Fatal Anaphylactic Shock After Aprotinin Reexposure in Cardiac Surgery

Diefenbach, C.; Abel, Miriam; Limpers, Barbara; Lynch, John P.; RUSKOWSKI, H.; Jugert, Frank K.; Buzello, W.

doi:10.1097/00132586-199602000-00009

Cited by 4 publications

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“…Allergic reactions after reexposure have been described. 25,26 The incidence of hypersensitivity reactions in one study was 2.8 % in 248 patients reexposed to aprotinin. 27 A time dependency for the risk of adverse reactions exists: the shorter the time interval between the two exposures, the higher the risk of a reaction.…”

Section: Charles Marc Samamamentioning

confidence: 99%

Aprotinin and Major Orthopedic Surgery

Samama

2004

Transfus Alt Transfus Med

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SUMMARY Aprotinin is a potent pharmacological agent which reduces bleeding and limits blood transfusion in current surgical practice. Many studies have been conducted in orthopedic surgery. Several trials have been performed in total hip replacement and total knee replacement patients, and aprotinin only moderately decreased blood loss requirements in these patients. Conversely, when aprotinin was used in patients with a high bleeding risk (cancer, sepsis, redo surgery, etc.), it developed a potent hemostatic activity and significantly decreased transfusion requirements. No increase in deep vein thrombosis and pulmonary embolism was observed. The only major side effect could be the potential occurrence of an anaphylactoid reaction. Prophylactic administration of aprotinin should be considered in extensive spine surgery and in high‐risk major orthopedic operations. The decision to use aprotinin will be guided by a risk/benefit analysis.

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Section: Charles Marc Samamamentioning

confidence: 99%

Aprotinin and Major Orthopedic Surgery

Samama

2004

Transfus Alt Transfus Med

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“…8 Several cases of aprotinin anaphylaxis during cardiac surgery, including some in which the patient died despite aggressive treatment with epinephrine or norepinephrine, have been reported in the literature. 8,9 The overall incidence of aprotinin-induced anaphylactic reactions in patients previously exposed to aprotinin has been reported to be 2.8%. 8 A recent study suggested that reexposure to aprotinin within three months of initial exposure was associated with a relatively high incidence of anaphylactic reactions.…”

Section: Conclusion : La Vasopressine Associée à Des Alpha-agonistesmentioning

confidence: 99%

Vasopressin for treatment of shock following aprotinin administration

Williams

Denault

Pellerin

et al. 2004

Can J Anesth/J Can Anesth

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P Pu ur rp po os se e: : To describe the utility of vasopressin in the treatment of acute distributive shock clinically compatible with the diagnosis of aprotinin anaphylaxis.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : A 57-yr-old female patient underwent repeat cardiac surgery to treat prosthetic valve endocarditis. She had received aprotinin during her first surgery 60 days ago. Despite a negative test dose of iv aprotinin 20,000 KIU, when aprotinin loading was initiated during the repeat surgery, the patient developed bronchospasm and hypotension secondary to acute distributive shock. Bronchospasm responded to inhaled salbutamol and ipatropium. The hypotension was refractory to high doses of phenylephrine. Two doses of iv vasopressin 5 U reversed the vasodilation and reestablished normal blood pressure.C Co on nc cl lu us si io on n: : Vasopressin, in association with alpha-agonists, can reverse acute refractory distributive shock following aprotinin administration. ASOPRESSIN has been recommended recently for the treatment of ventricular fibrillation, septic shock, 1,2 and post-cardiopulmonary bypass distributive shock. 3,4 In this case, we report the use of vasopressin in the treatment of acute distributive shock that occurred during the administration of aprotinin in a patient undergoing repeat cardiac surgery. ObjectifC Ca as se e r re ep po or rt t A 57-yr-old, 56 kg woman with a history of rheumatic fever, type II diabetes mellitus, hypertension, and smoking underwent combined mechanical mitral (St. Jude 27 mm) and aortic (St. Jude 19 mm) valve replacements and left anterior descending coronary artery bypass with a left internal mammary artery graft. Her preoperative medications were metformin and hydrochlorothiazide. She had no known allergies. At the time of surgery, she received aprotinin (Bayer Vital, Leverkusen, Germany) as per the Hammersmith protocol. 5 Her postoperative course was uneventful.Two months later, the patient presented to the emergency room with chills and an altered level of consciousness. The patient was disoriented, stuporous, but arousable. She was tachycardic and had a temperature of 39°C without signs of meningismus or focal neurological findings. Laboratory tests revealed leukocytosis and acute azotemia with a serum creatinine of 221 µmol·L -1 . Cranial computerized tomography showed two small hypodensities compatible with embolic cerebral infarcts in the territories of each middle cerebral artery. Transesophageal echocardiography demonstrated a large vegetation on the mitral valve prosthesis, for which an emergency repeat cardiac surgery was scheduled. The patient was rehydrated, started on iv heparin, and treated with vancomycin, CARDIOTHORACIC ANESTHESIA, RESPIRATION AND AIRWAY 169 CAN J

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“…Anaphylactic reactions to aprotinin have been described. [22][23][24][25] Dietrich reported reactions to reexposure for cardiac surgery in Germany between 1988 and 1995. 26 There were 248 reexposures to aprotinin in 240 patients: 101 adult and 147 pediatric cases.…”

Section: Allergy and Reexposurementioning

confidence: 99%

Applications of Aprotinin in Cardiac Surgery

Levy

2004

Transfus Alt Transfus Med

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SUMMARY Aprotinin has been studied extensively in cardiac surgery and is the only FDA approved pharmacological treatment to reduce blood transfusion in coronary artery bypass grafting (CABG) associated with cardiopulmonary bypass (CPB). Aprotinin has been evaluated in multiple double blind, placebo‐controlled, multicenter studies in cardiac surgery. In US studies, aprotinin has not been associated with an increased risk of post‐CPB myocardial infarction, graft closure, or increased risk of renal dysfunction, and may in fact be associated with a decreased risk of stroke. The mechanism of action is complex, but aprotinin displays antiinflammatory properties due to its complex array of protease inhibition. As with any polypeptide, there is a risk of anaphylaxis that is influenced by prior exposure. Cardiac surgery can be associated with significant bleeding and the need for allogeneic blood products. Although multiple approaches have been reported to reduce bleeding and transfusions, aprotinin represents an important pharmacologic strategy to reduce bleeding.

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Fatal Anaphylactic Shock After Aprotinin Reexposure in Cardiac Surgery

Cited by 4 publications

References 0 publications

Aprotinin and Major Orthopedic Surgery

Aprotinin and Major Orthopedic Surgery

Vasopressin for treatment of shock following aprotinin administration

Applications of Aprotinin in Cardiac Surgery

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