Hemostatic drugs

Matched cohort study of topical tranexamic acid in cementless primary total hip replacement

PURPOSE

Tranexamic acid has been shown to be effective in reducing blood loss after total hip replacement. The purpose of this study was to prospectively assess the effectiveness of topical TXA use to reduce blood loss after primary total hip replacement and to compare these outcomes with those of a matched control group from a similar cohort that did not have received tranexamic acid.

METHODS

This is a prospective matched control study to assess the effect of a 2 g topical tranexamic acid in 50 mL physiological saline solution in total hip replacement. Primary outcomes were hemoglobin and hematocrit drop, and total blood loss. Secondary outcomes were transfusion rates, length of hospital stay, deep vein thrombosis, and pulmonary embolism events.

RESULTS

We could match 100 patients to a control group. There were no statistical significantly differences between the two groups. The hemoglobin and hematocrit postoperative values were significantly higher in topical tranexamic acid group than in control group (P < 0.001). The mean total blood loss was 769 in topical tranexamic acid group and 1163 in control group with significant differences (P = 0.001), which meant 34% reduction in total blood loss. Length of stay was lower in topical tranexamic acid group. The risk of deep vein thrombosis and pulmonary events did not increase.

CONCLUSIONS

A single dose of 2 g tranexamic acid in 50 mL physiological saline solution topical administration was effective and safe in reducing bleeding in patients undergoing unilateral primary non-cemented total hip replacement compared to a matched control group.

Comparison of Cytotoxic Effects of Intra-Articular Use of Tranexamic Acid versus Epinephrine on Rat Cartilage

Background

Adequate visualization is known to be essential to perform arthroscopic procedures effectively and efficiently. We hypothesized that tranexamic acid may be considered as an alternative agent to reduce intra-articular bleeding during arthroscopic procedures, after comparing its potential chondrotoxicity with that of epinephrine.

Material/Methods

Seventy-two rats were randomized into 3 groups with 24 rats each. The injections were performed in the right knees, as follows: Group 1: 0.25 mL of tranexamic acid solution, Group 2: 0.25 mL of epinephrine solution, and Group 3: 0.25 mL of 0.9% saline, serving as control. One week after the injections, the animals were euthanized. Samples were evaluated histologically based on the Osteoarthritis Research Society International (OARSI) Histopathology Grading and Staging System and the “live/dead” staining technique to determine chondrocyte viability.

Results

Comparison of epinephrine and tranexamic acid revealed significantly higher OARSI scores in the epinephrine group (epinephrine: 3.42±1.31, TA: 0.92±0.90; P<0.001). The most significant difference between the 2 groups was in the number of joints diagnosed with OARSI grade III. The percentage of viability was significantly higher in the tranexamic acid group when compared with the epinephrine group (tranexamic acid: 79.74±3.343; epinephrine: 63.81±1.914; P<0.05).

Conclusions

Based on the histologic parameters and chondrocyte viability, tranexamic acid is less cytotoxic than epinephrine in rat chondrocytes at the doses typically used in irrigation fluid, and may be a good alternative to epinephrine in arthroscopic surgery.

Tranexamic acid in total shoulder arthroplasty and reverse shoulder arthroplasty: a systematic review and meta-analysis

BACKGROUND

The effects of tranexamic acid (TXA) in the setting of shoulder arthroplasty are unclear. The objective of this study was to examine the effects of TXA in reducing the need for blood transfusions and blood loss in patients undergoing primary total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and retrospective cohort studies (RCS) that compared outcomes of patients who did and did not receive TXA during TSA or RTSA. We searched Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE for relevant studies. We assessed the risk of bias of the included studies and calculated pooled risk estimates. The primary outcome was transfusion rate, and secondary outcomes were changes in hemoglobin, estimated total blood loss (ETBL), blood loss via drainage, operative time, hospital stay, overall complications, and thromboembolic events.

RESULTS

We identified 3 RCTs and 3 RCS including 677 patients with 680 shoulders (343 TXA and 337 non-TXA). The random-effects model meta-analysis showed that TXA group had a lower transfusion rate (risk ratio (RR) 0.34, 95% CI 0.14 to 0.79), less change in hemoglobin (mean difference (MD) -0.64 g/dl, 95% CI -0.81 to - 0.46), and reduced ETBL (MD -249.24 ml, 95% CI -338.74 to - 159.74). In patients with RTSA, the TXA group had a lower transfusion rate (RR 0.28, 95% CI 0.14 to 0.79), less ETBL (MD -249.15 ml, 95% CI -426.60 to - 71.70), less change in hemoglobin (MD - 0.64 g/dl, 95% CI -0.86 to - 0.42), and less blood loss via drainage (MD - 84.56 ml, 95% CI -145.72.14 to - 23.39) than non-TXA group.

CONCLUSIONS

The use of TXA in primary shoulder arthroplasty appears safe, and can reduce transfusion rate, changes in hemoglobin, and perioperative total blood loss, especially in patients with RTSA.

LEVEL OF EVIDENCE

Systematic Review and meta-analysis, III.

Medical treatment of epistaxis in hereditary hemorrhagic telangiectasia: an evidence-based review

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant hereditary disorder resulting in vascular dysplasia and formation of arteriovenous malformations. Recurrent epistaxis is a hallmark of the disease. An array of medical therapies are used in this patient population, but robust evidence-based recommendations regarding the medical treatment of epistaxis are lacking. This systematic review was performed to look at the current literature and make meaningful evidence-based recommendations.

METHODS

A search of the Ovid MEDLINE, Embase, and Cochrane databases was conducted by a research librarian. Abstracts in the English language and published in a peer-review journal were reviewed for relevance and inclusion. PRISMA guidelines were followed.

RESULTS

Eighteen studies met the inclusion criteria. In a few small studies, thalidomide was shown to consistently improve severity and frequency of epistaxis and improve hemoglobin concentrations while decreasing the need for transfusion. Tranexamic acid appeared to only impact the epistaxis severity score and not other clinical outcomes. Selective estrogen modulators (SERMs), propranolol, rose geranium oil, and N-acetylcysteine, have demonstrated promising efficacy in small trials.

CONCLUSION

Appropriate medical therapies for epistaxis outcomes in HHT remain undefined, and there is no "gold standard." Many of the studies are small and the data reported are heterogeneous, and therefore the ability to make strong evidence-based recommendations is limited. However, many different medications appear to be promising options.

Overview of small bowel angioectasias: clinical presentation and treatment options

Elderly patients with multiple co-morbidities are at an increased risk of developing small bowel angioectasias. Treating these lesions can be both challenging and costly with patients requiring extensive investigations and recurrent admissions for iron infusions and blood transfusions as well as invasive procedures. This review presents treatment options and describes in detail drugs that should be considered whilst taking into account their effectiveness and their safety profile. Areas covered: A PubMed search was carried out using the following keywords: small bowel angiodysplasias, small bowel angioectasias, small bowel bleeding and obscure gastrointestinal bleeding to assess existing evidence. The pathophysiology and risk factors are covered in this review together with appropriate methods of investigation and management. Treatment options discussed are endoscopic measures, surgical options and pharmacotherapy. The role of serum biomarkers is also discussed. Expert commentary: Future work should be directed at alternative drugs with a good safety profile that target biomarkers. Novel pharmacotherapy directed at biomarkers could potentially provide a non-invasive treatment option for angioectasias particularly in the elderly where management can be challenging.

Tranexamic acid use and risk of thrombosis in regular users ofantithrombotics undergoing primary total knee arthroplasty: a prospectivecohort study

BACKGROUND

The effect of tranexamic acid has not been examined in patients who are regular users of antithrombotics before undergoing total knee arthroplasty. The aim of this study was to determine the impact of tranexamic acid on bleeding and the risk of transfusion and thrombosis in patients taking an antithrombotic treatment before primary unilateral total knee arthroplasty.

MATERIAL AND METHODS

A prospective observational study was conducted in a series of 385 consecutive primary total knee arthroplasties performed with and without the administration of tranexamic acid. We compared post-operative bleeding, as determined by a bleeding index, and postoperative haemoglobin and haematocrit between patients taking an antithrombotic treatment before the operation (ATT+ group) and those naïve or non-regular users of antithrombotics (ATT- group). Post-operatively, rivaroxaban was prescribed for deep vein thrombosis prophylaxis, unless contraindicated. Antiplatelet therapy and vitamin K antagonist anticoagulants were not resumed during the early post-operative period.

RESULTS

The prevalence of total knee arthroplasty performed in patients who are regular users of antithrombotics was 33%. Tranexamic acid was administered during 62% of the arthroplasties in the ATT+ group and to 90% in the ATT- group. In both study groups, the bleeding index was significantly lower in patients who received tranexamic acid, both in the ATT+ (p<0.001) and in the ATT- group (p=0.001). No patients in the ATT+ group received a blood transfusion during the first post-operative week. No thrombotic complications were identified for up to 2 months in the ATT+ group.

DISCUSSION

Tranexamic acid use after the induction of general anaesthesia in total knee arthroplasty represents a fast, inexpensive, and effective opportunity to reduce peri-operative blood loss in patients on chronic antithrombotic treatment undergoing total knee arthroplasty.

Is Combined Administration of Tranexamic Acid Better than Both Intravenous and Topical Regimes for Total Loss, Hidden Loss and Post-operative Swelling? A Randomized Control Trial

BACKGROUND

Bleeding is one of the unavoidable complications of total knee arthroplasty (TKA). Tranexamic acid (TXA) in last decade has emerged as an effective and safe way to decrease postoperative bleeding and transfusion rates. Although there is little doubt on the efficacy of the drug, the debate on ideal mode is more recent. We undertook this study to find out the most effective and yet safest way of TXA administration.

MATERIALS AND METHODS

A single institution - two hospital-based, double-blinded, prospective, randomized control trial was conducted from January 2015 to December 2015. One hundred and fifty patients were randomly divided in one of the three groups using computer-generated tables - intravenous (IV), intraarticular and combined. Evident loss through drain, total loss based on gross method and hemoglobin balance method, hidden blood losses, hemoglobin, and hematocrit drop, all possible complications related to TXA were evaluated and compared among groups. The analysis of variance and Tukey's post hoc were used for continuous outcome variables and Chi-square test for binary outcome variables.

RESULTS

Evident loss in combined group was 574.25 ± 209.8 ml, significantly less than IV (685.4 ± 289.9 ml) and intraarticular group (724.3 ± 246.8 ml). Total loss was similarly least for combined group (930.1 ± 262.2 ml) compared to IV (1208.3 ± 368.8 ml) and intraarticular group (1198.1 ± 356.8 ml). There were no transfusions in combined group compared to five in IV and four in intraarticular group. Combined group also had least hidden losses after surgery. No patients in any group developed symptomatic deep venous thrombosis.

CONCLUSION

Combined administration of drug is most effective way to decrease postoperative bleeding and requirement of transfusion in unilateral TKA without increasing any risk of complications.

Gastrointestinal angiodysplasia and bleeding in von Willebrand disease

Von Willebrand disease (VWD), the most common genetic bleeding disorder, is characterised by a quantitative or qualitative defect of von Willebrand factor (VWF). Patients with VWD suffer from mucocutaneous bleeding, of severity usually proportional to the degree of VWF defect. In particular, gastrointestinal bleeding associated with angiodysplasia is often a severe symptom of difficult management. This review focuses on the pathophysiology, diagnosis and treatment of VWD-associated gastrointestinal angiodysplasia and related bleeding.

A prospective, randomized, comparative study of intravenous alone and combined intravenous and intraarticular administration of tranexamic acid in primary total knee replacement

Background

Studies on the use of tranexamic acid (TXA) to improve clinical outcomes after joint arthroplasty have reported contrasting results between intravenous (IV) TXA alone and combined IV and intraarticular (IA) administration. We compared the effectiveness of the 2 methods in providing higher postoperative hemoglobin (Hb) levels in patients undergoing primary total knee arthroplasty (TKA).

Methods

A total of 100 TKA patients were randomly assigned to receive either IV TXA alone (group 1) or combined IV and topical IA TXA (group 2). Hb and hematocrit levels were measured before and after surgery. The amount of drained blood and transfused blood for the 2 groups was compared.

Results

The Hb level was significantly higher at postoperative day 4, together with a positive, albeit not significant, trend toward less postoperative blood loss in the group that received combined IV and IA TXA. No postoperative infections or deep venous thrombosis events occurred.

Conclusions

This study reinforces evidence that, as compared to IV TXA alone, combined IV and IA administration of TXA has a synergic effect, leading to higher postoperative Hb levels without influencing drug safety in TKA patients.

Intravenous Tranexamic Acid Bolus plus Infusion Is Not More Effective than a Single Bolus in Primary Hip Arthroplasty

Background

Preoperative administration of the antifibrinolytic agent tranexamic acid reduces bleeding in patients undergoing hip arthroplasty. Increased fibrinolytic activity is maintained throughout the first day postoperation. The objective of the study was to determine whether additional perioperative administration of tranexamic acid would further reduce blood loss.

Methods

This prospective, double-blind, parallel-arm, randomized, superiority study was conducted in 168 patients undergoing unilateral primary hip arthroplasty. Patients received a preoperative intravenous bolus of 1 g of tranexamic acid followed by a continuous infusion of either tranexamic acid 1 g (bolus-plus-infusion group) or placebo (bolus group) for 8 h. The primary outcome was calculated perioperative blood loss up to day 5. Erythrocyte transfusion was implemented according to a restrictive transfusion trigger strategy.

Results

The mean perioperative blood loss was 919 ± 338 ml in the bolus-plus-infusion group (84 patients analyzed) and 888 ± 366 ml in the bolus group (83 patients analyzed); mean difference, 30 ml (95% CI, −77 to 137; P = 0.58). Within 6 weeks postsurgery, three patients in each group (3.6%) underwent erythrocyte transfusion and two patients in the bolus group experienced distal deep-vein thrombosis. A meta-analysis combining data from this study with those of five other trials showed no incremental efficacy of additional perioperative administration of tranexamic acid.

Conclusions

A preoperative bolus of tranexamic acid, associated with a restrictive transfusion trigger strategy, resulted in low erythrocyte transfusion rates in patients undergoing hip arthroplasty. Supplementary perioperative administration of tranexamic acid did not achieve any further reduction in blood loss.

Tranexamic Acid-Induced Acute Renal Cortical Necrosis in Post-Endoscopic Papillectomy Bleeding

Acute renal failure can be the result of acute renal cortical necrosis (RCN), which commonly occurs from complications occurring during pregnancy. RCN is rarely caused by medications, although tranexamic acid, which is used in patients with acute bleeding for its antifibrinolytic effects, reportedly causes acute RCN in rare cases. An 82-year-old woman experienced gastrointestinal bleeding after endoscopic papillectomy of an ampullary adenoma. The bleeding was controlled with tranexamic acid administration; however, 4 days later, her urine volume decreased and she developed pulmonary edema and dyspnea. Serum creatinine levels increased from 0.8 to 3.9 mg/dL and dialysis was performed. Abdominal pelvic computed tomography with contrast enhancement revealed bilateral RCN with no renal cortex enhancement. Renal dysfunction and oliguria persisted and hemodialysis was continued. Clinicians must be aware that acute RCN can occur after tranexamic acid administration to control bleeding.

Intravenous tranexamic acid reduces total blood loss in reverse total shoulder arthroplasty: a prospective, double-blinded, randomized, controlled trial

BACKGROUND

Patients undergoing reverse total shoulder arthroplasty (RTSA) are at risk of significant perioperative blood loss. To date, few studies have examined the effectiveness of tranexamic acid (TXA) to reduce blood loss in the setting of RTSA.

METHODS

In a prospective, double-blinded, single-surgeon trial, we analyzed 102 patients undergoing primary RTSA who were randomized to receive intravenous TXA (n = 53) or placebo (n = 49). Calculated total blood loss, drain output, and hemoglobin (Hb) drop were measured. Postoperative transfusions were recorded. Complications were assessed out to 6 weeks postoperatively.

RESULTS

Total blood loss was less for the TXA group (1122.4  ± 411.6 mL) than the placebo group (1472.6 ± 475.4 mL, P < .001). Total drain output was less for the TXA group (221.4 ± 126.2 mL) than the placebo group (371.9 ± 166.3 mL , P < .001). Total Hb loss was less in the TXA group (154.57 ± 60.29 g) compared with the placebo group (200.1 ± 65.5 g, P = .001). Transfusion rates differed significantly at postoperative day 1; however, overall transfusion rates did not vary significantly. Seven patients (14.3%) and 12 units were transfused in the placebo group compared with 3 patients (5.7%) and 3 units in the TXA group.

DISCUSSION

In this cohort of patients undergoing primary RTSA, TXA was effective in reducing total drain output, total Hb loss, and total blood loss compared with a placebo control.

Hemoglobin-based oxygen carriers promote systemic hyperfibrinolysis that is both dependent and independent of plasmin

BACKGROUND

Hyperfibrinolysis plays an integral role in the genesis of trauma-induced coagulopathy. Recent data demonstrate that red blood cell lysis promotes fibrinolysis; however, the mechanism is unclear. Hemoglobin-based oxygen carriers (HBOCs) have been developed for resuscitation and have been associated with coagulopathy. We hypothesize that replacement of whole blood (WB) using an HBOC results in a coagulopathy because of the presence of free hemoglobin.

MATERIALS AND METHODS

WB was sampled from healthy donors (n = 6). The clotting profile of each citrated sample was evaluated using native thromboelastography. Serial titrations were performed using both HBOC (PolyHeme) and normal saline (NS; 5%, 25%, and 50%) and evaluated both with and without a 75-ng/mL tissue plasminogen activator (tPA) challenge. Tranexamic acid (TXA) was added to inhibit plasmin-dependent fibrinolysis. Fibrinolysis was measured and recorded as lysis at 30 min (LY30), the percentage of clot LY30 after maximal clot strength. Dilution of WB with NS or HBOC was correlated using LY30 via Spearman rho coefficients. Groups were also compared using a Friedman test and post hoc analysis with a Bonferroni adjustment.

RESULTS

tPA-provoked fibrinolysis was enhanced by both HBOC (median LY30 at 5%, 25%, and 50% titrations: 11%, 21%, and 44%, respectively; Spearman = 0.94; P < 0.001) and NS (11%, 28%, and 58%, respectively; Spearman = 0.790; P < 0.001). However, HBOC also enhanced fibrinolysis without the addition of tPA (1%, 4%, 5%; Spearman = 0.735; P = 0.001) and NS did not (1%, 2%, 1%; r = 0.300; P = 0.186. Moreover, addition of TXA did not alter or inhibit this fibrinolysis (WB versus 50% HBOC: 1.8% versus 5.7%, P = 0.04). There was no significant difference in fibrinolysis of HBOC with or without TXA (50% HBOC versus 50% HBOC + TXA: 5.6% versus 5.7%, P = 0.92). In addition, the increased fibrinolysis seen with NS was reversed when TXA was present (WB versus 50% NS: 1.8% versus 1.7%, P = 1.0).

CONCLUSIONS

HBOCs enhance fibrinolysis both with and without addition of tPA; moreover, this mechanism is independent of plasmin as the phenomenon persists in the presence of TXA. Our findings indicate the hemoglobin molecule or its components stimulate fibrinolysis by both tPA-dependent and innate mechanisms.

Treatment of Persistent Gross Hematuria with Tranexamic Acid in Autosomal Dominant Polycystic Kidney Disease

BACKGROUND/AIMS

In this retrospective study we aimed to compare the effect of tranexamic acid (TXA) vs etamsylate, two hemostatic agents, on hematuria duration in autosomal dominant polycystic kidney disease (ADPKD) patients with persistent gross hematuria.

METHODS

This is a retrospective study of 40 patients with ADPKD and macroscopic hematuria. 20 patients receiving TXA and snake venom blood clotting enzyme injection were compared with 20 matched patients receiving etamsylate and snake venom blood clotting enzyme injection. The primary outcome was hematuria duration and the secondary outcomes were blood transfusion requirements and adverse events.

RESULTS

The hematuria duration was shorter in the TXA group compared with the etamsylate group (4[3-5] d vs 7[6-10] d, P<0.001). The volume of blood transfusion tended to be less in the TXA group than in the etamsylate group (300±115 ml vs 486±195 ml, P=0.12), and the number of patients needing a blood transfusion also tended to be lower [20% (4/20) vs 35% (7/20), P=0.29]. TXA and etamsylate were equally well tolerated and no serious adverse events were observed in both groups.

CONCLUSIONS

Our study indicates that TXA treatment was more effective than etamsylate in stopping bleeding in ADPKD patients with persistent gross hematuria.

The efficacy and safety of epinephrine for postoperative bleeding in total joint arthroplasty: A PRISMA-compliant meta-analysis

BACKGROUND

Total joint arthroplasty (TJA) usually results in postoperative bleeding. Some randomized controlled trials (RCTs) and nonrandomized controlled trials (non-RCTs) have been performed to evaluate the effects of epinephrine on postoperative bleeding after TJA. However, this remained controversial about the efficacy and safety of epinephrine for postoperative bleeding in TJA. The objective of our meta-analysis was to compare the overall effect and safety of epinephrine and placebo for postoperative bleeding in TJA.

METHODS

PubMed, Embase, and the Cochrane Library were searched to identify potentially relevant articles. RCTs or non-RCTs involving epinephrine and placebo for blood loss in total knee arthroplasty or total hip arthroplasty were included. Our study was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RevMan v5.3 was used to analyze the relevant data.

RESULTS

Four RCTs and 1 non-RCT involving 646 participants met the inclusion criteria. The overall pooled results from meta-analysis demonstrated that compared with control groups, epinephrine groups could significantly reduce the postoperative bleeding volume (mean difference [MD] = -168.42, 95% confidence interval [CI]: -272.37 to -64.47, P = 0.001). There was no significant difference in intraoperative bleeding volume between epinephrine and control groups (MD = -12.89, 95% CI: -53.45 to 27.69, P = 0.53). No significant difference was found between 2 groups in terms of postoperative hemoglobin loss (MD = -0.28, 95% CI: -0.66 to 0.10, P = 0.15). Compared with the control groups, no statistically significant difference was found in terms of postoperative transfusion rate in epinephrine groups (relative risk [RR] 0.86, 95% CI: 0.64-1.15, P = 0.31). In addition, the results of the meta-analysis also indicated no significant difference in terms of the incidence rate of deep venous thrombosis (DVT) between 2 groups (RR 0.28, 95% CI: 0.05-1.64, P = 0.16).

CONCLUSION

The meta-analysis showed that epinephrine could significantly reduce postoperative bleeding volume in TJA without increasing the incidence of DVT. However, there was no significant reduction in intraoperative bleeding volume, postoperative hemoglobin loss, and transfusion rate after the administration of epinephrine.

LIMITATIONS

In this study, a higher heterogeneity and a risk of selection bias may be present in postoperative hemoglobin loss. In addition, the sample size of the included studies was too small, so our findings need to be further validated with more high-quality and larger scale RCTs in the future.

SYSTEMATIC REVIEW REGISTRATION NUMBER

None.

The Efficacy of Combined Use of Rivaroxaban and Tranexamic Acid on Blood Conservation in Minimally Invasive Total Knee Arthroplasty a Double-Blind Randomized, Controlled Trial

BACKGROUND

Tranexamic acid (TXA) was reportedly to decrease postoperative blood loss after standard total knee arthroplasty (TKA). However, the blood-conservation effect of TXA in minimally invasive TKA, in particular, receiving a direct oral anticoagulant was unclear. The aim of the study was to investigate the efficacy of combined use of TXA and rivaroxaban on postoperative blood loss in primary minimally invasive TKA.

METHODS

In a prospective, randomized, controlled trial, 198 patients were assigned to placebo (98 patients, normal saline injection) and study group (100 patients, 1g TXA intraoperative injection) during primary unilateral minimally invasive TKA. All patients received rivaroxaban 10 mg each day for 14 doses postoperatively. Total blood loss was calculated from the maximum hemoglobin drop after surgery plus amount of transfusion. The transfusion rate and wound complications were recorded in all patients. Deep-vein thrombosis was detected by ascending venography of the leg 15 days postoperatively.

RESULTS

The mean total blood loss was lower in the study group (1020 mL [95% confidence interval, 960-1080 mL]) compared with placebo (1202 mL [95% confidence interval, 1137-1268 mL]) (P < .001). The transfusion rate was lower in the study group compared with placebo (1% vs 8.2%, P = .018). Postoperative wound hematoma and ecchymosis were higher in placebo than the study group (P = .003). There was no symptomatic deep-vein thrombosis or pulmonary embolism in either group.

CONCLUSION

Systemic administration of TXA can effectively reduce the postoperative blood loss which results in lower rate of transfusion requirement and wound hematoma in minimally invasive TKA patients when rivaroxaban is used for thromboprophylaxis. Rivaroxaban has a high rate of bleeding complications when used alone in TKA patients.

Browplasminin, a condensed tannin with anti-plasmin activity isolated from an aqueous extract of Brownea grandiceps Jacq. flowers

ETHNOPHARMACOLOGICAL RELEVANCE

Following Venezuelan traditional medicine, females with heavy menstrual blood loss (menorrhagia) drink Brownea grandiceps Jacq. flowers (BG) decoctions to reduce the bleeding. In a previous study, we demonstrated that BG aqueous extract (E) possesses a potent anti-fibrinolytic activity capable of inhibiting plasmin, the main serine-protease that degrades fibrin. It is widely known that plasmin inhibitors are often used as anti-fibrinolytics to reduce bleeding during surgeries with high risk of blood loss such as cardiac, liver, vascular, tooth extraction and large orthopedic procedures, as well as for menorrhagia treatments. The aim of this work was to isolate and characterize from BGE the compound responsible for the reported anti-fibrinolytic activity.

MATERIALS AND METHODS

A decoction of BG was prepared; then it was homogenized, centrifuged and lyophilized to obtain BGE. Subsequently the extract was fractionated by gel filtration and reverse phase using HPLC and the active compound was characterized by MALDI-ToF MS. The kinetic parameters of anti-plasmin activity were evaluated by an amidolytic assay using a chromogenic substrate; also the anti-plasmin activity was estimated by fibrin plate method. Data were analyzed by nonparametric statistics.

RESULTS

The active compound was a condensed tannin denominated Browplasminin, which is capable of inhibiting the plasmin activity in a dose-dependent manner when measured in fibrin plates or by the amidolytic activity method; it also has a minor effect on the FXa activity. However, it does not affect the activity of other serine-proteases such as trypsin, t-PA or u-PA. Browplasminin consists predominately of heteroflavan-3-ols of catechin with B-type linkages, and extents up to heptadecamers (~ 5000Da), with hexose residues attached to the polymer that presents a high degree of galloylation. Its IC₅₀ for plasmin was 47.80μg/mL and for FXa was 237.08μg/mL, while the Ki were 0.76 and 61.61μg/mL for plasmin and FXa, respectively.

CONCLUSIONS

The overall outcome of this study suggests that Browplasminin could be responsible for reducing heavy menstrual bleeding in women because its kinetic parameters showed that is a good plasmin inhibitor.

Intravenous Combined with Topical Administration of Tranexamic Acid in Primary Total Hip Arthroplasty: A Randomized Controlled Trial

OBJECTIVE

Although there are still some controversies, large previous studies have confirmed that intravenous (i.v.) tranexamic acid (TXA) can effectively reduce blood loss and transfusions in total hip arthroplasty (THA) without increasing the risk of deep venous thrombosis. However, few studies have investigated the combination of i.v. and topical application of TXA in primary THA. The purpose of our current study is to examine whether i.v. combined with topical administration of TXA decreases postoperative blood loss and transfusion rates after THA.

METHODS

From December 2013 to May 2014, all adult patients undergoing primary THA at our arthroplasty center were considered for inclusion in the present study. Included patients were randomly assigned to two groups by computer-generated list number: a TXA group and a placebo group. Patients in the TXA group received i.v. (15 mg/kg) combined with topical administration (1.0 g) of TXA during the THA procedure, and patients in the other group received the same dosage of normal saline both i.v. and topically. Our primary outcome measures were total blood loss (calculated using Gross's equation), hemoglobin, hematocrit and platelet concentration changes on the third postoperative day, the amount of drainage, the amount of intraoperative blood loss, the frequency of transfusion, and the number of blood units transfused. Secondary outcome measures were the length of postoperative stay, range of hip motion (measured by goniometer), Harris hip scores (HHS), and any perioperative complications or events such as infection, DVT or PE. Range of motion and HHS were measured at 3 week follow-up and compared with preoperative values.

RESULTS

This trial included 100 patients (50 in each group). Patients in the TXA group had significantly higher postoperative hemoglobin (103 vs 87.7 g/dL, P < 0.01), lower hemoglobin changes (32.2 vs 44.9 g/dL, P < 0.01), higher postoperative hematocrit (0.32 vs 0.27 L/L, P < 0.01), lower hematocrit changes (0.1 vs 0.14 L/L, P < 0.01), lower total blood loss (822 vs 1100 mL, P = 0.004), lower drainage (117.8 vs 242.4 mL, P < 0.01), lower intraoperative blood loss (193.8 vs 288.2 mL, P < 0.01), and lower transfusion rate (2% vs 34%, P < 0.01) compared with those in the placebo group. No statistical difference was found in postoperative platelets between the two groups. There were no differences in perioperative complications or venous thromboembolism (VTE) events.

CONCLUSIONS

The combined administration of i.v. and topical TXA resulted in a clinically relevant reduction in blood loss, compared with placebo group. No thromboembolic complications were observed. This randomized controlled trial supports the combined i.v. and topical administration of TXA in primary THA.

A randomized control trial to evaluate the effectiveness of intravenous, intra-articular and topical wash regimes of tranexamic acid in primary total knee arthroplasty

BACKGROUND

The efficacy of tranexamic acid to decrease post-operative blood loss and blood transfusion is well established in literature. However, the ideal mode of administration is debatable. Limited literature has compared all the available modes of administration including intravenous (IV), topical irrigation and retrograde through drain. We hypothesized that no difference would be present in either form of administration of tranexamic acid.

METHODS

Fifty patients in four groups were enrolled for study. Group 1 received drug intravenously, group 2 had topical washing with drug before closure, group 3 received drug after closure through drain and group 4 was control that received no tranexamic acid. Post-operative blood loss, calculated blood loss, haemoglobin drop, transfusion requirements and complications were studied for all four groups.

RESULTS

Tranexamic acid results in lower bleeding irrespective of the mode of administration compared to control group. Total loss at end of 5 days is similar in all tranexamic acid groups irrespective of method used to deliver the drug. Calculated blood loss and haemoglobin drop was minimum for IV and in patients who were administered drug retrograde through drain. Requirement for blood transfusion was found to be lower in all tranexamic acid patients compared to non-tranexamic acid group. The requirement was highest in topical wash group among all tranexamic acid groups.

CONCLUSION

We conclude that intra-articular administration through drain and IV administration are equally effective and superior to topical wash method in reducing blood loss, haemoglobin fall and transfusion requirements.

Hemostatic Mouthwashes in Anticoagulated Patients Undergoing Dental Extraction

Objective:

To evaluate the efficacy and safety of local acting hemostatic agents in patients who are undergoing dental extraction(s) and are taking oral anticoagulants.

Data Sources:

A search of MEDLINE (1966–July 2006), International Pharmaceutical Abstracts (1970–July 2006), and EMBASE (1966–July 2006) was conducted using the key terms anticoagulation, warfarin, hemostatic mouthwashes, epsilon aminocaproic acid, tranexamic acid, dental extraction, and oral surgery. Bibliographies of relevant papers were reviewed for additional references.

Study Selection and Data Extraction:

English-language literature, including abstracts, clinical trials, and review articles, were reviewed. Clinical trials were included if they evaluated hemostatic mouthwashes in patients receiving continued anticoagulation and undergoing dental extractions or various oral surgeries including dental extraction. Eight clinical trials met study selection criteria for evaluation of hemostatic mouthwashes in anticoagulated patients undergoing dental extraction. Eight studies evaluated tranexamic acid; one assessed epsilon aminocaproic acid. All studies were reviewed for efficacy and safety of hemostatic mouthwashes and intensity of continued anticoagulation therapy.

Data Synthesis:

Eight small studies enrolled populations that varied in the indications for oral anticoagulation (OA), target INR ranges, and oral surgeries performed. Patients receiving uninterrupted OA and using hemostatic mouthwashes had no greater and, in some cases, lesser bleeding incidence compared with various other treatment groups (including interrupted OA, uninterrupted OA, autologous fibrin glue with uninterrupted OA, and reduced OA with heparin bridge). No severe adverse effects were reported. No studies assessed the risk of thromboembolism between the different treatment strategies.

Conclusions:

Findings in recent studies indicate that dental extractions in anticoagulated patients can be performed without temporary discontinuation of oral anticoagulant therapy with the use of hemostatic mouthwashes to control localized bleeding. This practice should be more widely adopted due to minimized bleeding and thromboembolic risks.

Antifibrinolytic therapy to reduce haemoptysis from any cause

BACKGROUND

Haemoptysis is a common pathology around the world, occurring with more frequency in low-income countries. It has different etiologies, many of which have infectious characteristics. Antifibrinolytic agents are commonly used to manage bleeding from different sources, but their usefulness in pulmonology is unclear.

OBJECTIVES

To evaluate the effectiveness and safety of antifibrinolytic agents in reducing the volume and duration of haemoptysis in adult and paediatric patients.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library, EMBASE and LILACS for publications that describe randomized controlled trials (RCTs) of antifibrinolytic therapy in patients presenting with haemoptysis. We also performed an independent search in MEDLINE for relevant trials not yet included in CENTRAL or DARE. Searches are up to date to the 19th September 2016. We conducted electronic and manual searches of relevant national and international journals. We reviewed the reference lists of included studies to locate relevant randomized controlled trials (RCTs). An additional search was carried out to find unpublished RCTs.

SELECTION CRITERIA

We included RCTs designed to evaluate the effectiveness and safety of antifibrinolytic agents in reducing haemoptysis in adult and paediatric patients of both genders presenting with haemoptysis of any etiology and severity. The intervention of interest was the administration of antifibrinolytic agents compared with placebo or no treatment.

DATA COLLECTION AND ANALYSIS

All reviewers independently assessed methodological quality and extracted data tables pre-designed for this review.

MAIN RESULTS

The electronic literature search identified 1 original study that met the eligibility criteria. One unpublished study was also identified through manual searches. Therefore two randomized controlled trials met the inclusion criteria: Tscheikuna 2002 (via electronic searches) and Ruiz 1994 (via manual searches). Tscheikuna 2002, a double-blind RCT performed in Thailand, evaluated the effectiveness of tranexamic acid (TXA, an antifibrinolytic agent) administered orally in 46 hospital in- and outpatients with haemoptysis of various etiologies. Ruiz 1994, a double-blind RCT performed in Peru, evaluated the effectiveness of intravenous TXA in 24 hospitalised patients presenting with haemoptysis secondary to tuberculosis.Pooled together, results demonstrated a significant reduction in bleeding time between patients receiving TXA and patients receiving placebo with a weighted mean difference (WMD) of -19.47 (95% CI -26.90 to -12.03 hours), but with high heterogeneity (I² = 52%). TXA did not affect remission of haemoptysis evaluated at seven days after the start of treatment. Adverse effects caused by the drug's mechanism of action were not reported. There was no significant difference in the incidence of mild side effects between active and placebo groups (OR 3.13, 95% CI 0.80 to 12.24).

AUTHORS' CONCLUSIONS

There is insufficient evidence to judge whether antifibrinolytics should be used to treat haemoptysis from any cause, though limited evidence suggests they may reduce the duration of bleeding.

Hematology in palliative medicine

Advanced cancer and life-limiting chronic nonmalignant diseases are associated with a number of hematological problems. Anemia and coagulation disorders, principally venous thrombosis and thrombocytopenia, are most commonly observed. Patients undergoing chemotherapy and bone marrow transplant have unique problems that include neutropenias and chemotherapy-induced drug toxicities, which will not be covered in this article.

The Efficacy of Preoperative Oral Tranexamic Acid on Intraoperative Bleeding During Rhinoplasty

BACKGROUND

Perioperative bleeding is a common side effect of rhinoplasty which may impose the blood transfusion to the patients. As a result of risks and cost of blood transfusion, this study is planned to reduce blood loss in these surgeries. Since tranexamic acid (TXA) has been reported to reduce bleeding and subsequent possible need for blood transfusion, the purpose of this study was to evaluate the efficacy of oral TXA on blood loss during rhinoplasty.

METHODS AND MATERIALS

In this double-blind, randomized, placebo-controlled clinical trial, 50 participants underwent rhinoplastic surgery. These participants were divided into 2 groups; 25 were randomly assigned to each 1. The patients in the first group received 1 g (2 × 500 mg) tranexamic acid tablets, and the patients in the second group received placebo 2 hours before starting the surgery. All patients were operated by the same surgical team and the same anesthetic techniques were used during the surgery. Gender, age, BMI, duration of operation, the amount of blood loss, and surgeon's satisfaction rate were the variables studied.

RESULTS

The first group (TXA group) consisted of 11 males (44%) and 14 females (56%) and the second group consisted of 13 males (52%) and 12 females (48%). There was no statistical difference in the distribution of the variables between the 2 groups, except for the blood loss, duration of operation, and surgeon's satisfaction. The mean total blood loss was 144.6 ± 60.28 mL in "group 1" and 199.6 ± 73.05 mL in "group 2" (P < 0.05). Duration of operation in the first group was less than the second group (2.60 ± 0.53 hours vs. 2.99 ± 0.59 hours) (P = 0.017). The surgeon was more satisfied with the quality of surgical field and visualization in "group 1" (3.76 ± 0.72) than "group 2" (2.16 ± 0.50) (P = 0.001).

CONCLUSION

The preoperative administration of 1 g oral tranexamic acid significantly decreased the blood loss in patients undergoing rhinoplastic surgery without any significant adverse effects.Iranian registry no:IRCT201312271674N10 (www.irct.ir).

Efficacy of Local Administration of Tranexamic Acid for Blood Salvage in Patients Undergoing Intertrochanteric Fracture Surgery

OBJECTIVES

The primary aim of this study was to assess whether local administration of tranexamic acid (TXA) reduced the need for a blood transfusion in elderly patients treated with an intramedullary (IM) nail for an intertrochanteric fracture.

DESIGN

Randomized prospective trial.

SETTING

Academic level 1 trauma center.

PATIENTS

Two hundred patients (200 fractures) over 65 years with an intertrochanteric fracture treated by IM nail between April 1, 2012, and March 31, 2014.

INTERVENTION

Subfascial administration of 3 g of TXA around the fracture site at the end of the surgical procedure, versus a control group without TXA. Follow-up ranged from 12 to 24 months.

MAIN OUTCOME MEASURES

Group differences in number of transfused packed red blood cell (PRBC) units, and hematocrit, hemoglobin, and platelet count.

RESULTS

There was a 43% reduction in transfusion requirements in the TXA group (P < 0.01). Twenty-seven units of PRBC were transfused in 22/100 patients in the TXA group, whereas 48 PRBC units were transfused in 29/100 patients in control group. There was no difference between the 2 groups in terms of late complications and overall mortality rate.

CONCLUSIONS

Subfascial administration of TXA around the fracture site in elderly patients undergoing IM nailing for intertrochanteric fractures is safe and cost-effective. A significant reduction in blood loss and transfused blood units, and health care cost can be achieved.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Intravenous versus topical tranexamic acid in primary total hip replacement: A systemic review and meta-analysis

OBJECTIVE

Total hip arthroplasty (THA) is associated with substantial blood loss. Tranexamic acid (TXA) could reduce perioperative blood loss. The optimal administration routine of TXA remains controversial. The objective of the present systemic review and meta-analysis was to compare the effectiveness and safety of various application methods of tranexamic acid in primary THA.

METHODS

Potential relevant literature was identified from electronic databases including Medline, PubMed, Embase, ScienceDirect, web of science and Cochrane Library. Grey academic studies were also identified from the references of the included literature. There was no language restriction. The pooling of data was carried out by using RevMan 5.1.

RESULTS

Three randomized controlled trials (RCTs) and two non-RCTs involving 1614 patients met the inclusion criteria. Current meta-analysis indicated that there were no significant differences in terms of total blood loss (MD = -30.04, 95% CI: -114.67 to 54.59, P = 0.49), postoperative hemoglobin level (MD = -0.29, 95% CI: -0.68 to 0.10, P = 0.14), transfusion rate (RD = -0.02, 95% CI: -0.5 to -0.00, P = 0.09), length of stay ((MD = -0.14, 95% CI: -0.30 to 0.01, P = 0.07) or operation time ((MD = 1.00, 95% CI: -0.31 to 2.31, P = 0.14) between treatment groups. No significant differences were found regarding the incidence of adverse effects such as wound infection (RD = -0.01, 95% CI: -0.06 to 0.04, P = 0.66), myocardial infarction (MI) (RD = -0.01, 95% CI: -0.04 to 0.02, P = 0.61), deep venous thrombosis (DVT) (RD = 0.00, 95% CI: -0.01 to 0.01, P = 0.51) or pulmonary embolism (PE) (RD = RD = 0.00, 95% CI: -0.01 to 0.01, P = 0.63) between groups.

CONCLUSION

The topical administration of TXA in THA carried similar hemostasis effects compared with intravenous use without an increased risk of thrombotic complications. No other adverse effect was identified. Topical TXA application was a simple, safe, effective and cost-effective adjunct for blood management following primary THA. For patients with a high risk of thromboembolic events, there may be benefits with topical administration.

Peri-articular tranexamic acid injection in total knee arthroplasty: a randomized controlled trial

Background

Intravenous tranexamic acid (IV TXA) is one of the most effective agents in use for reducing blood loss following total knee arthroplasty (TKA) but its safety regarding venous thromboembolic events (VTEs) remains in question. The direct, local application of TXA may reduce systemic toxicity whilst maintaining good or better bleeding control compared to IV TXA. The topical application of TXA via Hemovac drains has been reported previously with good results. However, there are no data on peri-articular TXA injections during TKA.

Methods

We conducted an open randomized, pilot study of peri-articular vs. IV TXA in 60 patients undergoing TKA. 30 patients received either: (i) 750 mg peri-articular TXA into the medial, lateral capsules and the quadriceps tendon prior to capsular closure and tourniquet deflation (group1), or (ii) 750 mg of IV TXA just before tourniquet deflation. Blood loss in the hemovac drain and hemoglobin (Hb) concentrations were measured at 24 and 48 h (h), and the number of blood transfusions and leg circumference measurements were recorded.

Results

At 48 h, the total blood loss in the hemovac drain was 445 mL in group 1 vs. 520 mL in group 2 (p = 0.081) and the corresponding declines in Hb were 1.85 g/dL vs. 1.87 g/dL (p = 0.84). 16 patients received blood transfusions: 9 vs. 7 in groups 1 and 2, respectively (p = 0.928). There were no differences in thigh and lower leg circumferences, pain scores, knee flexion at discharge date and lengths of hospital stay. There were no clinically detected venous thromboembolic events.

Conclusion

This pilot study has shown promising results for peri-articular TXA during TKA. Additional, larger studies are needed to confirm our results and be powered to show differences in efficacy and safety of peri-articular vs. IV TXA.

Trial registration

ClinicalTrials.gov Identifier NCT02829346. Retrospectively registered: 07/11/2016.

Gastrointestinal chronic graft-versus-host disease: management options

Chronic graft-versus-host disease (GVHD) is a common and debilitating condition afflicting a number of allogeneic stem cell recipients more than 100 days after their transplant. Limited options are available for the acute management of patients with severe gastrointestinal (GI) symptoms including gastric bleeding. Along with increased immunosuppression and aggressive supportive care, we report here the use of aminocaproic acid in the management of patients with GI bleeding resulting from severe GVHD. The use of aminocaproic acid enabled us to reduce the frequency and number of blood product transfusions required to manage our patient. Anti-fibrinolytic agents may therefore serve as useful adjunctive but underutilized therapy in the management of patients with severe GI chronic GVHD. J Oncol Pharm Practice (2007) 13: 49–51.

Tranexamic Acid Administration in Primary Total Hip Arthroplasty: A Randomized Controlled Trial of Intravenous Combined with Topical Versus Single-Dose Intravenous Administration

BACKGROUND

The use of tranexamic acid (TXA) in primary total hip arthroplasty is well documented. However, considering the potential side effects, including deep vein thrombosis and pulmonary embolism, the ideal method of providing TXA to patients undergoing total hip arthroplasty remains controversial. The objective of this trial was to assess the efficacy and safety of intravenous (IV) administration combined with topical administration of TXA regarding postoperative blood loss and transfusion rates in patients treated with primary unilateral total hip arthroplasty.

METHODS

In this prospective, randomized controlled trial, 150 patients were divided into three groups: the combined group (IV administration of 15 mg/kg of TXA combined with topical administration of 1 g/100 mL of TXA), the single IV group (IV administration of 15 mg/kg of TXA), and the placebo group. The primary outcomes included blood-loss variables (total, intraoperative, and drainage blood loss; changes in hemoglobin, hematocrit, and platelet concentration; and amount of IV transfusion fluid) and transfusion values (frequency of transfusion and number of transfused blood units). The secondary outcomes included the length of the hospital stay, range of hip motion, Harris hip score, and prevalences of deep vein thrombosis and pulmonary embolism.

RESULTS

The total blood loss in the combined group (mean and standard deviation, 835.49 ± 343.50 mL) was significantly reduced (p < 0.05) in comparison with that in the single IV group (1002.62 ± 366.85 mL) and placebo group (1221.11 ± 386.25 mL). The combined group also had fewer transfusions in comparison with the single IV and placebo groups (1, 8, and 19, respectively; p < 0.05). There was no difference among the 3 groups with regard to the rates of deep vein thrombosis or pulmonary embolism.

CONCLUSIONS

Intravenous combined with topical administration of TXA in patients undergoing a primary unilateral total hip arthroplasty significantly reduced postoperative bleeding and the transfusion rate. Studies with more patients and longer follow-up are needed to confirm whether this promising combined strategy is safe with regard to thromboembolic complications.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Combined Intra-Articular and Intravenous Tranexamic Acid Reduces Blood Loss in Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

In total knee arthroplasty, both intravenous (IV) and intra-articular (IA) administration of tranexamic acid (TXA) have been shown to reduce blood loss in several randomized controlled trials, although routine use of systemic TXA is considerably more common. However, to our knowledge, the additional benefit of IA administration of TXA when combined with IV administration, without the use of a tourniquet, has not been previously investigated. Thus, the aim of this study was to evaluate whether combined IV and IA administration of TXA reduced total blood loss compared with IV-only administration of TXA.

METHODS

In this randomized, double-blind, placebo-controlled trial, 60 patients scheduled for total knee arthroplasty were randomized to one of two interventions. The TXA IV and IA group received combined administration of TXA consisting of 1 g administered intravenously preoperatively and 3 g diluted in 100 mL of saline solution administered intra-articularly after closure of the capsule. The TXA IV and placebo group received 1 g of TXA administered intravenously only and 100 mL of saline solution administered intra-articularly. IA TXA was administrated through a needle. The primary outcome was the 24-hour calculated blood loss. Secondary outcomes were blood loss on postoperative day 2, thromboembolic complications, and transfusion rate. Blood loss was calculated by hemoglobin differences using the Gross formula.

RESULTS

Data on the primary outcome were available for all 60 included patients. Baseline characteristics were comparable between the allocation groups. The mean 24-hour blood loss (and standard deviation) was 466 ± 313 mL in the TXA IV and IA group compared with 743 ± 358 mL in the TXA IV and placebo group; treatment effect (difference), 277 mL (95% confidence interval [CI], 103 to 451 mL) (p = 0.002). Second-day blood loss was 644 ± 382 mL in the TXA IV and IA group compared with 1017 ± 519 mL in the TXA IV and placebo group; treatment effect, 373 mL (95% CI, 132 to 614 mL) (p = 0.003). No thromboembolic complications were observed within 90 days postoperatively.

CONCLUSIONS

The combined administration of IV and IA TXA resulted in a clinically relevant reduction in blood loss of 37% compared with IV TXA alone both at 24 hours postoperatively and on postoperative day 2. No thromboembolic complications were observed.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Retrospective Study of 122 Dogs That Were Treated with the Antifibrinolytic Drug Aminocaproic Acid: 2010-2012

Antifibrinolytic drugs are used to promote hemostasis and decrease the need for red blood cell transfusion. Medical records of 122 dogs that were prescribed either oral or intravenous aminocaproic acid between 2010 and 2012 were evaluated retrospectively. Of the 122 dogs, three experienced possible drug-related adverse effects. No significant differences were identified between dogs that experienced adverse effects and those that did not and the possible adverse effects noted were all minor. All dogs that received packed red blood cell transfusions were evaluated for correlations between baseline packed cell volume or dose of red blood cells and aminocaproic acid dose and no correlation was identified. Dogs that received aminocaproic acid as a treatment for active bleeding were divided by cause of hemorrhage into the following groups: neoplastic, non-neoplastic, and unknown. No significant differences in aminocaproic acid dose or the percentage of patients requiring a blood transfusion were identified between groups.

Single-dose tranexamic acid for reducing bleeding and transfusions in total hip arthroplasty: A double-blind, randomized controlled trial of different doses

BACKGROUND

Tranexamic acid can be effective at decreasing blood loss and transfusion requirements associated with total hip arthroplasty (THA), but few studies have compared the efficacy of different intravenous dosing regimes. This double-blind, randomized controlled trial compared the ability of two doses of intravenous TXA (IV-TXA, 10 or 15mg/kg) to reduce bleeding and transfusions associated with THA.

MATERIALS AND METHODS

A total of 124 patients scheduled for THA were consecutively randomized 1:1:1 into three parallel arms: control (placebo), 10mg/kg IV-TXA and 15mg/kg IV-TXA.

RESULTS

The proportion of patients who experienced bleeding and required transfusions was significantly lower in the 15mg/kg IV-TXA group (1 of 42, 2.4%) than in the 10mg/kg IV-TXA group (8 of 39, 20.5%; P=0.012) and in the control group (10 of 38, 26.3%; P=0.002). In fact, this proportion was similar between the 10mg/kg IV-TXA and control groups (P=0.547). Ultrasound examination on postoperative day 3 revealed only one case of asymptomatic deep vein thrombosis (in the femoral vein) in the 10mg/kg IV-TXA group, which was managed by administering low-molecular-weight heparin. No cases of deep-vein thrombosis were observed in the other two groups. No cases of symptomatic pulmonary embolism were observed.

CONCLUSION

IV-TXA at 10mg/kg significantly reduced blood loss and mitigated the decrease in hemoglobin and hematocrit after THA, but it did not significantly reduce the need for transfusions. In contrast, a dose of 15mg/kg reduced both bleeding and transfusion requirements. Our results argue for a dose of 15mg/kg when using single-dose IV-TXA.

LEVEL OF EVIDENCE

Therapeutic Level I.

Impact of Aprotinin - A Proteolytic Enzyme on Postsurgical Symptoms in Patients Undergoing Third Molar Surgeries

INTRODUCTION

Dealing with postoperative pain and inflammation remains an arena for never ending research. Different agents have been the subject of many studies to prevent the occurrence of unpleasant postoperative sequel. Extraction of third molars is often associated with significant deterioration in oral health related quality of life (physical, social and psychological) in immediate postoperative period. The complaints of pain, swelling and limitation of mouth opening, which ensue as a result of acute inflammatory response, are frequent consequences of postsurgical procedures involving extraction of impacted 3(rd) molars.

AIM

Aprotinin, a naturally occurring protease inhibitor was assessed for its effectiveness in plummeting postsurgical pain and swelling, after surgical removal of impacted 3(rd) molars.

MATERIALS AND METHODS

Thirty randomly selected adult patients age ranging from 16-35 years, who required simultaneous surgical removal of bilateral impacted mandibular third molars were recruited. Before the surgical procedure, randomly selected side of the patient was injected with 1 m of 10,000 Kallikrein Inactivator Units (KIU) of aprotinin sub-mucosally around the surgical site and the contra lateral side with 1ml of isotonic saline as a control following which adequate local anaesthesia was obtained. The surgical removal of impacted 3(rd) molars was conducted in a similar manner on both test and control sides on all patients. Postoperatively, the patients were evaluated for pain and swelling for one week i.e., 1(st), 2(nd) and 7(th) day.

RESULTS

It was observed that there was marked clinical reduction in postoperative pain and swelling. There were no adverse affects observed after using aprotinin.

CONCLUSION

Since, the current pharmacologic agents being used have adverse effects and associated morbidity which still pose a problem, aprotinin a naturally occurring agent could be efficiently used after surgical extraction of 3(rd) molars in management of postsurgical symptoms and improve patient comfort and quality of life. In future, further studies with use of aprotinin in a large number of patients and comparative studies with other drugs are required.

Low dose tranexamic acid reduces blood transfusion rate after total knee arthroplasty: A population-based study in Taiwan

BACKGROUND/PURPOSE

Previous reports, mostly small clinical trials conducted in USA or Europe, indicated that tranexamic acid (TXA) would be effective for reducing blood transfusions after total knee arthroplasty (TKA). However, large scale studies are needed regarding the effectiveness and safety issue of complication events following TKA, especially for the Asian population. We aimed to evaluate the efficacy and safety of TXA use based on data from an elderly population in Taiwan.

METHODS

This was a retrospective population-based study using an inpatient dataset from the nationwide health insurance research database in Taiwan. Patients aged >65 years with a diagnosis of osteoarthritic knee in 2012 were included (n = 10,321). A low-dose intravenous form of TXA (250-1000 mg) was identified perioperatively during the TKA. The surgical outcomes of interest were allogeneic red blood cell transfusion and postoperative 30-day complications.

RESULTS

A total of 1205 (11.7%) patients received TXA. Based on a multilevel logistic regression model, we found a 47% odds reduction of blood transfusion without elevating the complications of infection and vascular-related diseases. Furthermore, the drug effect in reducing transfusion was different among hospital levels, and medical centers had a relatively lower transfusion rate.

CONCLUSION

The use of perioperative TXA was an efficient strategy to prevent blood loss after TKA.

Combined Administration of Systemic and Topical Tranexamic Acid for Total Knee Arthroplasty: Can It Be a Better Regimen and Yet Safe? A Randomized Controlled Trial

BACKGROUND

Total knee arthroplasty (TKA) is associated with substantial blood loss in postoperative period. Tranexamic acid (TXA) is potent antifibrinolytic agent, routinely administered by intravenous (IV) and topical route, which can possibly interrupt cascade of events due to hemostatic irregularities close to source of bleeding. However, scientific evidence of combined administration of TXA in TKA is still meagre. The present study aimed to compare efficacy of combined IV and topical TXA with IV use alone in terms of blood loss, transfusion rate, and incidence of deep vein thrombosis and thromboembolism.

PATIENTS AND METHODS

119 patients undergoing unilateral TKA were randomized into IV alone and combined group. Patients assigned to IV group were given IV TXA as a preoperative and postoperative dose given 3 and 6 hours after surgery, whereas in combined group, topical TXA solution was applied intraarticularly about 5 minutes before closure of arthrotomy in addition to IV doses.

RESULTS

Combined use of IV and topical TXA provided better results than IV use alone with mean calculated total blood loss (590.69±191.1 vs 385.68±182.5, P<.001), blood transfusion rate (6.6% vs 1.6%, P = .364), hemoglobin drop (1.82±0.6 vs 1.14±0.5, P<.001). No case of DVT or TE was noted among the 2 study groups.

CONCLUSION

Combined use of IV and intraarticular TXA provided significantly better results compared with IV use alone with respect to all variables related to postoperative blood loss in TKA. Moreover, TXA use is safe in terms of incidence of symptomatic DVT and TE.

Overview of Agents Used for Emergency Hemostasis

CONTEXT

In today's modern world, despite the multiple advances made in the field of medicine, hemorrhagic shock is still the main cause of battlefield mortality and the second most prevalent cause of mortality in civilian trauma. Hemostatic agents can play a key role in establishing hemostasis in prehospital situations and preventing hemorrhage-associated death. In this respect, this article aims to review different aspects of known hemostatic agents.

EVIDENCE ACQUISITION

A comprehensive search of the academic scientific databases for relevant keywords was conducted; relevant articles were compiled and assessed.

RESULTS

Hemostatic agents can establish hemostasis by means of different mechanisms, including concentrating coagulation factors, adhesion to the tissues, in which traumatic hemorrhage occurred, and delivering procoagulant factors to the hemorrhage site. Presently, these hemostatics have been significantly improved with regard to efficacy and in adverse consequences, resulting from their use. Several hemostatic dressings have been developed to the degree that they have received FDA approval and are being used practically on the battlefield. In addition, there are currently several case reports on the use of such hemostatics in the hospital setting, in conditions where commonly known approaches fail to stop life-threatening bleeding.

CONCLUSIONS

The use of hemostatic dressings and agents is one of the main advancements achieved in recent decades. However, it can be claimed that the ideal hemostatic has not been recognized yet; therefore, this topic needs to be brought into focus and further addressed.

Comparison between topical and intravenous administration of tranexamic acid in primary total hip arthroplasty

BACKGROUND

Tranexamic acid has been reported to be safer with topical administration than with intravenous administration in total knee arthroplasty. However, the most effective administration route of tranexamic acid in total hip arthroplasty remains controversial. This study compared the effectiveness of topical tranexamic acid administration with that of intravenous tranexamic acid administration in total hip arthroplasty.

METHODS

We retrospectively examined the medical records of 886 patients with osteoarthritis of the hip joint, who had undergone unilateral primary total hip arthroplasty. The patients were divided into a control group (n = 302; did not receive tranexamic acid), topical group (n = 265; topically administered 2 g tranexamic acid in 30 mL normal saline via drain tubes placed in the joint before wound closure along with posterior soft tissue repair), and intravenous group (n = 319; intravenously administered 1 g tranexamic acid before skin incision along with posterior soft tissue repair). Data on blood loss, hemoglobin levels, transfusion rates, and occurrence of deep vein thrombosis and pulmonary embolization were collected.

RESULTS

The mean operation times were approximately 40 min in all of the groups. The operation time and intra-operative blood loss were significantly lower in the control group than in the topical and intravenous groups. However, the post-operative blood loss, total blood loss, and decrease in the hemoglobin level were significantly higher in the control group than in the topical and intravenous groups. There were no significant differences in terms of blood loss and systemic complications between the tranexamic acid administration methods.

CONCLUSIONS

Tranexamic acid reduces both post-operative and total blood loss in total hip arthroplasty. Moreover, a lower amount of tranexamic acid can be used to reduce blood loss in total hip arthroplasty with intravenous tranexamic acid administration than with topical tranexamic acid administration. Therefore, we suggest that tranexamic acid should be intravenously administered pre-operatively and the posterior soft tissue should be repaired to decrease total hip arthroplasty-related complications.

Two Doses of Tranexamic Acid Reduce Blood Transfusion in Complex Spine Surgery: A Prospective Randomized Study

STUDY DESIGN

Prospective, double-blinded, randomized controlled study.

OBJECTIVE

To determine whether the use of 2 doses of tranexamic acid (TXA) can reduce perioperative blood loss and blood transfusions in low-risk adult patients undergoing complex laminectomy.

SUMMARY OF BACKGROUND DATA

Complex laminectomy (multilevel laminectomy or laminectomy and instrumentation) is a procedure with a medium risk of blood loss, which may require allogeneic blood transfusion. Previous studies of TXA showed its inconsistent effectiveness in reducing blood loss during spine surgery. The negative results may stem from ineffective use of a single dose of TXA during long and complex operations.

METHODS

80 adult (18-65 yr old) patients in Siriraj Hospital, Mahidol University, Thailand were enrolled and allocated into 2 groups (40 patients in each group) by computer-generated randomization. Patients with history of thromboembolic diseases were excluded. Anesthesiologists in charge and patients were blinded. Group I received 0.9% NaCl (NSS) or placebo and group II received 2 doses (15 mg/kg) of TXA. The first dose was administered before anesthesia induction and the second dose, after 3 hours. The assessed outcomes were the amount of perioperative blood loss and the incidence of blood transfusions.

RESULTS

78 patients were analyzed (1 patient in each group was excluded) with 39 patients randomized to each group. There were no differences in patient demographics and pre and postoperative hematocrit levels. The total blood loss in the control group (NSS) was higher [900 (160, 4150) mL] than in the TXA group [600 (200, 4750) mL]. Patients in the control group received more crystalloid, colloid, and packed red blood cell transfusions. Within 24 hours, we observed a 64.6% reduction of blood transfusions (43.5% vs.15.4%, P = 0.006). No serious thromboembolic complications occurred.

CONCLUSION

2 effective doses (15 mg/kg) of TXA can reduce blood loss and transfusions in low-risk adults undergoing complex spine surgery.

LEVEL OF EVIDENCE

1.

Topical Application of Tranexamic Acid Plus Diluted Epinephrine Reduces Postoperative Hidden Blood Loss in Total Hip Arthroplasty

We evaluated the efficacy and safety of topical application of tranexamic acid (TXA) plus diluted epinephrine (DEP) and its effect on perioperative hidden blood loss and transfusion requirement in primary unilateral total hip arthroplasty (THA). We randomized 107 patients undergoing THA into two groups: 53 received intra-articular TXA 3 g plus 1:200,000 DEP 0.25 mg; 54 received topical TXA 3 g alone. Results showed that combined administration significantly reduced total blood loss (P=0.009), hidden blood loss (P=0.001) and transfusion rate (1.9 vs. 9.3%) compared with TXA alone, without increasing the risks of thromboembolic and hemodynamic complications. Topical TXA plus DEP in THA can decrease postoperative hidden blood loss and avoid homologous transfusion without substantial complications.

Is there a role for antifibrinolytics in pelvic and acetabular fracture surgery?

BACKGROUND

Pelvic and acetabular fractures are rare, complex injuries associated with significant morbidity. Fixation of these injuries requires major orthopaedic surgery which in itself is associated with substantial blood loss owing to the extensile operative approach and prolonged operating time required to address the complex fracture anatomy. In order to reduce morbidity, a multifactor approach to blood conservation must be adopted.

CURRENT ROLE OF ANTIFIBRINOLYTICS IN ORTHOPAEDIC SURGERY

The use of antifibrinolytics to reduce operative blood loss is well documented in many surgical specialties, including orthopaedic surgery. Elective spinal surgery and joint arthroplasty have benefited from the introduction of antifibrinolytics; however, their role in trauma and fracture surgery is not fully defined. Pelvic and acetabular fracture surgery would benefit from further investigation on the benefit and safety of these agents.

CONCLUSION

Routine use cannot be recommended at this time but agents may be considered on a case-specific basis.