Con: The routine use of aprotinin during pediatric cardiac surgery is not a benefit

Abstract

ORE THAN HALF of the children undergoing cardiopulmonary bypass (CPB) in North America are younger than 1 year old, and neonates comprise approximately 36% of this group. 1 Many of these children undergo multiple-stage reconstructive procedures as well as repeat operations to replace conduits and valves, which are often performed at low temperatures with long bypass times. Bleeding complications are common and are secondary to increased tissue friability, extensive suture lines, and increasingly complicated surgical repairs. In addition, clotting mechanisms are incompletely developed in infants, and they tolerate hemorrhage and tamponade poorly. These issues underscore the need to develop therapeutic modalities directed at the attenuation of the inflammatory reaction and coagulation cascade initiated by CPB. Several studies in children suggest that aprotinin is beneficial for pediatric patients during cardiac surgery. Aprotinin, isolated in 1930, is a serine protease inhibitor that has been used in numerous clinical settings, including acute pancreatitis, adult respiratory distress syndrome, trauma, and septic shock. In the 1960s, aprotinin was used in adult cardiac surgery in an attempt to reduce excessive blood loss thought to be due to increased fibrinolysis. By 1984, the benefits of aprotinin in pediatric CPB were being studied, and decreases in postoperative blood loss and fibrin split products were demonstrated. 2 Attention has turned to aprotinin's potential as a kallikrein inhibitor to attenuate the inflammatory response associated with CPB. Numerous studies have demonstrated a reduction in blood loss associated with aprotinin use in pediatric CPB. Herynkopf et aP noted that homologous donor exposure was decreased by about half in the patients who received aprotinin. A study of children undergoing repair of tetralogy of Fallot showed significant decreases in the total volume of blood loss and blood transfused. 4 Penkoske et al 5 showed similar decreases in blood loss, volume of transfusion, and number of units transfused. In pediatric lung transplants, Jaquiss et al6 demonstrated that high-risk patients receiving aprotinin bled less than, or similar to, low-risk transplant patients who had not received aprotinin. In a study at this institution, aprotinin decreased the number of