
>Phil Hess is one of my partners that is currently studying aprotinin in a
>variety of ways and he is much more eloquent at defending aprotinin than me.
>According to Phil, an STS advisory committee found that 23 of 26 
>studies that they
>reviewed on aprotinin showed no significant detrimental effects. The current
>"study" that was in the NY Times, as I understand it has a lot more review to
>be done.
>Again, I still think the jury is still out and that in the end we will have a
>different recommendation from the FDA.
>
>Tom Martin
>U of Florida
>Gainesville
>_______________________________________________

Out of every crisis can come some good.
One thing this publicity is doing is making people look at their 
practice, not only wrt aprotinin but other things as well.
Hal is quite prepared to use lots of blood products - that is his 
decision. Does Florida have a separate consent for use of blood 
products delineating the potential adverse effects, and the lack of 
data on efficacy?
What are the true factors that determine renal insufficiency or 
failure or need for new dialysis (even fluid overload as a reason) ? 
How do we define renal problems? There are simple measures to 
estimate GFR which relate to body mass. Is this going to help us? 
Possibly.
Maybe the patient (or his lawyer) should be asked to make the choice.
The NNECVStudy group have a risk calculator which I believe can 
estimate the risk of renal problems after cardiac surgery.

If you look at the paper by Cosgrove et al they showed an increase in 
creatinine clearance with aprotinin. How do you reconcile that with 
the discussion going on at present ?
There is also a paper by Fauli Eur J Anesth 2005) and a subsequent 
comment by McBride in 2006 that suggests there is a possible 
protective effect of aprotinin on the renal tubule.
Many years ago we measured urine output and found it was increased in 
40 patients receiving aprotinin (high dose) for CABG when compared 
with a similar group receiving placebo for the period of 24 hours 
from induction of anaesthesia.
-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon
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