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Antifibrinolytic — Cardiac Surgery Pregnancy: Not applicable — cardiac surgery indication

Aprotinin

Brand names: Trasylol

Adult dose

Dose: Test dose 1 mL (10000 KIU) IV, then loading dose 1-2 million KIU IV over 20-30 min, then 250000-500000 KIU/hr infusion
Route: Intravenous
Frequency: Continuous intraoperative infusion
Max: 7 million KIU total per procedure
Restricted to cardiac surgery on cardiopulmonary bypass with high bleeding risk. Re-introduced in 2012 after temporary suspension; mandatory test dose to exclude hypersensitivity before full loading dose

Paediatric dose

Dose: Seek specialist opinion N/A/kg
Route: IV
Frequency: Seek specialist opinion
Max: Seek specialist opinion
Seek specialist opinion — used in paediatric cardiac surgery under specialist cardiac anaesthesia

Dose adjustments

Renal

Use with caution — renally excreted; protease inhibition may affect renal tubules

Hepatic

No specific adjustment

Paediatric weight-based calculator

Seek specialist opinion — used in paediatric cardiac surgery under specialist cardiac anaesthesia

Clinical pearls

  • BART trial (2007): aprotinin associated with increased mortality vs tranexamic acid and aminocaproic acid in cardiac surgery — temporarily suspended by manufacturers; re-approved in EU in 2012 with restricted indication (high-risk cardiac surgery with CPB)
  • Anaphylaxis risk: dramatically elevated on re-exposure (up to 5% with repeat within 6 months); mandatory 10-minute observation after 1 mL test dose; emergency resuscitation must be immediately available
  • ACT monitoring during CPB: aprotinin prolongs activated clotting time (ACT) by inhibiting kallikrein — kaolin-based ACT is required (not celite-based) to correctly measure heparin anticoagulation during bypass
  • Tranexamic acid is now first-line antifibrinolytic in most cardiac and orthopaedic surgery — evidence-based, safer profile, and widely available; aprotinin reserved for highest-risk cases
  • Licensed only for adult cardiac surgery on CPB — specialist cardiac anaesthetist decision only

Contraindications

  • Prior aprotinin exposure within 12 months (anaphylaxis risk — antibody formation)
  • Hypersensitivity to aprotinin
  • Known or suspected exposure to fibrin sealants containing aprotinin

Side effects

  • Anaphylaxis (especially re-exposure — fatal reactions reported)
  • Renal dysfunction
  • Thrombosis (venous and graft thrombosis)
  • Myocardial infarction risk (BART trial signal)

Interactions

  • Fibrinolytic agents (antagonism — expected)
  • ACE inhibitors (enhanced hypotensive effect)
  • Heparin monitoring (aprotinin prolongs ACT — requires higher doses of heparin for CPB; use kaolin-ACT not celite-ACT to measure heparin effect accurately)

Monitoring

  • Kaolin-ACT (during CPB)
  • Renal function post-operatively
  • Hypersensitivity reaction monitoring during administration
  • Signs of graft thrombosis

Reference: BNFc; BNF 90; Trasylol SPC; BART Trial (2007); MHRA Safety Advice; ESA Perioperative Haemostasis Guidelines 2022. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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