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Ann Thorac Surg 1994;58:1580-1588
© 1994 The Society of Thoracic Surgeons

Articles

Metaanalysis of prophylactic drug treatment in the prevention of postoperative bleeding

Stephen E. Fremes, MD*,1,a,b, Bill I. Wong, MDa,b, Eileen Lee, MSca,b, Ryan Maia,b, George T. Christakis, MDa,b,1, Richard F. McLean, MDa,b, Bernard S. Goldman, MDa,b, C.David Naylor, MDa,b

a Division of Cardiovascular Surgery, Department of Anaesthesia, Department of Medicine, and Clinical Epidemiology Unit, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
b Career Scientist of the Ministry of Health of Ontario Canada

* Address reprint requests to Dr Fremes, Sunnybrook Health Science Centre, 2075 Bayview Ave—H405, Toronto, Ont, Canada M4N 3M5.

Prophylactic drug treatment is one of several strategies to reduce postoperative blood loss and potentially limit homologous blood use in open heart surgery. A computerized MEDLINE search supplemented with manual bibliography reviews was performed for randomized clinical trials published in peer-reviewed English-language journals from January 1980 to June 1993. A metaanalysis was conducted of trials evaluating desmopressin (group DD, n = 13), {epsilon}-aminocaproic acid or tranexamic acid (group EA, n = 4), and aprotinin (group AP, n = 16). Eligible studies used placebo controls and administered the drug in a prophylactic manner. The primary study end point was postoperative chest tube loss (mL, mean ± standard deviation). There was a significant reduction in postoperative chest tube loss detected for each of the active treatments versus the placebo (DD versus controls: percent reduction 0.11, p = 0.0021; EA versus controls: percent reduction 0.30, p < 0.0001; and AP versus controls: percent reduction 0.36, p < 0.0001). Therapy with EA or AP was associated with a greater reduction in chest tube loss than DD (EA versus DD, p = 0.0033, and AP versus DD, p < 0.0001). Secondary study end points were transfusion requirements, chest reexploration, and perioperative mortality. The volume of postoperative red cell transfusion (mean ± standard deviation) was reduced with EA (p < 0.0001) or AP treatment (p < 0.0001) compared with a placebo or DD, whereas the proportion of patients given transfusions was limited only in the AP-treated patients (odds ratio 0.23; 95% confidence interval, 0.16 to 0.33; p < 0.0001). The prevalence of chest reopening for bleeding was decreased in the EA-treated (p = 0.07) and AP-treated patients (p = 0.07) versus controls. Mortality was not affected significantly for any of the treatment comparisons. The metaanalysis supports the prophylactic use of {epsilon}-aminocaproic acid, tranexamic acid, or preferably AP rather than DD for the reduction of postoperative bleeding associated with an open heart operation and the limitation of homologous blood use where indicated.




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