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Department of Anesthesiology; Washington University School of Medicine; St. Louis, Missouri; nielsenc{at}msnotes.wustl.edu
To the Editor:
Reconstructive spinal fusion procedures are often associated with loss of large amounts of blood. Kokoszka et al. (1) made a "Grade A" recommendation to use high-dose aprotinin in long, orthopedic procedures associated with large blood losses, such as spine and hip surgery. We adopted this recommendation. If the surgeons expected a significant blood loss, patients received a 1 mL equivalent to 1.4 mg aprotinin test dose preoperatively, and they were observed for 20 min before induction of anesthesia. Shortly after induction, an initial loading dose of 200 mL equivalent to 280 mg aprotinin was administered IV over 30 min, followed by an infusion of 50 mL equivalent to 70 mg of aprotinin per hour. The infusion was continued until skin closure.
Over a 7-mo period, during which 118 spine operations were performed with routine use of an intraoperative aprotinin infusion, acute renal failure was seen in four female patients. One patient was taking enalapril, one benazepril, and one losartan. One of the four patients received neither an angiotensin-converting enzyme inhibitor nor an angiotensin II receptor antagonist.
Renal failure has not been reported in patients after major spine reconstruction, and was not observed in our patients prior to the use of aprotinin. The combination of aprotinin and an angiotensin-converting enzyme inhibitor may have increased the risk of renal failure after operations on the spine for two of our patients. This conclusion was reached with the combination used in cardiac surgery (2). The cause for postoperative renal failure is often multifactorial; contributing factors are anemia, nephrotoxic antibiotics, decreased renal blood flow and perfusion pressure, and low oxygen saturation in the glomerulus. None of these risk factors were different before, during, and after the 7-mo period in which aprotinin was used. We speculate that the long case duration, and the large total dose of aprotinin, may have contributed to the risk of renal failure in our patients.
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