A systematic review of the use of antifibrinolytic agents in pediatric surgery and implications for craniofacial use

A systematic review aimed to evaluate the efficacy and safety of aprotinin, epsilon-aminocaproic acid (EACA), and tranexamic acid (TXA) in reducing perioperative blood loss, risk for transfusion, and total perioperative transfusion volume in major pediatric surgery. Medline, Embase, and Cochrane Reviews were searched for relevant articles published from January 1990 to January 2012. Additional studies were identified by cross-referencing citations and extracting data from recent published reviews. Data were recorded and analyzed using Cochrane's RevMan5.1 software. Thirty-four studies were included in this review of which 21 provided level 1b evidence, 11 were level 2b, and two were level 3b. As compared to control groups, antifibrinolytics reduced perioperative blood loss by standardized mean difference (SMD) of -0.70 (-0.89, -0.50; p < 0.00001), total transfusion volume by SMD of -0.78 (-0.95, -0.61; p < 0.00001), and Odds Ratio (OR) for transfusion was 0.39 (0.23, 0.64; p = 0.002). The OR for adverse events attributable to treatment was not statistically significant across groups (OR = 0.96; p = 0.58). Antifibrinolytics are effective in reducing blood loss and transfusion requirements in major pediatric surgery. TXA and EACA also appear to have reasonable side-effect profiles. Application to craniofacial surgery is promising, though further investigation is necessary.