Abstract
To evaluate if the use of hemostatic high-dose aprotinin seems influence to myocardial, renal and metabolic functions in children submitted to surgical correction with extracorporeal circulation (ECC). Material and Methods A prospective randomized study was conducted on children aged 30 days to 4 years submitted to correction of acyanogenic congenital heart disease with ECC and divided into two groups: Control (n=9) and Aprotinin (n=10). In the Aprotinin Group the drug was administered before and during ECC and the myocardial and multiorgan dysfunctions were analyzed on the basis of clinical and biochemical markers. Differences were considered to be significant when P<0.05. The groups were similar regarding demographic and intraoperative variables, except for a greater hemodilution in the Aprotinin Group. The drug had no benefit regarding time of mechanical pulmonary ventilation, permanence in the pediatric postoperative intensive care unit (ICU) and length of hospitalization, or regarding the use of inotropic drugs and renal function. The partial arterial oxygen pressure/inspired oxygen fraction ratio (PaO2/FiO2) was significantly reduced 24h after surgery in the Control Group. Blood loss was similar for both groups. Cardiac troponin I (cTnI), creatine kinase MB fraction (CKMB), serum glutamic-oxaloacetic transaminase (SGOT) and the aminoterminal fraction of natriuretic peptide type B (NT-proBNP) did not differ significantly between groups. Post-ECC blood lactate concentration and metabolic acidosis was more intense in the Aprotinin Group. There were no complications with the use of aprotinin. High-dose aprotinin did not significant influence in serum markers troponin I, NT-proBNP and renal function, but did associated with hemodilution, blood lactate concentration and metabolic acidosis more intense.
Highlights
The surgical techniques and the perioperative multidiscipline approach used in children holding congenital cardiopathies have presented important advances in the last few years, still with important risks of post-perfusion multiorganic systemic dysfunction, expressed by myocardial depression, vasomotor dysfunction, respiratory, renal or hepatic insufficiencies, neurocognitive and thermal regulation maladjustments, and bleeding by coagulopathy, triggered by the limited biocompatibility of the materials during extracorporeal circulation (ECC)
These factors might determine the exposition to a higher number of hemoderivative donors, prolonged time of hemostasia in the operation room, need of late sternal closure, with consequent prolongation of mechanical ventilation and stay in the Pediatric Intensive Care Unit (PICU), and preoccupying morbidity-mortality associated to high hospital expenses [1,2,3,4]
The use of aprotinin, an unspecific inhibitor of serine proteases consisted of a hydrophilic and basic polypeptide chain of 6512 Daltons, which haemostatic property reduces bleeding after ECC in children, was one of the medicine strategies used to prevent, avoid or fight coagulopathy and the frequent referred complications in this population [1]
Summary
The surgical techniques and the perioperative multidiscipline approach used in children holding congenital cardiopathies have presented important advances in the last few years, still with important risks of post-perfusion multiorganic systemic dysfunction, expressed by myocardial depression, vasomotor dysfunction, respiratory, renal or hepatic insufficiencies, neurocognitive and thermal regulation maladjustments, and bleeding by coagulopathy (systemic inflammatory response syndrome - SIRS), triggered by the limited biocompatibility of the materials during extracorporeal circulation (ECC) These factors might determine the exposition to a higher number of hemoderivative donors, prolonged time of hemostasia in the operation room, need of late sternal closure, with consequent prolongation of mechanical ventilation and stay in the Pediatric Intensive Care Unit (PICU), and preoccupying morbidity-mortality associated to high hospital expenses [1,2,3,4]. Even much higher doses seem to be well tolerated, once there were no side effects in poly-traumatized patients treated with 17.5 millions CIU of the drug, in a 24h period [5]
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