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LETTERS TO THE EDITOR

Increased Safety in the Administration of Aprotinin: Need for a Test-Dose

Service of Anesthesiology and Post-Surgical Critical Care Unit , Hospital Clínico Universitario de Valencia , 46010-Valencia, Spain

We have read with interest the article published by Lentschener et al. (1), in relation to the use of aprotinin in surgery of the spinal column. It highlights the use of this drug for bloodless practice in orthopedic surgery, as recently proposed by various authors (2–4). Perhaps, the most important immediate adverse events associated with its administration are allergic phenomena, which have created considerable controversy and have even placed doubts on the suitability of this drug in orthopedic surgery (5).

The reason behind this letter is to stress the need for the administration of an IV dose of 10,000 KIU of aprotinin (test dose) before beginning the administration of the complete dose. The time period proposed between the administration of the test dose and start of the perfusion has been 10 min (6), although in our opinion, it should not be less than 20 min. After this time, if no hypersensitivity reactions have appeared, the administration of the complete aprotinin dose seems safe. This measure is recommended before any administration of aprotinin, whether or not the patient may have been exposed on a previous occasion.

Sometimes, it has been suggested to perform the test dose by subcutaneous administration of 50,000 KIU (5 mL) of aprotinin, but the results in this approach are nonspecific and only of questionable clinical relevancy; so we do not recommend this system.

There is no doubt that aprotinin is a promising drug for orthopedic surgery. Its indication continues to be controversial, but because one of the objectives whenever aprotinin is administered must be the safety of its use, the test dose should be included in the protocol for any administration of the drug.

References

1. Lentschener C, Cottin P, Bouaziz H, et al. Reduction of blood loss and transfusion requirement by aprotinin in posterior lumbar spine fusion. Anesth Analg 1999;89:590–7.[Abstract/Free Full Text]
2. Janssens M, Joris J, David JL, et al. High-dose aprotinin reduces blood loss in patients undergoing total hip replacement surgery. Anesthesiology 1994;80:23–9.[Web of Science][Medline]
3. Capdevila X, Calvet Y, Biboulet P, et al. Aprotinin decreases blood loss and homologous transfusions in patients undergoing major orthopedic surgery. Anesthesiology 1998;88:50–7.[Web of Science][Medline]
4. Llau JV, Aguilar G, Soliveres J, et al. Aprotinin administration reduces blood loss and transfusion requirements in patients undergoing total hip arthroplasty [abstract]. Br J Anaesth 1998;80 (S1):A271.
5. Kasper SM, Schmidt J, Rütt J. Is aprotinin worth the risk in total hip replacement [letter]? Anesthesiology 1994;81:517–8.[Medline]
6. Dietrich W, Spath P, Ebell A, Richter JA. Prevalence of anaphylactic reactions to aprotinin: analysis of two hundred forty-eight reexposures to aprotinin in heart operations. J Thorac Cardiovasc Surg 1997;113:194–201.[Abstract/Free Full Text]

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