[HSF] More Bad News About Trasylol

Mon Oct 2 19:45:16 EDT 2006

have you checked for ASA resistance?

michael

On Oct 2, 2006, at 6:08 PM, Tea Acuff wrote:

> Well I only take 81mg so hopefully it is cheaper!
> Tea
>
>
> ----- Original Message ----
> From: Michael Firstenberg <msfirst at gmail.com>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Monday, October 2, 2006 3:13:26 PM
> Subject: Re: [HSF] More Bad News About Trasylol
>
>
> Tea,
> In the interest of full disclosure - coated or uncoated
>    (and why not generic?   who is paying you off!)
>
> michael
>
> On Oct 1, 2006, at 11:28 PM, Tea Acuff wrote:
>
>> 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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