Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942007000600010
Brazilian Journal of Anesthesiology
Clinical Information

Anestesia para tratamento de aspergilose cardíaca em paciente com trombocitopenia: o uso criterioso da aprotinina

Anesthesia for treatment of cardiac aspergillosis in a patient with thrombocytopenia and the judicious use of aprotinin

Raquel Reis Soares; Viviane Ferreira Albergaria; Michelle Nacur Lorentz; Friederike W. Valadares

http://dx.doi.org/10.1590/S0034-70942007000600010 Braz J Anesthesiol, vol.57, n6, p.672-677, 2007
PDF Português
PDF English
Downloads: 0
Views: 977

Resumo

JUSTIFICATIVA E OBJETIVOS: A aprotinina tem sido muito utilizada em intervenções cirúrgicas cardíacas como recurso terapêutico para redução dos efeitos da circulação extracorpórea (CEC) sobre a coagulação e fibrinólise. A recuperação da hemostasia adequada ao final do procedimento é um dos objetivos do anestesiologista. Porém, o uso da aprotinina tem indicação específica. O objetivo deste trabalho foi apresentar o caso de um paciente com plaquetopenia intensa submetido à intervenção cirúrgica cardíaca no qual a interconsulta com a Hematologia e o planejamento adequado permitiram o sucesso do procedimento. RELATO DO CASO: Paciente do sexo masculino, 18 anos, 64 kg, estado físico ASA IV, portador de aplasia de medula, em investigação para ser submetido a transplante de medula. Apresentava febre persistente, de um mês de evolução, sem melhora com antibioticoterapia. Na investigação com métodos de imagem, diagnosticou-se massa intra-atrial esquerda. Ao exame laboratorial apresentava hemoglobina de 9 g.dL-1 e trombocitopenia - 6.000 plaquetas.mm-3. Foi submetido à esternotomia com CEC para retirada de trombo intracavitário. Com objetivo de controlar o sangramento intra-operatório foram administrados: plaquetaférese, hidrocortisona e aprotinina. Durante a intervenção cirúrgica não houve aumento do sangramento nem instabilidade hemodinâmica e o paciente foi encaminhado à Unidade de Terapia Intensiva (UTI) sem intercorrências. O exame anatomopatológico revelou trombo repleto de Aspergillus (massa fúngica). No sétimo dia de pós-operatório o paciente evoluiu com insuficiência respiratória e parada cardiorrespiratória sem resposta às manobras de reanimação. CONCLUSÕES: Apesar do grande risco de sangramento no paciente descrito, conseguiu-se realizar intervenção cirúrgica cardíaca com CEC sem intercorrências graças ao uso de aprotinina e plaquetoaférese.

Palavras-chave

ANESTESIA, Cardíaca, geral, CIRURGIA Cardíaca, DOENÇAS, DROGAS

Abstract

BACKGROUND AND OBJECTIVES: Aprotinin has been widely used in cardiac surgeries as a therapeutic resource for reducing the effects of cardiopulmonary bypass (CPB) on coagulation and fibrinolysis. Recovery of adequate hemostasia at the end of the procedure is one of the objectives of the anesthesiologist. However, aprotinin has specific indications. The objective of this report was to present the case of a patient with severe thrombocytopenia undergoing cardiac surgery in which consultation with Hematology and adequate planning were responsible for the success of the procedure. CASE REPORT: An 18-year old male patient, weighing 64 kg, physical status ASA IV, with a diagnosis of bone marrow aplasia, was being investigated to undergo bone marrow transplantation. He had persistent fever for a month, which did not improve with antibiotics. During the investigation with imaging exams, a left atrial mass was discovered. Laboratory exams revealed hemoglobin 9 g.dL-1 and thrombocytopenia with 6,000 platelets.mm³. He underwent a sternotomy with CPB to remove the intracavitary thrombus. In order to control intraoperative bleeding, the following was administered: plateletpheresis, hydrocortisone, and aprotinin. Increased bleeding and hemodynamic instability did not develop during the surgery, and the patient was transferred to the Intensive Care Unit (ICU) without intercurrences. The anatomo-pathologic exam revealed the thrombus to be filled with Aspergillus (fungal mass). On the seventh postoperative day the patient developed respiratory failure and cardiorespiratory arrest that did not respond to resuscitation maneuvers. CONCLUSIONS: Despite the increased risk of bleeding in this patient, cardiac surgery with CPB was performed without intercurrences due to the use of aprotinin and plateletpheresis.

Keywords

ANESTHESIA, Cardiac, general, DISEASES, DRUGS, SURGERY, Cardiac

References

Kang Y, Audu P. Coagulation and liver transplantation. Int Anesthesiol Clin. 2006;44:17-36.

Blaine Easley R, Sanders D, McElrath-Schwartz J. Anesthetic implications of Jacobsen syndrome. Pediatr Anesth. 2006;16:66-71.

Alam M, Higgins R, Alam Z. Aspergillus fungal mass detected by transesophageal echocardiography. J Am Soc Echocardiogr. 1998;11:83-85.

Rubio Alvarez J, Sierra Quiroga R, Rubio Taboada C. Cardiac aspergillosis with pedunculated mass in the left ventricle. Texas Heart Inst J. 2004;31:439-441.

Petrovitch CT. The Bleeding Patient. Anesthesia for Vascular Surgery. 1990.

Majerus PW, Miletich JP. Relationships between platelets and coagulation factors in hemostasis. Annu Rev Med. 1978;29:41-49.

Rich JB. The efficacy and safety of aprotinin use in cardiac surgery. Ann Thorac Surg. 1998;66(^ssuppl):S6-11.

Mangano DT, Tudor IC, Dietzel C. The risk associated with aprotinin in cardiac surgery. N Engl J Med. 2006;354:353-365.

Sedrakyan A, Treasure T, Elefteriades JA. Effect of aprotinin on clinical outcomes in coronary artery bypass grafting surgery: a systematic review and meta-analysis of randomized clinical trials. J Thorac Cardiovasc Surg. 2004;128:442-448.

Levi M, Cromheecke ME, de Jonge E. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinical relevants endpoints. Lancet. 1999;354:1940-1947.

Henry DA, Moxey AJ, Carless PA. Anti-fibrinolytic use to minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2001;1.

Sedrakyan A, Atkins D, Treasure T. The risk of aprotinin: a conflict of evidence. Lancet. 2006;367:1376-1377.

Ferraris VA, Bridges CR, Anderson RP. Aprotinin in cardiac surgery. N Engl J Med. 2006;354:1953-1957.

Al-Anazi KA, Al-Jasser AM, Evans DA. Outcome of surgery in patients with hematological malignancies: a 12-year retrospective analysis. Asia-Pacific J Clin Oncol. 2006;2:91-97.

5dd81c220e88258a7513f287 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections