The feasibility of multiple-tract mini-percutaneous nephrolithotomy as an overnight surgery for the treatment of complex kidney stones.

To demonstrate the feasibility of applying multiple-tract percutaneous nephrolithotomy (PCNL) as an overnight surgery for treatment of complex kidney stones. We reviewed a prospectively collected database of all multiple-tract PCNL planned as overnight surgery performed by a single surgeon since 2018. A clinical pathway including the removal of nephrostomy tube and discharge on the morning after surgery was carried out. A definition for tube removal was outlined. Ability to adhere to the pathway and achieving the described parameters and whether any resulting complications occurred were determined. A total of 136 consecutive patients were enrolled with mean stone burden of 960.5 mm2 and 5.1 cm. Mean operative time was 71.7 ± 30.7 min. The average hemoglobin drop was 17.6 ± 12.2 g/L, and the incidence of drop > 25 g/L was 21.9%. Overall, 125 patients (91.9%) but 11 patients were discharge on postoperative day 1. One case required readmission. Among the 11 patients, 7 patients (5.1%) underwent a delayed tube removal (≥ 2 days) and 4 patients underwent complications after next-day nephrostomy tube removal, including renal colic (2 cases), hydrothorax (1 case), and fever (1 case). Postoperative fever or severe hematuria was the major reason for delayed nephrostomy tube removal. The total complication rate was 8.8% (n = 12). Multiple-tract PCNL as an overnight surgery can be safely performed by experienced surgeons in most patients. An early nephrostomy tube removal could be achieved in nearly 95% patients.

Effects of five treatment regimens on blood loss and blood transfusion in total knee arthroplasty: a preliminary study in China
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OBJECTIVE: Our study is aimed to explore effects of five treatment regimens on blood loss and blood transfusion rate in total knee arthroplasty (TKA) patients. METHODS: 191 TKA patients were divided into the rivaroxaban, nadroparin, and tranexamic acid groups (n = 37 each) as well as into the affected-limb-position and tourniquet group (n = 40 each). A 3-month follow-up after operation was needed for all patients. The total blood loss, hidden blood loss, and dominant blood loss were recorded, and hemoglobin and red blood cell changes, pain and knee swelling degrees, hospital for special surgery (HSS), and American knee society (KSS) knee scores were observed. RESULTS: When compared with the rivaroxaban, nadroparin, and tourniquet groups, TKA patients' dominant blood loss, hidden blood loss, total blood loss, rate and volume of blood transfusion in the tranexamic acid and affected-limb-position groups were significantly decreased. While 7 days after operation, the hemoglobin and red blood cells in the tranexamic acid and affected-limb-position groups were significantly increased. At 1 month and 3 months after operation, when compared with the rivaroxaban, nadroparin, and tourniquet groups, the HSS and KSS scores in the tranexamic acid and affected-limb-position groups were all increased. In comparison with the rivaroxaban, nadroparin, and tourniquet groups, the D-Dimers after operation in the tranexamic acid and affected-limb-position groups were significantly lower. CONCLUSION: These results demonstrated that for TKA patients, the tranexamic acid and affected-limb-position could obviously reduce the blood loss and blood transfusion rate.
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Is there a need for routine post-operative hemoglobin level estimation in total knee arthroplasty with tranexamic acid use?

BACKGROUND: Total knee arthroplasty (TKA) can result in significant blood loss, leading to a need for blood transfusion. The major indication of transfusion is post-operative hemoglobin (Hb) levels in association with symptomatic anemia. The aim of this study was to determine the possibility of eliminating routine post-operative Hb tests in patients undergoing TKA with intra-articular tranexamic acid (TXA) use based on the predictability of pre-operative factors. METHODS: We conducted a retrospective analysis of 487 patients who underwent TKA with intra-articular TXA use. Statistical analysis was done to predict the transfusion risk based on multiple pre-operative parameters. RESULTS: Post-operative blood transfusions were required in 2.5% of all patients. Pre-operative-Hb was the only significant predictor of post-operative transfusion (p<0.0001). Age, sex, weight, height and body mass index (BMI) were not related to post-operative transfusion risk. Transfusions were needed in 4.2% of patients with pre-operative Hb levels <14 g/dl. No patient with a pre-operative Hb >14 g/dl required a transfusion (p<0.0001). CONCLUSIONS: Pre-operative Hb is a strong predictor of post-operative blood transfusion risk. Patients who receive TXA in TKA, with a pre-operative Hb >14 g/dl do not require routine post-operative Hb evaluation. LEVEL OF EVIDENCE: IV.

[A WHO concept- patient blood management]. / Ein WHO Konzept - Patient Blood Management.

Blood transfusions are in general considered as lifesaving. Current data and evidence show, that blood transfusions are associated with increased morbidity and mortality, and this apparently dose-dependent. Basic research and results from randomized controlled trials show a causal relationship between blood transfusion and adverse outcome. Based on the current state of knowledge it has to be questioned that blood transfusions are "life-saving" as patients are exposed to an increased risk of disease or death. Furthermore, blood transfusions are more costly than previously assumed. For these reasons novel approaches in the treatment of anemia and bleeding are needed. Patient Blood Management (PBM) allows reduction of transfusion rates by correcting anemia by stimulating erythropoiesis, minimizing perioperative blood loss and optimizing the physiological tolerance of anemia. In 2010 the World Health Organization has claimed PBM to be considered as golden standard. PBM reduces morbidity and mortality by lowering the excessive use of blood transfusions. This concept has partially and successfully been implemented in the University Hospital Balgrist in Zurich.

A l'heure actuelle les transfusions sanguines sont généralement considérées comme salvatrices. Les données actuelles par contre montrent que les transfusions sanguines sont associées, et cela clairement en fonction des doses appliquées, à une morbidité et mortalité augmentées. Outre différentes tentatives d'explication fournies par la recherche fondamentale, les résultats récents d'études contrôlées et randomisées ont clairement démontré qu'il s'agit d'une relation de cause à effet. Pour cela l'opinion que des transfusions sanguines sont salvatrices doit être revue de façon critique car ce traitement peut promouvoir des maladies et même représenter un danger vital. En plus les transfusions sanguines génèrent des coûts beaucoup plus élevés que présumé jusqu'à présent. En cas d'anémie ou de saignement de nouveaux concepts de traitements comme le «patient blood management¼ (PBM) sont indispensables et essentiels. Le PBM réduit la nécessité de transfusions en corrigeant l'anémie par des substances stimulant l'érythropoïèse, en réduisant les pertes sanguines durant l'intervention chirurgicale et en augmentant la tolérance physiologique de l'anémie. Une résolution de l'organisation mondiale de la santé en 2010 exige que le PBM soit considéré comme «le golden standard¼ pour le traitement des patients. La réduction de l'utilisation de produits sanguins peut clairement diminuer la mortalité et morbidité. Depuis que le concept a partiellement été introduit à l'hôpital universitaire Balgrist, Zurich et montre clairement des résultats positifs.

Retransfusion of cardiotomy suction blood impairs haemostasis: ex vivo and in vivo studies.

OBJECTIVES: Cardiotomy suction blood in volumes corresponding to 10-20% of the systemic blood volume is retransfused during cardiopulmonary bypass. We hypothesized that retransfusion of unwashed cardiotomy suction blood influences coagulation and platelet function. DESIGN: Systemic blood samples collected during cardiopulmonary bypass were supplemented ex vivo with autologous wound blood (5, 10 and 20%, respectively). Clot formation and platelet function were assessed with thromboelastometry and platelet aggregometry. In an in vivo pilot study 30 patients were randomized into a retransfusion and a no-retransfusion group. Clot formation, platelet aggregability and thrombin generation capacity were compared between the groups. RESULTS: Cardiotomy suction blood had markedly impaired clot stability and reduced levels of fibrinogen and platelets compared with systemic blood. Ex vivo addition of 10% and 20% suction blood to systemic blood impaired platelet aggregability and clot stability. Retransfusion of small amounts of wound blood in vivo (mean volume 280 ml, corresponding to 5% of the blood volume) did not significantly influence haemostasis. CONCLUSIONS: The ex vivo results suggest that addition of unwashed cardiotomy suction blood in clinically relevant volumes impairs systemic haemostasis. Retransfusion of smaller volumes in vivo has no or limited impact. Avoiding retransfusion of larger amounts of unwashed cardiotomy suction may improve postoperative haemostasis.

Patient blood management -- the GP's guide.

BACKGROUND: There is accumulating evidence of a strong association between blood transfusion and adverse patient outcomes. Patient blood management aims to achieve improved patient outcomes by avoiding unnecessary exposure to blood products through effective conservation and management of a patient's own blood. OBJECTIVE: To introduce the general practitioner's role in patient blood management. DISCUSSION: There are a number of ways in which GPs can contribute to patient blood management, particularly in the care of patients scheduled for elective surgery. These include awareness, identification, investigation and management of patients with or at risk of anaemia; assessment of the adequacy of iron stores in patients undergoing planned procedures in which substantial blood loss is anticipated; awareness and assessment of medications and complementary medicines that might increase bleeding risk; and awareness of and ability to discuss with patients, the possible risks associated with blood transfusion and alternatives that may be available.

A new hemostatic agent (Ankaferd Blood Stopper(®)) in tubeless percutaneous nephrolithotomy: a prospective randomized study.

PURPOSE: The present study evaluates the efficiency and reliability of a hemostatic agent ABS (Ankaferd Blood Stopper(®)) in tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: A total of 90 patients were divided into two subgroups. The first group had ABS applied during the intervention, whereas the control group underwent regular tubeless PCNL in this prospective randomized study. Age, stone size, operative time, postoperative hemoglobin change, renal parenchyma thickness, postoperative ureteral catheter removal time, access number, nephroscope time, blood transfusion rate, serum creatinine change, complication rate, visual analogue scale (VAS), and hospitalization time were compared between the two groups. RESULTS: Preoperative and postoperative data obtained from both groups were compared. No statistically meaningful differences were found related to variables of mean age, stone size, access number, serum creatinine change, operative time, renal parenchyma thickness, VAS scores, and hospitalization period. Whereas the nephroscope time (minutes) was longer in the ABS group (Group 1 [G1]:3, 33±1, 72 vs G2:2, 62±1, 43, P=0.035), hemoglobin (Hb) decrease, and urine clarity time were statistically lower compared with the control group. Hb decrease was (mg/dL) (G1: 1.40±1.04 vs G2: 1.84±1.15, P=0.034), and urine clarity time was (hour) (G1: 9.60±5.50 vs G2: 11.95±4.71, P=0.012), respectively. Complications were encountered in three (6.6%) patients of the ABS group and in four (8.8%) of the control group. CONCLUSION: ABS is an efficient and reliable hemostatic agent in tubeless PCNL. Comparative studies are needed, however, with other hemostatic agents that might be applied in tubeless PCNL.

Drivers of transfusion decision making and quality of the evidence in orthopedic surgery: a systematic review of the literature.

Reasons for variation in transfusion practice in orthopedic surgery are not well understood. This systematic review identified and appraised the quality of the literature in this area to assess the impact of factors associated with the use of allogeneic red blood cell (RBC) transfusion in orthopedic procedures. MEDLINE and EMBASE databases were searched for relevant English language publications. Articles containing a range of MeSH and text terms regarding "blood transfusion," "predictors," and "multiple logistic regression" were retrieved. Articles that focused on patients undergoing orthopedic procedures and that met prespecified inclusion criteria were appraised in terms of potential bias and the appropriateness of statistical approach. A total of 3641 citations were retrieved, and 29 met the inclusion criteria for the review. Articles reported on a range of orthopedic procedures including total hip arthroplasty; total knee arthroplasty, total shoulder arthroplasty, and spinal surgery. Most studies were conducted in the United States (n = 12) or Canada (n = 5). Study quality was moderate; 50% or more of the quality criteria were assessed in 15 articles. Particular areas of concern were the lack of prospective studies, lack of clarity in defining the time interval between risk factor assessment and transfusion outcome, and lack of model validation. A narrative synthesis found that 2 factors consistently influenced the use of RBC transfusion-decreased hemoglobin (n = 25) and increased patient age (n = 18). Increased surgical complexity (n = 12), low body weight (n = 9), presence of additional comorbidities (n = 9), and female sex (n = 7) were also important factors. The general quality of the studies in the field is weak. However, low hemoglobin and increasing age were consistently identified as independent risk factors for RBC transfusion in orthopedic practice. Additional or alternative analytical approaches are required to obtain a more comprehensive, holistic understanding of the decision to transfuse RBCs to patients undergoing orthopedic surgery.

Prothrombin complex concentrate mitigates diffuse bleeding after cardiopulmonary bypass in a porcine model.

BACKGROUND: Extracorporeal circuit priming and intravascular volume expansion during cardiopulmonary bypass (CPB) may lead to dilutional coagulopathy and excessive diffuse postoperative bleeding. Prothrombin complex concentrate (PCC) containing clotting factors II (FII), VII (FVII), IX (FIX), and X (FX) could be of potential value in correcting dilutional coagulopathy and reducing blood loss. METHODS: Anaesthetized pigs underwent CPB with hypothermia for 2 h at 25°C followed by 1 h of normothermia. Approximately 1 h after CPB, animals randomly received either isotonic saline 1 ml kg⁻¹ or PCC 30 IU kg⁻¹ in a volume of 1 ml kg⁻¹. Diffuse coagulopathic bleeding was assessed as suture hole blood loss from a Gore-Tex patch placed over a full-thickness incision in the left carotid artery. RESULTS: After CPB, levels of FII, FVII, FIX, and FX declined from baseline by 32% to 48%, and PCC fully or partially reversed those deficits. Median suture hole blood loss after administration of saline placebo was 74 ml. PCC reduced suture hole bleeding by a median of 54 ml with a 95% confidence interval of 6-112 ml (P=0.026) compared with saline. PCC, but not saline, normalized skin bleeding time. Peak thrombin generation markedly decreased after CPB, but then returned in PCC-treated animals to a level higher than baseline by 28.7 nM (14.5-41.1 nM; P=0.031). CONCLUSIONS: PCC was effective in correcting dilutional coagulopathy and reducing diffuse bleeding in an in vivo large-animal CPB model. Further research is warranted on PCC as a haemostatic agent in CPB.

Postoperative autotransfusion of mediastinal shed blood does not influence haemostasis after elective coronary artery bypass grafting.

OBJECTIVES: The rationale of using autotransfusion of mediastinal shed blood after cardiac surgery is to preserve haemoglobin levels and reduce the need for allogenic blood transfusions. However, the method is controversial and its clinical value has been questioned. We hypothesised that re-transfusion of mediastinal shed blood instead impairs haemostasis after routine coronary artery bypass grafting and thus increases postoperative bleeding. METHODS: Seventy-seven consecutive elective coronary artery bypass surgery patients (mean age 67±9 years, 77% men) were included in a prospective, randomised controlled study. The patients were randomised to postoperative re-transfusion of mediastinal shed blood (n=39) or to a group where mediastinal shed blood was discarded (n=38). Primary end point was bleeding during the first 12 postoperative hours. Secondary end points were postoperative transfusion requirements, haemoglobin levels, thrombo-elastometric variables and plasma concentrations of interleukin-6, thrombin-anti-thrombin complex and D-dimer. RESULTS: Mean re-transfused volume in the autotransfusion group was 282±210 ml. There was no difference in postoperative bleeding (median 394 ml (interquartile range 270-480) vs 385 (255-430) ml, p=0.69), proportion of patients receiving transfusions of blood products (11/39 vs 11/38, p=0.95), haemoglobin levels 24h after surgery (116±13 vs 116±14 g l(-1), p=0.87), thrombo-elastometric variables, interleukin-6 (219±144 vs 201±144 pg ml(-1), p=0.59), thrombin-anti-thrombin complex (11.0±9.1 vs 14.8±15, p=0.19) or D-dimer (0.56±0.49 vs 0.54±0.44, p=0.79) between the autotransfusion group and the no-autotransfusion group. CONCLUSIONS: Autotransfusion of small-to-moderate amounts of mediastinal shed blood does not influence haemostasis after elective coronary artery bypass grafting.

Advantages of autologous blood transfusion in off-pump coronary artery bypass.

BACKGROUND: In this randomized controlled study, we investigated the effects of autologous Hemobag blood transfusion (AHBT) and allogenic blood transfusion (ABT) in off-pump coronary artery bypass (OPCAB) surgery. METHODS: Sixty patients who underwent surgery between February 2008 and August 2008 were randomized into 2 groups. The AHBT group (n = 30) consisted of patients who received autologous Hemobag blood transfusion, and the ABT group (n = 30) consisted of patients who received allogenic blood transfusion. All patients underwent OPCAB via sternotomy. The time to extubation, chest tube drainage volume, postoperative white blood cell counts, amount of blood transfusion, sedimentation rate, C-reactive protein concentration, postoperative temperature, and the presence of atelectasis were recorded in the intensive care unit. RESULTS: Intraoperative bleeding and fluid resuscitation were similar in the 2 groups (P > .05); however, there were significant decreases in postoperative blood loss, extubation period, postoperative white cell counts, sedimentation rate, incidence of atelectasis, C-reactive protein, and fever in the AHBT group compared with the ABT group (P < .05). The rate of atrial fibrillation in the AHBT group tended to be lower than in the ABT group. CONCLUSION: Autologous blood transfusion in OPCAB may be beneficial in certain cardiac surgery patients; however, these beneficial effects require further study to be proved.

[Autohemotransfusion in multifield hospital].

Autohemotransfusions were used at 120 patients before surgery and in first day after it. Control group of patients was treated with donor blood components. Level of hemoglobin and hematocrit was controlled in both groups. It was demonstrated that these parameters returned to normal level on 5-7 days earlier at the patients of study group (with autohemotransfusions) than at ones of control group.

Which patients are more likely to benefit from postoperative shed blood salvage after unilateral total knee replacement? An analysis of 581 consecutive procedures.

INTRODUCTION: Requirements for allogeneic blood transfusion (ABT) after total knee replacement (TKR) are still high (30-50%), and salvage of unwashed filtered postoperative shed blood (USB) may represent an alternative to ABT. We evaluated that patients are more likely to benefit of USB reinfusion after TKR. PATIENTS AND METHODS: Data from 581 consecutive primary TKR, managed with (reinfusion group, n = 382) or without (control group, n= 199) reinfusion of USB, were retrospectively reviewed. RESULTS: Patients from reinfusion group received 119 +/- 88 ml of red blood cells from USB, without clinically relevant incidents, and showed a lower ABT rate (30.6% vs. 8.4%, for control and reinfusion groups, respectively; P = 0.001) (transfusion trigger, haemoglobin [Hb] < 9 g/dl). Differences in ABT rate between groups were significant for all preoperative Hb levels, except for Hb < or = 12 g/dl. A lower transfusion threshold (Hb < 8 g/dl) might have further decreased ABT rate (14.6% vs. 5.2%, respectively; P < 0.001), with differences being significant for preoperative Hb between 12 and 15 g/dl. There were no differences with respect to postoperative infection rate, but patients from reinfusion group had a shorter length of hospital stay (11 +/- 4 vs. 13 +/- 4 days, respectively; P= 0.001). CONCLUSIONS: Return of USB after TKR seems to reduce the need for ABT, especially in patients with preoperative Hb between 12 and 15 g/dl. There is little benefit of USB reinfusion for patients with preoperative Hb > 15 g/dl, whereas patients with preoperative Hb < 12 g/dl would probably benefit from the combination of USB with some other blood-saving method.

[Postoperative autologous retransfusion of collected shed blood after total knee arthroplasty with the cell saver]. / Postoperative Drainageblutretransfusion mit dem Cellsaver bei endoprothetischem Kniegelenkersatz.

AIM: The purpose of this study was to examine if it is possible to reduce transfusion of blood units by collecting shed blood with the Cell Saver for autologous retransfusion in total knee arthroplasty (TKA). METHOD: In 186 patients drainage blood was collected over a 6-h period after total knee arthroplasty with a Cell Saver system in order to make retransfusions if necessary. A tourniquet was used routinely throughout the operation. No preoperative blood donation was performed. In 19 patients preoperative haemoglobin levels were below 12 g/dL (group A, anaemic patients). In the other 167 patients (group B) the preoperative haemoglobin levels were higher. RESULTS: 4 patients (21 %) in group A received a homologous blood transfusion. Only 1 patient (0.6 %) in group B received one unit of erythrocyte concentrate (difference statistically significant, P < 0.001). In group A 8 patients (42 %) received 284 ml (145-621 ml) Cell-Saver concentrate on average, 38 patients (23 %) in group B received 358 mL (147-776 ml) Cell-Saver concentrate on average. CONCLUSION: With a risk lower than 1 % for patients without anaemia to get a homologous blood transfusion one can do without the more expensive preoperative blood donation in total knee arthroplasty if a tourniquet is used for the operation and a Cell Saver is used for facultative retransfusion of drainage blood.

[Pathogenetic mechanisms of infectious-inflammatory and thrombohemorrhagic complications of transurethral prostatic resection]. / Patogeneticheskie mekhanizmy infektsionno-vospalitel'nykh i trombogemorragicheskikh oslozhnenii transuretral'noi rezektsii prostaty.

The role of hemostatic disorders and alterations in urine proteolytic activity in pathogenesis of infectious-inflammatory and thrombohemorrhagic complications of prostatic transurethral resection (PTR) was studied. Hemostasis and urine proteolytic activity were investigated with biochemical and coagulological tests in 54 patients with benign prostatic hyperplasia (BPH) before and after PTR. Significant hypercoagulation in early postoperative period found in the examinees promoted formation of inflammation-related contaminated dense protein products which serve a source of permanent reinfection. The patients had low proteolytic activity of the urine caused by renal dysfunction as a result of abnormal urodynamics in this disease. Thus, hemostatic disorders and subnormal proteolytic activity of the urine are essential factors in pathogenesis of infectious-inflammatory and thrombohemorrhagic complications of PTR. The conceptual scheme of postoperative complications pathogenesis in BPH patients subjected to PTR is proposed.

Vascular complications of transsphenoidal surgery.

Vascular complication of transsphenoidal surgery can lead to mortality and serious morbidity. In a series of 3,061 transsphenoidal operations for pituitary disease, 24 such complications were encountered, seven of which were fatal. The anatomic substrate for such complications is discussed, along with technical aspects of surgery and other methods for the avoidance of vascular complications.

Intraoperative autologous blood donation preserves red cell mass but does not decrease postoperative bleeding.

BACKGROUND: Postoperative bleeding and transfusion remain a source of morbidity and cost after open heart operations. The benefit of the acute removal and reinfusion of fresh autologous blood around the time of cardiopulmonary bypass-a technique known as intraoperative autologous donation (IAD)-has not been universally accepted. We sought to more clearly evaluate the effects of IAD on allogeneic transfusion and postoperative bleeding by removing, preserving, and reinfusing a calculated maximum volume of fresh autologous whole blood. METHODS: Ninety patients undergoing coronary artery bypass grafting or valvular operations were prospectively randomized to either have (IAD group) or not have (control group) calculated maximum volume IAD performed. Treatment was otherwise identical. Transfusion guidelines were uniformly applied to all patients. RESULTS: An average volume of 1,540 +/- 302 mL of fresh autologous blood was removed and reinfused in the IAD group. Postoperative hematocrits were significantly greater at 12 and 24 hours postoperatively in the IAD group versus the control group despite a significant decrease in both the percentage of patients in whom allogeneic red blood cells were transfused (17% versus 52%; p < 0.01) and the number of red blood cell units transfused per patient per group (0.28 +/- 0.66 and 1.14 +/- 1.19 units; p < 0.01). Conversely, chest tube output, incidence of excessive postoperative bleeding, postoperative prothrombin time, and platelet and coagulation factor transfusion requirement did not differ between groups. CONCLUSIONS: These results indicate that intraoperative autologous donation serves to preserve red blood cell mass. Its routine use in eligible patients is therefore justified. However, the removal and reinfusion of an individually calculated maximum volume of fresh autologous blood had no effect on postoperative bleeding or platelet and coagulation factor transfusion requirement. This lack of hemostatic effect belies the beliefs of many about the primary action of IAD, helps to delineate the optimal way in which to perform IAD, and carries implications regarding the use of allogeneic platelet and coagulation factors for the treatment of early postoperative bleeding.

Intraoperative antifibrinolysis and blood-saving techniques in cardiac surgery. Prospective trial of 3 antifibrinolytic drugs.

Sixty consecutive patients undergoing elective open-heart surgery were prospectively enrolled in a study to compare the efficacy of 3 different antifibrinolytic drugs to reduce postoperative bleeding and to reduce homologous blood requirements in combination with blood-saving techniques and restrictive indications for blood transfusion. The patients were randomized to 1 of 4 intraoperative treatment regimens: 1) control (no antifibrinolytic therapy); 2) epsilon-aminocaproic acid (10 g IV at induction of anesthesia, followed by infusion of 2 g/h for 5 hours); 3) tranexamic acid (10 mg/kg IV within 30 minutes after induction of anesthesia, followed by infusion of 1 mg/kg per hour for 10 hours); or 4) high-dose aprotinin (2 million KIU IV at induction of anesthesia and 2 million KIU added to the extracorporeal circuit, followed by infusion of 500 thousand KIU/h during surgery). Hemoconcentration and reinfusion of blood drained from the operative field and the extracorporeal circuit after operation were used in all patients. Indications for blood transfusion were hypotension, tachycardia, or both, with hemoglobin values < 8.5 g/dL; or severe anemia with hemoglobin values < 7 g/dL. Compared with the blood loss in the control group, patients receiving aprotinin and epsilon-aminocaproic acid showed significantly less postoperative blood loss at 1 hour (control, 128 +/- 94 mL; aprotinin, 54 +/- 47 mL, p = 0.01; and epsilon-aminocaproic acid, 69 +/- 35 mL, p = 0.03); this trend continued at 24 hours after operation (control, 724 +/- 280 mL; aprotinin, 344 +/- 106 mL, p < 0.0001; and epsilon-aminocaproic acid, 509 +/- 148 mL, p = 0.01). Aprotinin was significantly more efficient than epsilon-aminocaproic acid (p=0.002). Tranexamic acid did not have a statistically significant effect on blood loss. Homologous blood requirements were not significantly different among the groups; postoperative hematologic values and coagulation times were also comparable. Despite the efficacy of aprotinin and epsilon-aminocaproic acid shown in the present study, the blood requirements were not significantly different from those that are found when transfusions are restricted, autotransfusions are used, and blood from the operative field and extracorporeal circuit is concentrated and reinfused. Therefore, intraoperative antifibrinolysis may not be indicated in routine cardiac surgery when other blood-saving techniques are adopted.