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CARDIOVASCULAR ANESTHESIA

Reduction of Blood Loss and Transfusion Requirement by Aprotinin in Posterior Lumbar Spine Fusion

Claude Lentschener, MD^*, Philippe Cottin, MD, Hervé Bouaziz, MD^*, Frederic J. Mercier, MD^*, Martine Wolf, MD, Yasser Aljabi, MD, Catherine Boyer-Neumann, MD, and Dan Benhamou, MD^*

Departments of *Anesthesiology, Orthopedic Surgery, and Hematology, Hôpital Antoine-Béclère, Université Paris-Sud, Clamart Cedex, France

Address correspondence and reprint requests to Claude Lentschener, MD, Department of Anesthesiology, Hôpital Antoine-Béclère, Université Paris-Sud, 157 rue de la Porte de Trivaux, 92141 Clamart Cedex, France. Address e-mail to claude.lentschener{at}abc.ap-hop-paris.fr

Aprotinin reduces blood loss in many orthopedic procedures. In posterior lumbar spine fusion, blood loss results primarily from large vein bleeding and also occurs after the wound is closed. Seventy-two patients undergoing posterior lumbar spine fusion were randomly assigned to large-dose aprotinin therapy or placebo. All patients donated three units of packed red blood cells (RBCs) preoperatively. Postoperative blood loss was harvested from the surgical wound in patients undergoing two- and/or three-level fusion for reinfusion. The target hematocrit for RBC transfusion was 26% if tolerated. Total (intraoperative and 24 h postoperative) blood loss, transfusion requirements, and percentage of transfused patients per treatment group were significantly smaller in the aprotinin group than in the placebo group (1935 ± 873 vs 2809 ± 973 mL per patient [P = 0.007]; 42 vs 95 packed RBCs per group [P = 0.001]; 40% vs 81% per group [P = 0.02]). Hematological assessments showed an identically significant (a) intraoperative increase in both thrombin-antithrombin III complexes (TAT) and in activated factor XII (XIIa) and (b) decrease in activated factor VII (VIIa), indicating a similar significant effect on coagulation in patients of both groups (P = 0.9 for intergroup comparisons of postoperative VIIa, XIIa, and TAT). Intraoperative activation of fibrinolysis was significantly less pronounced in the aprotinin group than in the placebo group (P < 0.0001 for intergroup comparison of postoperative D-dimer levels). No adverse drug effects (circulatory disturbances, deep venous thrombosis, alteration of serum creatinine) were detected. Although administered intraoperatively, aprotinin treatment dramatically reduced intraoperative and 24-h postoperative blood loss and autologous transfusion requirements but did not change homologous transfusion in posterior lumbar spine fusion.

Implications: In our study, aprotinin therapy significantly decreased autologous, but not homologous, transfusion requirements in posterior lumbar spine fusion.

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