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Intervention Review

Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion

  1. DA Henry,
  2. AJ Moxey,
  3. PA Carless,
  4. D O'Connell,
  5. B McClelland,
  6. KM Henderson,
  7. K Sly,
  8. A Laupacis,
  9. D Fergusson

Editorial Group: Cochrane Injuries Group

Published Online: 25 OCT 1999

DOI: 10.1002/14651858.CD001886


How to Cite

Henry DA, Moxey AJ, Carless PA, O'Connell D, McClelland B, Henderson KM, Sly K, Laupacis A, Fergusson D. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD001886. DOI: 10.1002/14651858.CD001886.

Author Information

*Prof David Henry, Professor of Clinical Pharmacology, Faculty of Health, University of Newcastle, Level 5, Clinical Sciences Building, Newcastle Mater Hospital, Waratah, NSW, 2298, AUSTRALIA. david.henry@newcastle.edu.au.

Publication History

  1. Published Online: 25 OCT 1999

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Abstract

  1. Top of page
  2. Abstract
  3. Synopsis

Background

Concerns regarding the safety of transfused blood have prompted re-consideration of the use of allogeneic (blood from an unrelated donor) blood transfusion.

Objectives

To assess the effects of the anti-fibrinolytic drugs aprotinin, tranexamic acid, and epsilon aminocaproic acid, on peri-operative red blood cell (RBC) transfusion.

Search strategy

We searched MEDLINE (to May 1998), EMBASE (to December 1997), web sites of international health technology assessment agencies (to May 1998). References in identified trials and review articles were checked and authors contacted to identify any additional studies.

Selection criteria

Randomised controlled trials of anti-fibrinolytic drugs in adults scheduled for non-urgent surgery.

Data collection and analysis

Two reviewers independently assessed trial quality and extracted data.

Main results

We found 61 trials of aprotinin (7027 participants). Aprotinin reduced the rate of RBC transfusion by a relative 30% (RR=0.70: 95%CI: 0.64 to 0.76). The average absolute risk reduction (ARR) was 20.4% (95%CI: 15.6% to 25.3%). On average, aprotinin use saved 1.1 units of RBC (95%CI: 0.69 to 1.47) in those requiring transfusion. Aprotinin also significantly reduced the need for re-operation due to bleeding (RR=0.40: 95%CI: 0.25 to 0.66).

We found 18 trials of tranexamic acid (TXA) (1,342 participants). TXA reduced the rate of RBC transfusion by a relative 34% (RR=0.66: 95%CI: 0.54 to 0.81). This represented an ARR of 17.2% (95%CI: 8.7% to 25.7%). TXA use resulted in a saving of 1.03 units of RBC (95%CI: 0.67 to 1.39) in those requiring transfusion. We found four trials of epsilon aminocaproic acid (EACA) (208 participants). EACA use resulted in a statistically non-significant reduction in RBC transfusion (RR=0.48: 95%CI: 0.19 to 1.19).

Comparisons between agents
Eight trials made 'head-to-head' comparisons between TXA and aprotinin. There was no significant difference between the two drugs in the rate of RBC transfusion: RR=1.21 (95%CI: 0.83 to 1.76) for TXA compared to aprotinin.

Adverse Effects
Aprotinin did not seem to be associated with an excess risk of adverse effects, including thrombo-embolic events (thrombosis RR=0.64: 95%CI: 0.31 to 1.31) and renal failure (RR=1.19: 95%CI: 0.79 to 1.79). Fewer data were available for TXA and EACA.

Authors' conclusions

From this review it appears that aprotinin reduces the need for red cell transfusion, and the need for re-operation due to bleeding, without serious adverse effects. However, there was significant heterogeneity in trial outcomes, and some evidence of publication bias. Similar trends were seen with TXA and EACA, although the data were rather sparse. The poor evaluation of these latter drugs is unfortunate as results suggest they may be equally as effective as aprotinin, but are significantly cheaper. The evidence reviewed here supports the use of aprotinin in cardiac surgery. Further small trials of this drug are not warranted. Future trials should be large enough to compare the efficacy and cost-effectiveness of aprotinin with that of TXA and EACA.

 

Synopsis

  1. Top of page
  2. Abstract
  3. Synopsis

Plain language summary

Anti-fibrinolytic drugs may reduce the need for red blood cell tranfusions.

Risks of infection from transfused blood given by an unrelated donor are minimal when blood is screened by a competent tranfusion service but concerns remain high. Other techniques are available to reduce the need for a transfusion. The review of trials found that anti-fibrinolytic drugs reduce bleeding and reduce the need for transfusions without serious adverse effects. The drugs reviewed were aprotinin, tranexamic acid and epsilon aminocaproic acid.