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Wulf Dietrich

Publications and source records attributed to Wulf Dietrich.

9 recordsLinked to original sources
PubMed2006

Thrombophilia in cardiac surgery--patients with protein S deficiency.

BACKGROUND: Thrombophilic diathesis may cause severe problems in cardiac surgical patients. Among these, protein S deficiency is a coagulation disorder associated with recurrent thromboembolic events. We analyzed our experience with 7 patients with protein S deficiency who underwent cardiac surgery. METHODS: We retrospectively reviewed the clinical data, operative and postoperative courses, and the long-term results of 7 patients who were diagnosed to have protein S deficiency. Six of them were operated on using cardiopulmonary bypass, one was operated on with an off-pump procedure. RESULTS: Procedures performed were emergent pulmonary embolectomy (patient 1), aortic valve replacement and coronary artery bypass grafting (CABG, patient 2), re-CABG (patients 3 and 7), and CABG (patients 4, 5, and 6). In patients 1, 2, 3, and 7, the diagnosis was made perioperatively. Patients 4, 5, and 6 were treated with a modified regimen of warfarin or protamine. All of the latter 3 patients had an uneventful perioperative course without thromboembolic complication. At follow-up, all but 1 of the 7 patients were on continuous warfarin, and were well and without any further thromboembolic events. CONCLUSIONS: In patients with a past medical history of thromboembolic events or with a perioperative thromboembolic complication, elaborate laboratory investigation should lead to a definite diagnosis. For instance, patients with protein S deficiency undergoing cardiac surgery belong to a high-risk subgroup. Although rare, this and other coagulation disorders can be a critical issue in cardiac surgery. In such patients, we suggest perioperative warfarin therapy with a target international normalized ratio of 2.0 and incomplete protamine antagonism to minimize the risk of a perioperative thromboembolic event.

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PubMed2006

High-dose aprotinin in cardiac surgery: is high-dose high enough? An analysis of 8281 cardiac surgical patients treated with aprotinin.

In this retrospective analysis we tested the hypothesis that aprotinin doses of more than 6 x 10(6) kallikrein inhibiting units (KIU) per patient may be more effective in reducing bleeding compared with the high-dose regimen of 5-6 x 10(6) KIU aprotinin. The aprotinin doses administered for 8281 adult cardiac surgical patients were correlated to body weight and time of operation and calculated in KIU per kg body weight and minute of operation. Linear and logistic regression models were designed to detect potential associations between dose and postoperative bleeding, transfusion, and other covariates. The 6-h chest tube drainage in the lowest quartile dosing group was 447 +/- 319 mL (mean +/- sd) compared with 360 +/- 290 mL in the highest quartile dosing group (P < 0.001). The proportion of patients requiring allogeneic blood transfusion was reduced from 55% to 47% comparing the lowest with the highest dosing group (P < 0.01). Aprotinin dose was also an independent predictor for rethoracotomy for surgical hemostasis (1.9% in the highest quartile to 2.4% in the lowest dosing quartile; P < 0.01). The risk of renal failure requiring dialysis (2.3% in the highest dosing group vs 3.3% in the lowest dosing group; P < 0.01) or impairment of renal function (creatinine increase of >or=2 mg/dL postoperatively, 6.4% in the highest dosing group vs 10.0% in the lowest dosing group; P < 0.01) was lower with higher doses of aprotinin. Thus, there was no association between aprotinin dose and renal function. Our results support the hypothesis that a more individualized aprotinin regimen with potentially higher doses may optimize the effectiveness of aprotinin therapy in cardiac surgery.

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PubMed2006

Full-dose aprotinin use in coronary artery bypass graft surgery: an analysis of perioperative pharmacotherapy and patient outcomes.

BACKGROUND: Inappropriate activation of hemostasis and inflammation may contribute to postoperative morbidity and mortality. The serine protease inhibitor, aprotinin, has been shown to prevent tissue and organ injury in laboratory and animal studies. In this retrospective analysis, we evaluated the relationship of aprotinin therapy with organ dysfunction in humans undergoing coronary artery bypass graft surgery (CABG). METHODS: Data from prospective randomized, double-blind, placebo-controlled studies evaluating the safety and efficacy of full-dose aprotinin (2 million KIU load, 2 million KIU pump prime, and 0.5 million KIU/h continuous infusion) to reduce blood loss and transfusion requirements in patients undergoing CABG (placebo, n = 861; aprotinin, n = 862) were examined retrospectively. Primary end-points were death, adverse cerebrovascular outcome, myocardial infarction (MI), and pharmacological interventions (inotropic drugs, vasopressors, and antiarrhythmics). RESULTS: Univariate analysis showed that relative to placebo, full-dose aprotinin therapy was associated with significant effects on the incidence of adverse cerebrovascular outcome (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.19-0.93; P = 0.03) and use of inotropic drugs (OR 0.79, 95% CI 0.65-0.97; P = 0.02), vasopressors (OR 0.74, 95% CI 0.61-0.90; P < 0.01), and antiarrhythmics (OR 0.79, 95% CI 0.65-0.96; P = 0.02), but not death (OR = 1.00, 95% CI 0.54-1.85; P = 1.0) or MI (OR 0.92, 95% CI 0.64-1.31; P = 0.6). Multivariate analysis confirmed results of univariate analysis. CONCLUSIONS: This retrospective analysis of data collected from prospective, randomized, placebo-controlled studies in CABG shows that full-dose aprotinin use was associated with a lower risk of adverse cerebrovascular outcomes and a reduced need for use of vasoactive drugs; the risk of death and perioperative MI was not affected by aprotinin therapy.

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PubMed2005

Forty years of clinical aprotinin use: a review of 124 hypersensitivity reactions.

Since its clinical introduction, the anaphylactic potential of aprotinin has been a major concern. World wide, its use is expanding so there is an increased chance that patients have reexposure from various sources. The risk of anaphylaxis is approximately 2.8% in reexposed patients. From 1963 to 2003, 124 cases of aprotinin-induced anaphylaxis were reported in 61 publications. Eleven patients died. The reexposure interval was less than 3 months in 72% (38 of 53 patients). This review looks at the profile of patients at risk so preventive measures may be taken. Past and future exposures have to be taken into account before any aprotinin administration.

Aprotinin↗
PubMed2005

Autologous blood donation in cardiac surgery: reduction of allogeneic blood transfusion and cost-effectiveness.

OBJECTIVE: The purpose of this study was to assess transfusion requirements in patients undergoing cardiac surgery with and without autologous blood donation and to calculate the costs of predonation from the hospital perspective. DESIGN: Observational study. SETTING: Single university hospital. PARTICIPANTS: Four thousand three hundred twenty-five patients undergoing elective cardiac surgery with and without autologous blood donation. INTERVENTIONS: Eight hundred forty-nine patients (20%) underwent autologous blood donation, whereas 3,476 (80%) did not. Perioperative allogeneic blood transfusion was recorded as the primary endpoint. To avoid selection bias, patients were stratified according to their preoperative risk score. A decision model was derived from acquired data for the optimization of autologous blood donation. MEASUREMENTS AND MAIN RESULTS: Allogeneic blood transfusion rate was 13% in patients with predonation versus 48% without predonation (p < 0.05). This difference remained statistically significant even after risk stratification. The predonation of 1, 2, or 3 units reduced the probability of receiving allogeneic blood to 24%, 14%, and 9%, respectively. An efficient program of predonation within the department of anesthesiology allowed keeping the costs of predonation low. Decision-tree analysis revealed that predonation of 2 autologous units of blood saved the most allogeneic blood for the smallest increase in costs. Incremental cost for male patients predonating 2 units was dollars 33 (US), whereas for females predonation could be done at no extra cost in comparison to patients without predonation. CONCLUSION: Autologous blood donation significantly reduces allogeneic blood requirement in cardiac surgery. If adjusted for diagnosis and gender, autologous blood donation is a cost-effective alternative to reduce allogeneic blood consumption.

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PubMed2004

Platelet transfusions during coronary artery bypass graft surgery are associated with serious adverse outcomes.

BACKGROUND: Platelet (PLT) transfusions are administered in cardiac surgery to prevent or treat bleeding, despite appreciation of the risks of blood component transfusion. The current analysis investigates the hypothesis that PLT transfusion is associated with adverse outcomes associated with coronary artery bypass graft surgery (CABG). STUDY DESIGN AND METHODS: Data originally collected during double-blind placebo-controlled phase III trials for licensure of Trasylol (aprotinin injection) were retrospectively analyzed. Adverse outcome data of patients (n = 1720) that received, and did not receive, perioperative PLT transfusion were compared. Logistic regression analysis was used to assess the association of perioperative adverse events with PLT transfusion. Propensity scoring analysis was used to verify results of the logistic regression. RESULTS: Patients receiving PLTs were more likely to have prolonged hospital stays, longer surgeries, more bleeding, re-operation for bleeding, and more RBC transfusions, and less likely to have full-dose aprotinin administration. Adverse events were statistically more frequent in patients that received one or more PLT transfusion. Logistic regression analysis showed that PLT transfusion was associated with infection, vasopressor use, respiratory medication use, stroke, and death. Propensity scoring analysis confirmed the risk of PLT transfusion. CONCLUSIONS: PLT transfusion in the perioperative period of CABG was associated with increased risk for serious adverse events. PLT transfusion may be a surrogate marker for sicker patients and have no causal role in the outcomes observed. However, a direct contribution to outcomes remains possible.

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PubMed2003

High-dose aprotinin reduces activation of hemostasis, allogeneic blood requirement, and duration of postoperative ventilation in pediatric cardiac surgery.

BACKGROUND: Though multiple studies have affirmed the effectiveness of aprotinin in reducing blood loss in adult cardiac surgery, the possible benefit in pediatric cardiac surgery is controversial. METHODS: In a double-blind, randomized, and placebo-controlled study, the efficacy of aprotinin in attenuating the hemostatic and inflammatory activation during cardiopulmonary bypass in 60 patients weighing less than 10 kg was investigated. Secondary endpoints were the influence of aprotinin on the reduction of blood loss and allogeneic blood requirement, as well as postoperative oxygenation and length of mechanical ventilation. Aprotinin was administered in a high-dose of 3 x 10(4) KIU/kg plus a bolus of 5 x 10(5) KIU (not weight adjusted) added to the pump prime. RESULTS: Aprotinin plasma concentration at the end of cardiopulmonary bypass (CPB) was with 184 +/- 45 KIU/mL, within the targeted range of 200 KIU/mL. Coagulation and fibrinolysis were suppressed (F1.2 1 hour after CPB: 5.35 +/- 2.9 nmol/L vs 14.5 +/- 23.1 nmol/L; D-dimer 1 hour after CPB: 0.63 +/- 0.6 ng/mL vs 2.3 +/- 3.1 ng/mL; p < 0.05), inflammatory markers (interleukin [IL]-6, IL-8, IL-10) increased over time without significant differences between the groups, and only complement C3a activation was significantly attenuated at the end of CPB in the aprotinin group. Chest tube drainage was significantly reduced (24 hours: median 13.5 [IQR 12.2] mL/kg vs 19.4 [8.2] mL/kg; p < 0.05). All patients received one unit of packed cells to prime the heart lung machine. A second unit was needed significantly less often in the aprotinin group (13% vs 47%; p < 0.05). Postoperative oxygenation (pO2/FIO2 172 [IQR 128] mm Hg vs 127 [74]; p < 0.05) improved, and the time on ventilator was shorter in the aprotinin group (median 45 hours [IQR 94] vs 101 [IQR 74]; p < 0.05). No side effects were attributable to the use of aprotinin. CONCLUSIONS: High-dose aprotinin effectively attenuated hemostatic activation and reduced blood loss and transfusion requirement in pediatric cardiac surgery. Postoperative ventilation was also shortened in the aprotinin group.

Aprotinin↗
PubMed2003

The predictive value of modified computerized thromboelastography and platelet function analysis for postoperative blood loss in routine cardiac surgery.

UNLABELLED: Hemorrhage after cardiopulmonary bypass (CPB) remains a clinical problem. Point-of-care tests to identify hemostatic disturbances at the bedside are desirable. In the present study, we evaluated the predictive value of two point-of-care tests on postoperative bleeding after routine cardiac surgery. Prospectively, 255 consecutive patients were studied to compare the ability of modified thromboelastography (ROTEG) as well as a platelet function analyzer (PFA-100) to predict postoperative blood loss. Measurements were performed at three time points: preoperatively, during CPB, and after protamine administration with three modified thromboelastography and PFA tests. The best predictors of increased bleeding tendency were the tests performed after CPB. The angle alpha is the best predictor (area under the receiver operating characteristic curve 0.69) and, in combination with the adenosine diphosphate-PFA test, the predictive accuracy is enhanced (area under the receiver operating characteristic curve 0.73). The negative predictive value for the angle alpha is 82%, although the positive predictive value is small (41%). Thromboelastography is a better predictor than PFA. In routine cardiac surgery, impaired hemostasis as identified by point-of-care tests does not inevitably lead to hemorrhage postoperatively. However, patients with normal test results are unlikely to bleed for hemostatic reasons. Bleeding in these patients is probably caused surgically. The high negative predictive value supports early identification and targeted treatment of surgical bleeding by distinguishing it from a significant coagulopathy. IMPLICATIONS: Thrombelastography and platelet function analysis in routine cardiac surgery demonstrate high negative predictive values for postoperative bleeding, which supports early identification and targeted treatment of surgical bleeding by distinguishing it from a significant coagulopathy. The positive predictive values are small. The best predictors are thrombelastography values obtained after cardiopulmonary bypass.

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