Topical application of antifibrinolytic drugs for on-pump cardiac surgery: a systematic review and meta-analysis

Abstract

Purpose This systematic review aimed to evaluate the efficacy and safety of topical application of antifibrinolytic drugs to reduce postoperative bleeding and transfusion requirements in patients undergoing on-pump cardiac surgery. Methods We searched The Cochrane Library, MED-LINE, EMBASE and SCI-EXPANDED for all randomized controlled trials on the topic. Trial inclusion, quality assessment, and data extraction were performed independently by two authors. Standard meta-analytic techniques were applied. Results Eight trials (n = 622 patients) met our inclusion criteria. The medication/placebo was applied into the pericardial cavity and/or mediastinum at the end of cardiac surgery. Seven trials compared antifibrinolytic agents (aprotinin or tranexamic acid) versus placebo. They showed that, on average, topical use of antifibrinolytic agents reduced the amount of 24-h postoperative chest tube (blood) loss by 220 ml (95% confidence interval: -318 to -126, P \ 0.00001, I 2 = 93%) and resulted in a saving of 1 unit of allogeneic red blood cells per patient (95% confidence interval: -1.54 to -0.53, P \ 0.0001, I 2 = 55%). The incidence of blood transfusion was not significantly changed following topical application of the medications. One study comparing topical versus intravenous administration of aprotinin found comparable results between the two methods of administration for the abovementioned outcomes. No adverse effects were reported following topical use of the medications. Conclusion This review suggests that topical application of antifibrinolytics can reduce postoperative bleeding and transfusion requirements in patients undergoing on-pump cardiac surgery. These promising findings need to be confirmed by more trials with large sample size using patient-related outcomes and more assessments regarding the systemic absorption of the medications. RésuméObjectif Le but de cette e´tude me´thodique e´tait d'e´valuer l'efficacite´et l'innocuite´de l'application topique d'agents anti-fibrinolytiques afin de re´duire les saignements et les besoins transfusionnels postope´ratoires chez les patients subissant une chirurgie cardiaque avec circulation extracorporelle. Méthode Nous avons fouille´les bases de donne´es suivantes afin d'extraire toutes les e´tudes randomise´es contrôle´es traitant de cette question : The Cochrane Library, MEDLINE, EMBASE et SCI-EXPANDED. L'inclusion des e´tudes, l'e´valuation de la qualite´et l'extraction des donne´es ont e´te´re´alise´es de façon inde´-pendante par deux auteurs. Des techniques de me´ta-analyse standard ont e´te´utilise´es. Résultats Huit e´tudes (n = 622 patients) ont satisfait aǹ os crite`res d'inclusion. Le me´dicament/placebo a e´teá pplique´dans la cavite´pe´ricardique et/ou dans le me´dia-stin a`la fin de la chirurgie cardiaque. Sept e´tudes ont compare´des agents anti-fibrinolytiques (aprotinine ou acide tranexamique) a`un placebo. Ces e´tudes ont montre´que, en moyenne, l'application topique d'agents

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