Reduction of blood loss and transfusion requirement by aprotinin in posterior lumbar spine fusion

Aprotinin reduces blood loss in many orthopedic procedures. In posterior lu mbar spine fusion, blood loss results primarily from large vein bleeding an d also occurs after the wound is closed. Seventy-two patients undergoing po sterior lumbar spine fusion were randomly assigned to large-dose aprotinin therapy or placebo. All patients donated three units of packed red blood ce lls (RBCs) preoperatively. Postoperative blood loss was harvested from the surgical wound in patients undergoing two- and/or three-level fusion for re infusion. The target hematocrit for RBC transfusion was 26% if tolerated. T otal (intraoperative and 24 h postoperative) blood loss, transfusion requir ements, and percentage of transfused patients per treatment group were sign ificantly smaller in the aprotinin group than in the placebo group (1935 +/ - 873 vs 2809 +/- 973 mL per patient [P = 0.007]; 42 vs 95 packed RBCs per group [P = 0.001]; 40% vs 81% per group [P = 0.02]). Hematological assessme nts showed an identically significant (a) intraoperative increase in both t hrombin-antithrombin III complexes (TAT) and in activated factor XII (XIIa) and (b) decrease in activated factor VII (Wa), indicating a similar signif icant effect on coagulation in patients of both groups (P = 0.9 for intergr oup comparisons of postoperative VIIa, XIIa, and TAT). Intraoperative activ ation of fibrinolysis was significantly less pronounced in the aprotinin gr oup than in the placebo group (P < 0.0001 for intergroup comparison of post operative D-dimer levels). No adverse drug effects (circulatory disturbance s, deep venous thrombosis, alteration of serum creatinine) were detected. A lthough administered intraoperatively, aprotinin treatment dramatically red uced intraoperative and 24-h postoperative blood loss and autologous transf usion requirements but did not change homologous transfusion in posterior l umbar spine fusion. Implications: In our study, aprotinin therapy significa ntly decreased autologous, but not homologous, transfusion requirements in posterior lumbar spine fusion.