Aprotinin in lung transplantation is associated with an increased incidence of primary graft dysfunction.

OBJECTIVE: Aprotinin has been widely used to reduce bleeding and transfusion requirements in cardiac surgery and in lung transplantation. A recent study found a significant reduction in severe (grade III) primary graft dysfunction (PGD) in lung transplantation where aprotinin had been used. However, recently, concerns regarding the safety of aprotinin have been raised, and the future use of aprotinin is uncertain. In our institution, aprotinin has been widely used in cardiac surgery and transplantation. We decided to review our lung transplant caseload to investigate the impact of aprotinin on PGD and mortality and to guide our future clinical use of this antifibrinolytic. METHODS: A retrospective review of prospectively collected data on 213 consecutive patients who underwent single- or double-lung transplantation was performed. Ninety-nine patients, who received aprotinin, were compared with 114 patients who did not. The main outcome variables analysed were development of primary graft dysfunction, renal impairment and mortality. RESULTS: Aprotinin was associated with a significantly increased risk of PGD in the first 48 h postoperatively (p=0.01). CONCLUSIONS: In conclusion, although the benefits of aprotinin on blood loss are well established, this study does not provide support for the use of aprotinin to reduce PGD in lung transplantation and indicates that aprotinin may in fact have a detrimental effect.

Anesthetic management of thoracic trauma.

PURPOSE OF REVIEW: Trauma remains a leading cause of death across all age groups. Thoracic injury is a contributing cause in approximately half of these. Despite being potentially life threatening, most thoracic trauma is managed nonoperatively or with an intercostal catheter. Only 10% of thoracic trauma patients will require emergency thoracotomy. Many more will undergo emergency or urgent surgical intervention for coexisting injuries. Thoracic injuries are dynamic. It is crucial for the anesthesiologist to continually reassess the patient, so that the manifestations of evolving injuries may be detected as early as possible and appropriate management decisions made. Up-to-date knowledge of injury patterns, mechanisms, pathophysiology, and operative and nonoperative management will facilitate optimal management of these patients. RECENT FINDINGS: There is recent literature discussing the surgical, anesthetic and critical care management of a range of thoracic injuries resulting from either blunt or penetrating trauma. SUMMARY: Initial resuscitation and surgical management of patients with thoracic trauma continue to evolve. Improvements in prehospital care and diagnostic techniques as well as development of minimally invasive interventions mean that the anesthesiologist may be required to provide care to unstable patients in an expanded range of scenarios and environments.