Ask the Experts on perioperative hemostatis with Dr. Jerrold J. Levy, January 2010
Most studies validating aminocaproic acid (EACA) use a bolus + infusion technique, including a 15 g bolus followed by infusion of 1 g/h [Hardy JF et al. Ann Thorac Surg 65: 371, 1998], a bolus of 5 g, an infusion of 2 g/h, and 2.5 g in the prime [Casati V et al. Ann Thorac Surg 68: 2252, 1999], a bolus of 150 mg/kg, followed by an infusion at 15 mg/kg/hr until the end of cardiopulmonary bypass [Kluger R et al. Anesthesiology 99: 1263, 2003], 100 mg/kg bolus followed by 1 g/hour until chest closure, and 10 g in the cardiopulmonary bypass circuit [Kikura M et al. J Am Coll Surg 202: 216, 2006], and 100 mg/kg initial loading dose, followed by 30 mg/kg/hr maintenance infusion and 5 g in the pump [Greilich PE et al. Anesth Analg 109: 15, 2009] FREE Full-text at Anesthesia & Analgesia. Whether EACA is given after incision or after heparin does not seem to make a difference [Kluger R et al. Anesthesiology 99: 1263, 2003]
Aminocaproic Acid Dosing: Ranges from the Literature
- Bolus: 5-15 g (100-150 mg/kg)
- Pump: 2.5-10 g
- Infusion: 1-2 g/hr (15-30 mg/kg/hr)
Infusion of protamine at 25 mg/hr for six hours after cardiopulmonary bypass appears to eliminate heparin rebound over the infusion period, although the effects of this intervention on mediastinal bleeding may be minimal [Teoh KH et al. J Thorac Cardiovasc Surg 128: 211, 2004]. Teoh et al.’s study was notable because it showed that after the six-hour infusion, heparin levels still rebound, thus implying that a longer post-operative infusion may be indicated. While the amount of blood loss was reduced by 13%, the amount of RBC transfusions was not different between groups (although the study may have been underpowered to detect it).