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The use of aprotinin in pediatric patients: a review
Jennifer McDonough1, Colleen Gruenwald
1Perfusion Services, The Hospital for Sick Children, Toronto, Ontario, Canada. mcdonough@sickkids.ca
Insights
Aprotinin use in pediatric cardiac surgery shows potential benefits, particularly high doses, in reducing blood loss and inflammatory responses in redo surgeries and neonates. Careful dosing is crucial for optimal outcomes.
Area of Science:
- Pediatric Cardiac Surgery
- Pharmacology
- Critical Care Medicine
Background:
- Congenital cardiac surgery in children often involves cardiopulmonary bypass (CPB).
- Aprotinin's efficacy in pediatric CPB remains debated, with varied study outcomes.
- Pediatric CPB presents unique challenges due to patient age and physiological differences.
Purpose of the Study:
- To review literature on aprotinin use in pediatric patients undergoing CPB for congenital cardiac surgery (1993-2000).
- To evaluate aprotinin's impact on post-operative blood loss and inflammatory response.
- To determine optimal dosing strategies and safety profile in pediatric populations.
Main Methods:
- Comprehensive literature review of studies published between 1993 and 2000.
- Inclusion of pediatric patients from neonates to 18 years undergoing CPB.
- Analysis of reported outcomes related to blood loss, inflammatory markers, and adverse events.
Main Results:
- Aprotinin demonstrated improved post-operative blood loss in pediatric redo cardiac surgery but not in primary repairs.
- High-dose aprotinin in neonates showed evidence of attenuated inflammatory response, reduced inotropic support, earlier extubation, and shorter hospital stays.
- Optimal dosing requires calculation based on weight or body surface area, including prime dose for target plasma concentration (200-400 KIU/mL).
Conclusions:
- High-dose aprotinin may offer benefits in specific pediatric CPB scenarios, particularly redo surgeries and neonates.
- Careful dose calculation is essential for achieving therapeutic plasma concentrations.
- No contraindications for aprotinin use in pediatric populations have been identified; anaphylaxis incidence is low (0.3-0.6%).
Abstract:
This literature review includes all reports from 1993 to 2000 concerning the use of aprotinin in children undergoing cardiopulmonary bypass (CPB) for congenital cardiac surgery. This review examined a nonhomogeneous pediatric patient population ranging from neonates to children up to 18 years of age, presenting many challenges. There have been publications advocating its use and those that have found no significant difference between the control group and those receiving aprotinin. The literature suggests that there is improvement in post-operative blood loss in pediatric patients undergoing redo cardiac surgery, but no significant difference in blood loss in those undergoing primary surgical repair. There is some evidence in the neonatal study groups that with high-dose aprotinin the inflammatory response is attenuated, leading to a reduction in inotropic support, earlier extubation, a tendency toward reduced post-operative blood loss and a reduced hospital stay. In most of the studies, the actual dose of aprotinin has varied with "high-dose aprotinin" demonstrating the most significant differences. To achieve an adequate dose of aprotinin, the dose must be calculated on either the patient's weight or their body surface area, and must include an appropriate dose in the prime of the cardiopulmonary bypass circuit, to achieve a plasma concentration between 200 KIU/mL to 400 KIU/mL. The incidence of anaphylactic reactions reported in the literature range from 0.3 to 0.6%. To date, there is no evidence to indicate any contraindication related to the use of aprotinin in the pediatric population.
