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PEDIATRIC ANESTHESIA

Avoiding Transfusions in Children Undergoing Cardiac Surgery: A Meta-Analysis of Randomized Trials of Aprotinin

Donald M. Arnold, MD, FRCP(C)^*, Dean A. Fergusson, PhD^¶, Anthony K.C. Chan, MD, FRCP(C), Richard J. Cook, PhD^**, Graeme A. Fraser, MD, FRCP(C)^***, Wendy Lim, MD, FRCP(C)^,, Morris A. Blajchman, MD FRCPC(C)^*, and Deborah J. Cook, MSc, MD, FRCP(C)^#

*Canadian Blood Services; Departments of Medicine, Pediatrics, Pathology and Molecular Medicine, and #Medicine & Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario; ¶Centre for Transfusion Research, University of Ottawa, Ottawa, Ontario; **Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Ontario; and ***Juravinski Cancer Centre, Hamilton, Ontario, Canada

Address correspondence to D. J. Cook, MSc, MD, Department of Medicine & Epidemiology and Biostatistics, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, Ontario, Canada, L8N 3Z5. Address e-mail to debcook{at}mcmaster.ca.

Aprotinin, a potent antifibrinolytic drug, reduces the proportion of adults who receive blood transfusions during cardiac surgery, although the effect in children remains unclear. We performed a systematic review of the literature to identify all English language, randomized controlled trials of aprotinin involving children undergoing corrective or palliative cardiac surgery with cardiopulmonary bypass. All studies were assessed for methodological quality, and sources of heterogeneity were examined. We measured the effect of aprotinin on the proportion of children transfused, the volume of blood transfused, and the volume of chest tube drainage. Twelve trials enrolling 626 eligible children met the inclusion criteria. Aprotinin reduced the proportion of children who received red blood cell or whole blood transfusions during cardiac surgery by 33% (relative risk = 0.67; 95% confidence interval, 0.51 to 0.89). Aprotinin did not have a significant effect on the volume of blood transfused or on the amount of postoperative chest tube drainage. Most of the studies were of poor methodological quality and predefined transfusion triggers were infrequently used. Overall, aprotinin reduced the proportion of children who received blood transfusion during cardiac surgery with cardiopulmonary bypass. Further high-quality trials with clinically important outcomes may be warranted before aprotinin can be routinely recommended in this population.

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