Molenaar et al. Anesth 2001; 94:433-8

Reviewed by: R. Prasad, MD

Summary:

• Previous study showed that prophylactic aprotinin during OLT significantly reduces blood loss (50%) and transfusion requirement (30%)
• Here, showed another benefit: need for vasopressors, especially in the early postreperfusion period, is also decreased.
• Regular- and high-dose regimens equivalent.

• Liver txp protocol seems similar to ours ... do results apply here? Would probably need to look at this ourselves, with our surgeons/anesthesiologists
• Interesting piece of information, but probably not enough in and of itself to justify cost of aprotinin

• 67 pts. Excluded: age <18y, h/o thromboembolic disorders ormalignancies, h/o exposure to aprotinin, h/o previous OLT
• Randomized: to different levels of aprotinin:

• OLT either conventional of "piggyback"
• 3 anesthesiologists, each did about a third of cases. All on dopamine 3 mcg/kg/min
• Epi protocol: 10 mcg boluses given if:
• prn SBP<70 (if fluid status OK)
• sudden 30% or greater decrease in MAP (if no increased bleeding)
• Data collected after induction, 10min before anhepatic, 10min before reperfusion, 5/30/120 min after reperfusion.

• CI, SVRI, CVP: similar all periods
• MAP: fell after reperfusion in all 3 groups. At 5min post-reperfusion, MAP lower in Control, High vs. Regular (58.4, 59.5 vs. 70.8)
• Epinephrine use (analysis per stage: most of the difference due to early postreperfusion period):

Discussion:

• Postreperfusion Syndrome
• dec MAP, SVRI; inc CI, MPAP
• etiology unknown.
• ?activation of proteolytic cascades (e.g., kallikrein system --> bradykinin formation)
• ?sudden inc VR
• ?cardiac reflexes
• ?evil humours from the graft, e.g., proinflammatory cytokines
• Aprotinin
• serine protease (e.g., plasmin, trypsin, kallikrein) inhibitor
• also decreases systemic inflammatory response and release of proinflammatory cytokines
• This study not designed to elucidate mechanism of aprotinin benefit
• Benefit shown probably not due to inadequate blood replacement in Control (similar periop Hgb levels, CVP's)