[HSF] Aprotinin

[Ben Bidstrup]

Talk to a few of the hospitals that advertise their expertise in 
bloodless cardiac surgery. Most use aprotinin as part of their 
strategy.
I do not see bowel ischemia as a frequent or even particularly rare 
occurrence in talking to them.

I think your 'protocol' should apply to all surgery. That would make 
a huge difference to the utilisation of blood and products (Hall for 
you!) and lead to improved patient outcomes.
We always ask the question in any outcome, what if or could I have 
done it better?
Unfortunately most of these questions are unanswerable as we are 
unable to turn back the clock.

As Michael says, the lawyers only look at the individual, we look not 
only at the individual, but also the population.
The level of evidence in legal parlance is the balance of 
probabilities.  But in Australian tort law, it is not necessarily 
what a majority of our peers would do in a similar situation, but 
what a reasonable group would do.
Medicine has a different view of evidence.

May not be the same in the USA as you have so many hired guns who say 
what they are paid to say.



>Ben:
>I agree with all that you say, and doubt that the aprotinin alone 
>was responsible.  I just wonder, in the absence of aprotinin, would 
>things have been different.  One of the benefits of operating on 
>Jehovah's Witness patients is that they usually live a clean life, 
>are intelligent and understanding, and are great patients.  This 
>lady has improved dramatically after colon resection and iliostomy.
>
>Grafts are open I think (ie, no myocardial ischemic changes and 
>tolerated septic shock).
>TEE in the OR (2 days before colectomy) showed no thrombus, and 
>a-fib was coincident with septic onset.
>
>Probable atheroembolus to the right colic artery is my working diagnosis.
>
>Ed Bender, MD
>
>
>On Sep 20, 2007, at 3:25 PM, Ben Bidstrup wrote:
>>>
>>E,
>>
>>I firstly must confess my potential conflict as a very long time 
>>investigator of aprotinin and recipient of research funding and 
>>honoraria from Bayer for that work.
>>
>>This lady has several issues.
>>
>>Here an IABP, a mechanical battering ram in a atherosclerotic aorta 
>>next to the origin of the blood supply to the bowel. She has had 
>>not stent thrombosis if I read this correctly but ongoing intimal 
>>proliferation that has led to in stent stenosis. This still occurs 
>>despite what our colleagues state about DES.
>>How long after the cath was the procedure performed? When was the 
>>IABP removed?
>>The pathology of the specimen may not show a lot apart from 
>>atherosclerotic arteries and patchy thrombosis that is likely 
>>secondary to the changes that occur with ischemia, edema and 
>>inflammation.
>>How have your grafts fared?
>>If there was a systemic problem, they could be affected.
>>The A fib did you do a TEE to look for clot in the LA?
>>Better do one now to make sure that has not been missed. It usually 
>>takes according to the literature about 48 hours in a person who 
>>has not been subjected to a period of CBP to develop clots. How 
>>long in a post cardiotomy patient? I am not sure of that answer, 
>>but may be longer.
>>Seems also that the ischemia developed very quickly - which would 
>>put embolism in my book a little higher than a thrombotic occlusion 
>>of the mesenteric blood supply.
>>
>>  Was the R colon in a watershed area?
>>
>>Al the studies have not flagged bowel ischemia as a common problem 
>>after aprotinin use. That is not to say it has not happened.
>>
>>I have seen it as a complication all too often and the patients 
>>have had a (usually) good cause for that dreaded complication.
>>
>>So on your list it would seem IABP related embolism would be no 1, 
>>post CBP (or rather peri CBP) inflammatory changes no 2,  Afib no 
>>3, and something related to aprotinin no 4.
>>--
>>Ben Bidstrup FRACS FRCSEd FEBCTS
>>Consultant Cardiothoracic Surgeon
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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon