Reopro and Blood Loss

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Pharmacological Methods to Reduce Blood Loss in
Surgery
George Despotis, MD Associate Professor of
Anesthesiology, Pathology and Immunology
Department of Anesthesiology and Blood Bank
Washington University School of Medicine St.
Louis, Missouri
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Risk Factors
Adverse Outcomes
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Single vs Combined Procedures
Operative History
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• Platelet inhibition - Dipyridamole -
  Prostacyclin (PGI2), PGE1 - IIb/IIIa receptor
  inhibition Abxcimab, integrelin

• Broad-spectrum inhibition Aprotinin

• Plasmin inhibition Tranexamic Acid, EACA

• Thrombin and Factor Xa inhibition - Heparin
  LMWH (Xa) vs UFH (Xa/IIa) - Heparin Adjuncts
  AT III, HCF II (Dermatan Sulfate) - Warfarin -
  Direct Thrombin Inhibitors

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Antifibrinolytic Actions
Effect on Hemostatic System Activation
200 KIU/mL gt 250-300 KIU/mL
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GOAL EFFECTIVE HEMOSTASIS
HEMORRHAGE
THROMBOSIS
ADEQUATE AND REVERSIBLE ANTICOAGULATION
? Pre-existing HYPERCOAGULABILITY ?
ATIII/Protein C/S, FV Leiden, LA/ACLAbs, ?
homocysteine, HIT, h/o thromboembolism, h/o
CHF, hypoperfusion ? INHIBITION OF
FIBRINOLYSIS (e.g. EACA) or PROTEIN C (e.g.
gt300 KIU/mL Aprotinin) ? INCREASED
PROCOAGULANTS DDAVP (e.g. vWF), Tx (e.g.
platelets, FEIBA) ? INADEQUATE SUPPRESSION OF
HEMOSTATIC ACTIVATION DURING CPB
? DECREASED PROCOAGULANTS CPB hemodilution,
consumption? INHIBITION OF HEMOSTASIS -
Antibodies to platelets, coag proteins -
Xa/IIa inhibitors (e.g. LMWH, r-hirudin)
- Platelet inhibitors (e.g Plavix, ? Reopro)
- Heparin rebound, FFP Tx (i.e., ATIII)
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Perioperative Bleeding Complications ? Can
lead to adverse outcomes related to complications
associated with reexploration, transfusion
and CNS injury ? Patients at high-risk
include those with congenital defects, on
long-acting anti-thrombotic agents, with trauma,
or patients who require complex cardiac
procedures (? CPB) Prevention ? When compared
to EACA/TA, aprotinin (full-dose regimen) - is
probably more effective in reducing bleeding,
transfusion and reexploration in high-risk
patients - and has an extensive safety record
? Optimal Anticoagulation results in
preservation of the hemostatic system
especially with prolonged CPB which leads to
reduced blood loss / transfusion and
possibly thrombotic complications
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Optimal Management of excessive bleeding ?
Although laboratory-based tests may be helpful,
the history and physical exam should
preoperatively identify patients at risk
who require further laboratory evaluation
? Use of POC diagnostic tests along with a
standardized transfusion approach (e.g.
algorithm) can optimize perioperative
transfusion/pharmacologic (e.g. DDAVP)
management ? Although factor concentrates used
as a rescue therapy can be life-saving,
thrombotic risk and cost preclude routine use