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Pharmacological agents: antifibrinolytics and desmopressin

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This article provides an overview of the scientific evidence regarding the efficacy and safety of antifibrinolytic agents and desmopressin to reduce surgical blood loss. The synthetic derivatives of lysine are the only antifibrinolytics available in clinical practice since the withdrawal of aprotinin. There is evidence that the prophylactic use of lysine analogues is efficacious in reducing perioperative blood loss in cardiac and major orthopaedic surgery. The impact on exposure to blood transfusion is, however, variable. There is no evidence at present that they improve the overall outcome. Lysine analogues appear to be well tolerated in coronary artery bypass surgery, but less is known regarding their risk–benefit profile in special patient groups. Further studies are needed to elucidate the best compromise between dosing regimen, efficacy and safety in various clinical settings. Desmopressin may reduce excessive bleeding and transfusion requirements in some specific patient populations with acquired platelet dysfunction, but this needs to be validated in future studies.

Section snippets

Antifibrinolytics: lysine analogues

Aprotinin has been used for 20 years in cardiac surgery and liver transplantation. Its blood-sparing efficacy has been widely recognised and many deemed the drug essential in high-risk procedures. Meta-analyses of RCTs were reassuring with regard to safety issues. In October 2007 were released the preliminary findings of the Canadian trial titled Blood Conservation Using Antifibrinolytics in a Randomised Trial (BART). The interim analysis of the BART trial results pointed to a strong and

In cardiopulmonary bypass surgery

It is widely accepted that non-operative blood loss after CPB mainly results from a combination of excessive fibrinolysis and an acquired platelet dysfunction. Consequently, attempts have been made to reduce blood loss by the prophylactic use of antifibrinolytic drugs. In addition to inhibiting fibrinolysis, lysine analogues may lessen plasmin-induced platelet activation, consequently preserving platelet function.

Desmopressin

Desmopressin acetate (1-deamino-8-d-arginine vasopressin or dDAVP) is a synthetic analogue of the antidiuretic hormone arginine vasopressin that was initially devoted to the treatment of central diabetes insipidus. Through a direct action on endothelial V2 receptors, desmopressin raises factor VIII and von Willebrand factor (vWF) plasma concentrations in healthy volunteers. The increase in vWF concentrations is related to a release from endothelial intracellular storage sites and not to de novo

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