Pharmacologic methods to reduce postoperative bleeding in adult cardiac surgery. A mini-review

Because blood for transfusion is a scarce resource and since allogeneic transfusion may even be harmful, there is a growing awareness among surgeons and anesthesiologists regarding the use of multimodal blood conservation programs in cardiac surgery in order to reduce bleeding, transfusion and re-exploration. Pharmacologic methods should be part of a multimodal blood conservation programs. Three drugs for anti-fibrinolytic prophylaxis have been available for more than two decades: Aprotinin, tranexamic acid and epsilon aminocaproic acid. These drugs can be administered intravenously and topically in the pericardium during cardiac surgery. However, aprotinin marketing was temporarily suspended in 2007/2008 based on results from a randomized study indicating a risk for increased mortality associated with the use of aprotinin. This mini-review on the use of anti-fibrinolytic drugs and other pharmacologic methods to reduce perioperative bleeding in cardiac surgery is provided as aprotinin probably will become increasingly available again in several western countries. A number of randomised and observational studies suggest a minor advantage of aprotinin over the synthetic lysine analogues, which in contrast are cheaper and without the risk of anaphylactic reactions. Other drugs that have been used in order to reduce bleeding in cardiac surgery are recombinant activated factor VIIa, desmopressin and prothrombin complex concentrate, but the value and risks of these drugs in cardiac surgery needs further clarification. Every patient should be evaluated individually according to the risk/benefit ratio of any drug used. Safety issues as well as cost-effective analyses should be in focus in future clinical studies.