The additive effects of antifibrinolytics: dangers in the OR

The use of antifibrinolytic agents in recent years had been heralded as a major breakthrough in the prevention of postoperative bleeding. However, whenever the delicate balance between coagulation and fibrinolysis is altered, the potential exists for disaster. There have been a number of complications reported in the literature related to the use of antifibrinolytics. With the availability of oral epsilon aminocaproic acid (EACA) as treatment for the symptoms of hemophilia and other secondary bleeding disorders, the possibility exists that a patient presenting for heart surgery may already be receiving antifibrinolytic therapy. A 72 year-old female underwent double valve replacement which was complicated by postoperative bleeding. Her medical history included gastrointestinal bleeding which was being treated with oral EACA. The patient was heparin resistant with a dose response of 55 sec/unit/ml. Heparin was administered during cardiopulmonary bypass to maintain the ACT between 400-500 seconds using a heparin-coated bypass circuit. In spite of this, the patient became thrombocytopenic and bled excessively in the postoperative period. Administration of additional antifibrinolytic agents in the operating room may be contraindicated when the patient is receiving this therapy preoperatively, and may contribute to the development of a procoagulant state during bypass.