Abstract
Epsilon-aminocaproic acid and tranexamic acid, two synthetic antifibrinolytics, and aprotinin, an antifibrinolytic derived from bovine lung, are used to reduce excessive bleeding and transfusion of homologous blood products (HBP) after cardiac surgery. This review analyzes the studies on the utilization of antifibrinolytics in adult cardiac surgery according to the epidemiological concepts of efficacy, effectiveness and efficiency. A majority of published studies confirm the efficacy of antifibrinolytics administered prophylactically to reduce postoperative bleeding and transfusion of HBP. More studies are needed, however, to compare antifibrinolytics and determine if any one is superior to the others. Despite their demonstrated efficacy, antifibrinolytics are only one of the options available to diminish the use of HBP. Other blood-saving techniques, surgical expertise, temperature during cardiopulmonary bypass and respect of established transfusion guidelines may modify the effectiveness of antifibrinolytics to the point where antifibrinolytics may not be necessary. At this time, insufficient data have been published to perform a cost vs benefit analysis of the use of antifibrinolytics. This complex analysis takes into account not only direct costs (cost of the drug and of blood products), but also the ensuing effects of treatment such as: length of stay in the operating room, in the intensive care unit and in the hospital; need for surgical re-exploration; treatment of transfusion or drug-related complications, etc. In particular, the risk of thrombotic complications associated with antifibrinolytics is the subject of an ongoing, unresolved controversy. In conclusion, it is important for each institution to determine if their patient population (or a subset of this population) is likely to benefit from prophylactic treatment with antifibrinolytics, and to confirm that treatment is not associated with an increased incidence of untoward effects, before engaging in the routine use of any of these medications.
Résumé
Trois antifibrinolytiques sont présentement utilisés en chirurgie cardiaque afin de réduire le saignement postopératoire et la transfusion de produits sanguins homologues (PSH). Il s’agit de l’acide epsilon-aminocaproïque et de l’acide tranexamique, deux antifibrinolytiques de synthèse, ainsi que de l’aprotinine, un antifibrinolytique naturel isolé à partir de poumons de bovins. Cet article fait une revue de l’utilisation des antifibrinolytiques en chirurgie cardiaque de l’adulte en fonction des concepts épidémiologiques fondamentaux que sont l’efficacité expérimentale, l’efficacité clinique et l’efficience. La majorité des études publiées confirme l’efficacité expérimentale des antifibrinolytiques administrés prophylactiquement dans le but de diminuer le saignement postopératoire et la transfusion de PSH. Cependant, les études cherchant à comparer les antifibrinolytiques entre eux sont rares. Seuls d’autres travaux nous permettront d’établir l’efficacité comparée de ces médicaments. Malgré leur efficacité expérimentale, les antifibrinolytiques ne sont qu’une des options à notre disposition pour diminuer le recours à la transfusion. Ainsi, l’efficacité clinique des antifibrinolytiques sera modifiée par l’utilisation des autres technologies visant à minimiser les pertes sanguines et la transfusion, par l’expertise de l’équipe chirurgicale, par la température durant la perfusion extra-corporelle, ainsi que par le respect des indications bien établies de la transfusion. Ainsi, dans un contexte donné, l’utilisation de ces médicaments pourra même s’avérer superflue. Nous ne disposons pas actuellement de données suffisantes pour compléter une analyse coûts/ bénéfices des antifibrinolytiques en chirurgie cardiaque de l’adulte. Cette analyse complexe devra tenir compte non seulement des coûts directs (médicaments et produits sanguins), mais aussi des effets associés au traitement tels que: durée de séjour en salle d’opération, aux soins intensifs et à l’hôpital; nécessité d’une ré-exploration pour hémostase; traitement des complications secondaires aux transfusions ou aux médicaments, etc. Plus spécifiquement, le risque de complications thrombotiques secondaires aux antifibrinolytiques fait l’objet d’une controverse non résolue à ce jour. En conclusion, avant de procéder à l’administration routinière de ces médicaments, chaque institution devra déterminer, dans la population chirurgicale qui lui est propre (ou dans un sous-groupe de cette population), l’utilité et l’innocuité des antifibrinolytiques administrés prophylactiquement.
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Hardy, JF., Bélisle, S. Natural and synthetic antifibrinolytics in adult cardiac surgery: efficacy, effectiveness and efficiency. Can J Anaesth 41, 1104–1112 (1994). https://doi.org/10.1007/BF03015662
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DOI: https://doi.org/10.1007/BF03015662