title: Antifibrinolytic use in adult cardiac surgery.
abstract: OBJECTIVE
  Antifibrinolytics are used to attenuate the coagulopathy associated with cardiopulmonary bypass. However, recent studies suggest that the antifibrinolytic aprotinin is associated with increased renal and vascular events and death compared to its alternatives. To develop a recommendation for antifibrinolytic use in adult cardiac surgery, we performed a systematic review and meta-analysis to determine the association of the antifibrinolytics with efficacy, safety and cost outcomes.
  
  
  RESULTS
  Aprotinin, when compared to placebo, significantly decreased blood transfusions and reoperations for bleeding, strokes and cognitive dysfunction, and significantly increased renal dysfunction but not renal failure. Tranexamic acid significantly decreased blood transfusions, but was not statistically associated with other outcomes. Aminocaproic acid was not statistically associated with any measured outcome. Although aprotinin costs more than its alternatives, its costs may approximate those of its alternatives when longer time horizons are considered.
  
  
  CONCLUSIONS
  We support the targeted use of aprotinin in adult cardiac surgery patients at high risk for bleeding or stroke, and discourage the use of aprotinin in those at high risk for renal failure. Although fewer data are available for tranexamic and aminocaproic acid, we support their use as alternatives to aprotinin in those at high risk for bleeding.
authors.affiliation: Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA. craig.umscheid@uphs.upenn.edu
authors.forename: Craig A
authors.initials: CA
authors.lastname: Umscheid
authors.forename: Benjamin A
authors.initials: BA
authors.lastname: Kohl
authors.forename: Kendal
authors.initials: K
authors.lastname: Williams
mesh_terms: D000328:Adult; D000933:Antifibrinolytic Agents / Q000008:administration & dosage* / Q000191:economics; D006348:Cardiac Surgical Procedures / Q000191:economics; D002315:Cardiopulmonary Bypass / Q000191:economics; D006470:Hemorrhage / Q000191:economics / Q000517:prevention & control*; D006801:Humans; D051437:Renal Insufficiency / Q000191:economics / Q000517:prevention & control*; D020521:Stroke / Q000191:economics / Q000517:prevention & control*
chemical_list: D000933:Antifibrinolytic Agents