401
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Sigrist NE, Hofer-Inteeworn N, Jud Schefer R, Kuemmerle-Fraune C, Schnyder M, Kutter APN. Hyperfibrinolysis and Hypofibrinogenemia Diagnosed With Rotational Thromboelastometry in Dogs Naturally Infected With Angiostrongylus vasorum. J Vet Intern Med 2017; 31:1091-1099. [PMID: 28480552 PMCID: PMC5508311 DOI: 10.1111/jvim.14723] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 03/10/2017] [Accepted: 03/29/2017] [Indexed: 01/12/2023] Open
Abstract
Background The pathomechanism of Angiostrongylus vasorum infection‐associated bleeding diathesis in dogs is not fully understood. Objective To describe rotational thromboelastometry (ROTEM) parameters in dogs naturally infected with A. vasorum and to compare ROTEM parameters between infected dogs with and without clinical signs of bleeding. Animals A total of 21 dogs presented between 2013 and 2016. Methods Dogs with A. vasorum infection and ROTEM evaluation were retrospectively identified. Thrombocyte counts, ROTEM parameters, clinical signs of bleeding, therapy, and survival to discharge were retrospectively retrieved from patient records and compared between dogs with and without clinical signs of bleeding. Results Evaluation by ROTEM showed hyperfibrinolysis in 8 of 12 (67%; 95% CI, 40–86%) dogs with and 1 of 9 (11%; 95% CI, 2–44%) dogs without clinical signs of bleeding (P = .016). Hyperfibrinolysis was associated with severe hypofibrinogenemia in 6 of 10 (60%; 95% CI, 31–83%) of the cases. Hyperfibrinolysis decreased or resolved after treatment with 10–80 mg/kg tranexamic acid. Fresh frozen plasma (range, 14–60 mL/kg) normalized follow‐up fibrinogen function ROTEM (FIBTEM) maximal clot firmness in 6 of 8 dogs (75%; 95% CI, 41–93%). Survival to discharge was 67% (14/21 dogs; 95% CI, 46–83%) and was not different between dogs with and without clinical signs of bleeding (P = .379). Conclusion and Clinical Importance Hyperfibrinolysis and hypofibrinogenemia were identified as an important pathomechanism in angiostrongylosis‐associated bleeding in dogs. Hyperfibrinolysis and hypofibrinogenemia were normalized by treatment with tranexamic acid and plasma transfusions, respectively.
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Affiliation(s)
- N E Sigrist
- Department for Small Animals, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - N Hofer-Inteeworn
- Department for Small Animals, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - R Jud Schefer
- Department for Small Animals, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - C Kuemmerle-Fraune
- Department for Small Animals, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - M Schnyder
- Institute of Parasitology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - A P N Kutter
- Section of Anaesthesiology, Equine Department, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
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402
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Yao Q, Wu M, Zhou J, Zhou M, Chen D, Fu L, Bian R, Xing X, Sun L, Hu X, Li L, Dai B, Wüthrich RP, Ma Y, Mei CL. Treatment of Persistent Gross Hematuria with Tranexamic Acid in Autosomal Dominant Polycystic Kidney Disease. Kidney Blood Press Res 2017; 42:156-164. [PMID: 28395294 DOI: 10.1159/000474961] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/17/2017] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Qing Yao
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Ming Wu
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jie Zhou
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Meiyang Zhou
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Present address: Department of Nephrology, Yinzhou People's Hospital, Ningbo, China
| | - Dongping Chen
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Lili Fu
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Rongrong Bian
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xiaohong Xing
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Lijun Sun
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xiaohong Hu
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Lin Li
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Bing Dai
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | | | - Yiyi Ma
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Chang-Lin Mei
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
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403
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Qiu M, Zhang X, Cai H, Xu Z, Lin H. The impact of hemocoagulase for improvement of coagulation and reduction of bleeding in fracture-related hip hemiarthroplasty geriatric patients: A prospective, single-blinded, randomized, controlled study. Injury 2017; 48:914-919. [PMID: 28238301 DOI: 10.1016/j.injury.2016.11.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 05/27/2016] [Accepted: 11/26/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Uncontrolled bleeding is associated with poor outcomes and mortality in geriatric patients undergoing hemiarthroplasty. Hemocoagulase agkistrodon is a hemocoagulative, anti-hemorrhagic enzyme complex from Deinagkistrodon acutus snake venom. This study aimed to investigate the efficacy of hemocoagulase agkistrodon on coagulation and bleeding outcomes in fracture-related hemiarthroplasty. PATIENTS AND METHODS This was a prospective, single-blinded, randomized controlled trial carried out between October 2013 and September 2014 in 96 geriatric patients undergoing hemiarthroplasty for unilateral femoral neck fracture. Patients were administrated hemocoagulase agkistrodon (n=48) or normal saline (n=48). Intraoperative blood loss, transfusion volume and rate, and drainage were assessed. Hemoglobin (Hb) and coagulation parameters (prothrombin time [PT], thrombin time [TT], plasma fibrinogen [FIB], and activated partial thromboplastin time [aPTT]) were recorded preoperatively and 30min and 1, 3, and 5days after surgery. Complications were followed up for 4 weeks. RESULTS Compared to controls, hemocoagulase patients exhibited lower intraoperative blood loss (P<0.01) and postoperative blood loss, total drainage, mean transfusion volume, and transfusion rates (all P<0.05), with lower aPTT at 30min (P<0.05). No significant differences in postoperative FIB were observed. Controls exhibited significantly higher PP and TT on day 1, and Hb on days 1, 3, and 5 (P<0.05). No serious complications were reported. CONCLUSIONS Hemocoagulase reduced blood loss and transfusion in fracture-related hip hemiarthroplasty without increasing short-term adverse event rates. In geriatric populations, hemocoagulase could be used for limiting bleeding and related complications. TRIAL REGISTRATION This trial is registered in the Chinese Clinical Trial Register (no. ChiCTR-TRC-14004379).
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Affiliation(s)
- Meiguang Qiu
- Department of Surgery, Fujian Provincial Hospital Emergency Center; Provincial Clinical College of Fujian Medical University; Fujian Provincial Emergency Medicine Institute, Fuzhou, China
| | - Xuming Zhang
- Department of Surgery, Fujian Provincial Hospital Emergency Center; Provincial Clinical College of Fujian Medical University; Fujian Provincial Emergency Medicine Institute, Fuzhou, China.
| | - Hongru Cai
- Department of Surgery, Fujian Provincial Hospital Emergency Center; Provincial Clinical College of Fujian Medical University; Fujian Provincial Emergency Medicine Institute, Fuzhou, China
| | - Zhixian Xu
- Department of Surgery, Fujian Provincial Hospital Emergency Center; Provincial Clinical College of Fujian Medical University; Fujian Provincial Emergency Medicine Institute, Fuzhou, China
| | - Hao Lin
- Department of Surgery, Fujian Provincial Hospital Emergency Center; Provincial Clinical College of Fujian Medical University; Fujian Provincial Emergency Medicine Institute, Fuzhou, China
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404
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Madsen RV, Nielsen CS, Kallemose T, Husted H, Troelsen A. Low Risk of Thromboembolic Events After Routine Administration of Tranexamic Acid in Hip and Knee Arthroplasty. J Arthroplasty 2017; 32:1298-1303. [PMID: 27843042 DOI: 10.1016/j.arth.2016.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 09/21/2016] [Accepted: 10/10/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The blood-conserving effect of intravenous (IV) tranexamic acid (TXA) is well-documented for total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, the risk of thromboembolic (TE) events after routine use of TXA is unclear and the safety profile is debated. This retrospective study investigates patient characteristics, occurrences, and predictors of TE events after routine administration of IV TXA in THA and TKA. METHODS Three thousand one hundred fifty-nine THA or TKA procedures performed from 2007-2013 at our institution were included. IV TXA, 1 g, was administered preoperatively if not contraindicated. Relevant patient characteristics and comorbidity information were extracted locally from the database. Data on TE events occurring within 90 days postoperatively came from The Danish National Patient Registry. Patient characteristics, comorbidities, and TE events were compared between TXA groups. A logistic regression model was used to evaluate predictors of TE events. RESULTS Of 3159 procedures, 2766 (87.6%) received TXA (TXA+ group) preoperatively, whereas 393 (12.4%) did not (TXA- group). Mean age, distributions of gender, American Society of Anesthesiologists score, anesthesia method, duration of surgery, diagnosis, and survival status were all statistically significant different (P values <.05) between TXA groups. The studied comorbidities were all significantly different (TXA+ vs TXA- group; P values ≤.002). We found 31 (1.0%) TE events out of 3159 procedures, with no significant group difference in TE events (TXA+: 27 out of 2766 = 1.0%, TXA-: 4 out of 393 = 1.0%, P value = .55 for any event). For the TXA+ group, 0.5% suffered from deep venous thrombosis, 0.3% from acute myocardial infarction, and 0.2% from a pulmonary embolism. In the TXA+ group, higher age (odds ratio [OR] = 1.06, 95% confidence interval = 1.02-1.11, P = .005) and present cardiovascular disease (OR = 4.78, 95% confidence interval = 1.72-13.28, P = .003) were associated with an increased risk of TE events. CONCLUSION The findings suggest that routine use of IV TXA for TKA and THA as safe with low occurrence of TE events, although a large prospective trial should confirm this.
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Affiliation(s)
- Rune V Madsen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Christian S Nielsen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark; Harris Orthopaedic Laboratory, Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas Kallemose
- Department of Orthopaedic Surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark; Clinical Research Centre, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Henrik Husted
- Department of Orthopaedic Surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
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405
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Landoni G, Pisano A, Lomivorotov V, Alvaro G, Hajjar L, Paternoster G, Nigro Neto C, Latronico N, Fominskiy E, Pasin L, Finco G, Lobreglio R, Azzolini ML, Buscaglia G, Castella A, Comis M, Conte A, Conte M, Corradi F, Dal Checco E, De Vuono G, Ganzaroli M, Garofalo E, Gazivoda G, Lembo R, Marianello D, Baiardo Redaelli M, Monaco F, Tarzia V, Mucchetti M, Belletti A, Mura P, Musu M, Pala G, Paltenghi M, Pasyuga V, Piras D, Riefolo C, Roasio A, Ruggeri L, Santini F, Székely A, Verniero L, Vezzani A, Zangrillo A, Bellomo R. Randomized Evidence for Reduction of Perioperative Mortality: An Updated Consensus Process. J Cardiothorac Vasc Anesth 2017; 31:719-730. [DOI: 10.1053/j.jvca.2016.07.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Indexed: 11/11/2022]
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406
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Abstract
Following results from the CRASH-2 trial, tranexamic acid (TXA) gained considerable interest for the treatment of hemorrhage in trauma patients. Although TXA is effective at reducing mortality in patients presenting within 3 hours of injury, optimal dosing, timing of administration, mechanism, and pharmacokinetics require further elucidation. The concept of fibrinolysis shutdown in hemorrhagic trauma patients has prompted discussion of real-time viscoelastic testing and its potential role for appropriate patient selection. The results of ongoing clinical trials will help establish high-quality evidence for optimal incorporation of TXA in mature trauma networks in the United States and abroad.
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Affiliation(s)
- Ricardo J Ramirez
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Philip C Spinella
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Grant V Bochicchio
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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407
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Fredericks C, Kubasiak JC, Mentzer CJ, Yon JR. Massive transfusion: An update for the anesthesiologist. World J Anesthesiol 2017; 6:14-21. [DOI: 10.5313/wja.v6.i1.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/04/2016] [Accepted: 12/19/2016] [Indexed: 02/06/2023] Open
Abstract
Exsanguination from trauma, gastrointestinal bleeding, and obstetric hemorrhage remains a major source of mortality across the planet. Continued research into resuscitation strategies and evolving technology and blood product storage has allowed for patient to undergo very large volume transfusions, even to the point of replacing a patient’s blood volume several times over. As massive transfusions have become more common, more studies have been performed delineating the exact patient population that would benefit, start- and stop-points of transfusions, complications and avoidance of the same. We discuss these points and provide information and strategies for massive transfusion.
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408
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Khouadja H, Rouissi W, Mahjoub M, Sakhri J, Beletaifa D, Jazia KB. [Transfusion strategy for patients with severe postpartum hemorrhage: a retrospective study of 47 cases]. Pan Afr Med J 2017; 25:169. [PMID: 28292131 PMCID: PMC5326027 DOI: 10.11604/pamj.2016.25.169.7095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 07/12/2016] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Postpartum haemorrhage is the leading cause of maternal morbidity and mortality worldwide. It requires a multidisciplinary approach. Transfusion strategy is essential, playing a key role in maternal prognosis. This study aims to determine FFP/RBC ratio (plasma frais congelé/concentrés de globules rouges; fresh frozen plasma/red blood cells) during the treatment of serious postpartum haemorrhages. METHODS We conducted a retrospective study at a Maternity Referral Center (level III) in eastern Tunisia over a period of 4 years (2009-2012). All parturients admitted due to severe postpartum bleeding requiring transfusion of more than 4 Units of RBC during the first 3 hours or of more than 10 Units of RBC during the first 24 hours of treatment were included in the study. RESULTS 47 parturients were enrolled in our study. The diagnosis of PPH was made on the basis of vaginal bleeding in 28 cases and following cesarean section in 19 cases. Preoperative hemoglobin level was of 6.3 g/dl. Transfusion ratio (FFP/RBC) was 1/0.7. CONCLUSION During tratment transfusion ratio was greater than that indicated in the existing guidelines stating an early and massive administration of FFP with a FFP/RBC ratio ranging between 1/2 and 1/1. Fibrinogen (Fbg) and tranexamic acid should be administered as early as possible. The use of recombinant activated factor VII (rFVIIa) should remain the ultimate treatment option.
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Affiliation(s)
- Hosni Khouadja
- Service Anesthésie Réanimation chirurgicale, Centre Hospitalo-Universitaire Farhat Hached Sousse-Tunisie; Unité de Recherche UR12SP32, CHU Farhat Hached, Sousse, Tunisie
| | - Wissem Rouissi
- Service Anesthésie Réanimation chirurgicale, Centre Hospitalo-Universitaire Farhat Hached Sousse-Tunisie
| | - Mohamed Mahjoub
- Service d'Hygiène Hospitalière. Centre Hospitalo-Universitaire Farhat Hached Sousse, Tunisie
| | - Jaballah Sakhri
- Unité de Recherche UR12SP32, CHU Farhat Hached, Sousse, Tunisie
| | - Dhafer Beletaifa
- Service Anesthésie Réanimation chirurgicale, Centre Hospitalo-Universitaire Farhat Hached Sousse-Tunisie
| | - Khaled Ben Jazia
- Service Anesthésie Réanimation chirurgicale, Centre Hospitalo-Universitaire Farhat Hached Sousse-Tunisie
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409
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Hooda B, Chouhan RS, Rath GP, Bithal PK, Suri A, Lamsal R. Effect of tranexamic acid on intraoperative blood loss and transfusion requirements in patients undergoing excision of intracranial meningioma. J Clin Neurosci 2017; 41:132-138. [PMID: 28283245 DOI: 10.1016/j.jocn.2017.02.053] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/13/2017] [Indexed: 11/18/2022]
Abstract
Surgical excision of meningioma is often complicated by significant blood loss requiring blood transfusion with its attendant risks. Although tranexamic acid is used to reduce perioperative blood loss, its blood conservation effect is uncertain in neurosurgery. Sixty adults undergoing elective craniotomy for meningioma excision were randomized to receive either tranexamic acid or placebo, initiated prior to skin incision. Patients in the tranexamic acid group received intravenous bolus of 20mg/kg over 20min followed by an infusion of 1mg/kg/h till the conclusion of surgery. Intraoperative blood loss, transfusion requirements and estimation of surgical hemostasis using a 5-grade scale were noted. Postoperatively, the extent of tumor excision on CT scan and complications were observed. Demographics, tumor characteristics, amount of fluid infusion, and duration of surgery and anesthesia were comparable between the two groups. The amount of blood loss was significantly less in tranexamic acid group compared to placebo (830mlvs 1124ml; p=0.03). The transfusion requirement was less in tranexamic acid group (p>0.05). The patients in tranexamic acid group fared better on a 5-grade surgical hemostasis scale with more patients showing good hemostasis (p=0.007). There were no significant differences between the groups with regards to extent of tumor removal, perioperative complications, hospital stay or neurologic outcome. To conclude, administration of tranexamic acid significantly reduced blood loss in patients undergoing excision of meningioma. Fewer patients in the tranexamic acid group received blood transfusions. Surgical field hemostasis was better achieved in patients who received tranexamic acid.
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Affiliation(s)
- Bhavna Hooda
- Department of Neuroanaesthesiology & Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rajendra Singh Chouhan
- Department of Neuroanaesthesiology & Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Girija Prasad Rath
- Department of Neuroanaesthesiology & Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
| | - Parmod Kumar Bithal
- Department of Neuroanaesthesiology & Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Ritesh Lamsal
- Department of Neuroanaesthesiology & Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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410
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Colomina M, Koo M, Basora M, Pizones J, Mora L, Bagó J. Intraoperative tranexamic acid use in major spine surgery in adults: a multicentre, randomized, placebo-controlled trial † †This Article is accompanied by Editorial Aew470. Br J Anaesth 2017; 118:380-390. [DOI: 10.1093/bja/aew434] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2016] [Indexed: 11/13/2022] Open
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411
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Ma TKW, Chow KM, Kwan BCH, Leung CB, Szeto CC, Li PKT. Manifestation of tranexamic acid toxicity in chronic kidney disease and kidney transplant patients: A report of four cases and review of literature. Nephrology (Carlton) 2017; 22:316-321. [DOI: 10.1111/nep.12762] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/03/2016] [Accepted: 03/06/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Terry King-Wing Ma
- Carol and Richard Yu Peritoneal Dialysis Research Centre; Department of Medicine & Therapeutics, Prince of Wales Hospital; The Chinese University of Hong Kong; Shatin Hong Kong
| | - Kai Ming Chow
- Carol and Richard Yu Peritoneal Dialysis Research Centre; Department of Medicine & Therapeutics, Prince of Wales Hospital; The Chinese University of Hong Kong; Shatin Hong Kong
| | - Bonnie Ching-Ha Kwan
- Carol and Richard Yu Peritoneal Dialysis Research Centre; Department of Medicine & Therapeutics, Prince of Wales Hospital; The Chinese University of Hong Kong; Shatin Hong Kong
| | - Chi Bon Leung
- Carol and Richard Yu Peritoneal Dialysis Research Centre; Department of Medicine & Therapeutics, Prince of Wales Hospital; The Chinese University of Hong Kong; Shatin Hong Kong
| | - Cheuk Chun Szeto
- Carol and Richard Yu Peritoneal Dialysis Research Centre; Department of Medicine & Therapeutics, Prince of Wales Hospital; The Chinese University of Hong Kong; Shatin Hong Kong
| | - Philip Kam-Tao Li
- Carol and Richard Yu Peritoneal Dialysis Research Centre; Department of Medicine & Therapeutics, Prince of Wales Hospital; The Chinese University of Hong Kong; Shatin Hong Kong
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412
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Abstract
Obstetric hemorrhage remains the leading cause of maternal death and severe morbidity worldwide. Although uterine atony is the most common cause of peripartum bleeding, abnormal placentation, coagulation disorders, and genital tract trauma contribute to adverse maternal outcomes. Given the inability to reliably predict patients at high risk for obstetric hemorrhage, all parturients should be considered susceptible, and extreme vigilance must be exercised in the assessment of blood loss and hemodynamic stability during the peripartum period. Obstetric-specific hemorrhage protocols, facilitating the integration and timely escalation of pharmacologic, radiological, surgical, and transfusion interventions, are critical to the successful management of peripartum bleeding.
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Affiliation(s)
- Emily J Baird
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mailcode UH2, Portland, OR 97239, USA.
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413
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Wang D, Xu J, Zeng WN, Zhou K, Xie TH, Chen Z, Yu HD, Li JL, Zhou ZK, Pei FX. Closed Suction Drainage Is Not Associated with Faster Recovery after Total Knee Arthroplasty: A Prospective Randomized Controlled Study of 80 Patients. Orthop Surg 2017; 8:226-33. [PMID: 27384732 DOI: 10.1111/os.12247] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 01/23/2016] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To evaluate whether closed suction drainage (CSD) is associated with early recovery of knee function in patients undergoing total knee arthroplasty (TKA). METHODS Between January 2015 and September 2015, 80 consecutive patients were prospectively randomized into two groups: a CSD group (40 cases; average age, 66.9 ± 8.6 years; male, 8; female, 32) and a non-CSD group (40 cases; average age, 66.8 ± 10.1 years; male, 9; female, 31). Local inflammation outcomes (assessed by a visual analog scale [VAS], swelling and skin temperature), calculated total blood loss (CBL), hidden blood loss (HBL), blood transfusion requirements and hemoglobin concentrations were recorded. Hospital for Special Surgery (HSS) knee scores, range of motion (ROM), limb swelling, tension vesicles, ecchymosis, time to regaining straight leg raising and duration of hospital stay were documented. All surgeries were performed by the same surgeon and followed up for 3 months. RESULTS The peri-wound skin temperature and knee VAS pain scores were lower in the non-CSD group. Patients in the non-CSD group had significantly better knee ROM (P = 0.028). The time to regaining active straight leg raising was significantly shorter in the non-CSD groupN than in the CSD group (P = 0.014). In addition, patients in the non-CSD group had a shorter length of hospital stay (P = 0.004) than those in the CSD group, indicating earlier recovery of knee function. HBL was significantly less in the CSD group than the non-CSD group (P = 0.006) on postoperative day (POD) 5. However, CBL did not differ significantly between the two groups on POD5. There were no significant differences between two groups in all other assessed variables. CONCLUSION In this randomized study, primary TKA without CSD was associated with faster recovery related to less local inflammation and better early knee function. Furthermore, use of a drain had no significant advantage with respect to other outcome measures and may have increased costs. Based on these data, CSD after primary TKA is not routinely indicated.
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Affiliation(s)
- Duan Wang
- Department of Orthopaedics, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Xu
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Wei-Nan Zeng
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Kai Zhou
- Department of Orthopaedics, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Tian-Hang Xie
- Department of Orthopaedics, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zhi Chen
- Department of Orthopaedics, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Hao-da Yu
- Department of Orthopaedics, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jin-Long Li
- Department of Orthopaedics, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zong-Ke Zhou
- Department of Orthopaedics, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Fu-Xing Pei
- Department of Orthopaedics, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
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414
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Tranexamic Acid (TXA) in Trauma Patients: Barriers to Use among Trauma Surgeons and Emergency Physicians. Emerg Med Int 2017; 2017:4235785. [PMID: 28316839 PMCID: PMC5338310 DOI: 10.1155/2017/4235785] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 12/01/2016] [Accepted: 01/22/2017] [Indexed: 01/11/2023] Open
Abstract
Objective. Tranexamic Acid (TXA) is currently the only drug with prospective clinical evidence supporting its use in bleeding trauma patients. We sought to better understand the barriers preventing its use and elicit suggestions to further its use in trauma patients in the state of Maryland. Methods. This is a cross-sectional study. Results. The overall response rate was 38%. Half of all participants reported being familiar with the CRASH-2 trial and MATTERs study. Half reported being aware of TXA as part of their institution's massive transfusion protocol. The majority of participants felt that TXA would have a significant positive impact on the survival of trauma patients. A majority also felt that the use of TXA would increase if its administration was the responsibility of both trauma surgeons and emergency physicians. Conclusion. Only half of responders reported being aware of TXA as being part of their institution's massive transfusion protocol. Lack of awareness of the clinical data supporting its use is a major barrier. However, most trauma providers and emergency physicians do have a favorable view of TXA and support its incorporation into massive transfusion protocols. We believe that more studies of this kind on both state and national level are needed.
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415
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Nishida T, Kinoshita T, Yamakawa K. Tranexamic acid and trauma-induced coagulopathy. J Intensive Care 2017; 5:5. [PMID: 28729903 PMCID: PMC5517948 DOI: 10.1186/s40560-016-0201-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/17/2016] [Indexed: 02/07/2023] Open
Abstract
Tranexamic acid (TXA) is a synthetic derivative of the amino acid lysine that inhibits fibrinolysis by blocking the interaction of plasminogen with the lysine residues of fibrin. Historically, TXA is commonly used for reduction of blood loss in perioperative situations, while recently it has attracted attention for clinical use in the trauma field. In 2010, the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage 2 (CRASH-2) trial demonstrated that intravenous administration of TXA improved mortality significantly in trauma patients with significant bleeding. After the launch of its sensational results, the main stream treatment protocol in trauma changed worldwide to include TXA administration. In this review, first we summarize the recent evidence or recommendations in the related guidelines concerning TXA. Also, we next tried to explore in detail not only the benefits but also the harm introduced by TXA in trauma patients, because the main adverse event results for TXA, such as vascular occlusive events in the CRASH-2 trial, are still being discussed in several papers. Thus, we briefly summarized the evidence for the safety of TXA administration by a systematic review method using observational studies. Consequently, the pooled relative risk for venous thromboembolisms was 1.61 (95% CI, 0.86–3.01), indicating a non-significant increase in the venous thromboembolism risk of TXA therapy. Regarding the basic mechanism, TXA potentially possesses the risk of venous thromboembolisms, so it should be used cautiously and selectively. Further investigation is needed to delineate the optimal targeted trauma patients to earn the maximum survival benefits with minimized risk of thrombotic complications.
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Affiliation(s)
- Takeshi Nishida
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558 Japan
| | - Takahiro Kinoshita
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558 Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558 Japan
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416
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Myles PS, Smith JA, Forbes A, Silbert B, Jayarajah M, Painter T, Cooper DJ, Marasco S, McNeil J, Bussières JS, McGuinness S, Byrne K, Chan MTV, Landoni G, Wallace S. Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery. N Engl J Med 2017; 376:136-148. [PMID: 27774838 DOI: 10.1056/nejmoa1606424] [Citation(s) in RCA: 398] [Impact Index Per Article: 56.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Tranexamic acid reduces the risk of bleeding among patients undergoing cardiac surgery, but it is unclear whether this leads to improved outcomes. Furthermore, there are concerns that tranexamic acid may have prothrombotic and proconvulsant effects. METHODS In a trial with a 2-by-2 factorial design, we randomly assigned patients who were scheduled to undergo coronary-artery surgery and were at risk for perioperative complications to receive aspirin or placebo and tranexamic acid or placebo. The results of the tranexamic acid comparison are reported here. The primary outcome was a composite of death and thrombotic complications (nonfatal myocardial infarction, stroke, pulmonary embolism, renal failure, or bowel infarction) within 30 days after surgery. RESULTS Of the 4662 patients who were enrolled and provided consent, 4631 underwent surgery and had available outcomes data; 2311 were assigned to the tranexamic acid group and 2320 to the placebo group. A primary outcome event occurred in 386 patients (16.7%) in the tranexamic acid group and in 420 patients (18.1%) in the placebo group (relative risk, 0.92; 95% confidence interval, 0.81 to 1.05; P=0.22). The total number of units of blood products that were transfused during hospitalization was 4331 in the tranexamic acid group and 7994 in the placebo group (P<0.001). Major hemorrhage or cardiac tamponade leading to reoperation occurred in 1.4% of the patients in the tranexamic acid group and in 2.8% of the patients in the placebo group (P=0.001), and seizures occurred in 0.7% and 0.1%, respectively (P=0.002 by Fisher's exact test). CONCLUSIONS Among patients undergoing coronary-artery surgery, tranexamic acid was associated with a lower risk of bleeding than was placebo, without a higher risk of death or thrombotic complications within 30 days after surgery. Tranexamic acid was associated with a higher risk of postoperative seizures. (Funded by the Australian National Health and Medical Research Council and others; ATACAS Australia New Zealand Clinical Trials Registry number, ACTRN12605000557639 .).
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Affiliation(s)
- Paul S Myles
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Julian A Smith
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Andrew Forbes
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Brendan Silbert
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Mohandas Jayarajah
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Thomas Painter
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - D James Cooper
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Silvana Marasco
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - John McNeil
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Jean S Bussières
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Shay McGuinness
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Kelly Byrne
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Matthew T V Chan
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Giovanni Landoni
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Sophie Wallace
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
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417
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Otero JJ, Detriche O, Mommaerts MY. Fast-track Orthognathic Surgery: An Evidence-based Review. Ann Maxillofac Surg 2017; 7:166-175. [PMID: 29264281 PMCID: PMC5717890 DOI: 10.4103/ams.ams_106_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The aim of this study was to establish a fast-track protocol for bimaxillary orthognathic surgery (OGS). Fast-track surgery (FTS) is a multidisciplinary approach where the pre-, intra-, and postoperative management is focusing maximally on a quick patient recovery and early discharge. To enable this, the patients' presurgical stress and postsurgical discomfort should be maximally reduced. Both referral patterns and expenses within the health-care system are positively influenced by FTS. University hospital-literature review through Medline, Embase, and the Cochrane Library (January 2000-July 2016) using the following words - "fast track, enhanced recovery, multimodal, and perioperative care" - to define a protocol evidence based for OGS, as well as evidenced-based medicine search of every term added to the protocol during the same period. The process has resulted in an OGS protocol that may improve the outcome of the patient through several nonoperative and operative measures such as preoperative patient education and intra/postoperative measures that should improve overall patient satisfaction, decrease morbidity such as postoperative nausea, headache, dizziness, pain, and intubation discomfort, and shorten hospital stay. A literature review allowed us to fine-tune a fast-track protocol for uncomplicated OGS that can be prospectively studied against currently applied ones.
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Affiliation(s)
- Joel Joshi Otero
- European Face Centre, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Olivier Detriche
- Department of Anesthesiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Maurice Yves Mommaerts
- European Face Centre, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
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418
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Seddighi A, Nikouei A, Seddighi AS, Zali A, Tabatabaei SM, Yourdkhani F, Naimian S, Razavian I. The role of tranexamic acid in prevention of hemorrhage in major spinal surgeries. Asian J Neurosurg 2017; 12:501-505. [PMID: 28761531 PMCID: PMC5532938 DOI: 10.4103/1793-5482.165791] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Blood loss that necessitates blood transfusion is one of the most frequent complications of major spinal surgeries. This study has been designed to evaluate the efficacy and safety of prophylactic tranexamic acid (TA) in decreasing perioperative blood loss. Materials and Methods: From January to August 2011, all the patients who needed major spinal surgeries and aged between 18 and 60-year-old were divided into two groups randomly, the experimental group received 10 mg/kg of TA 20 min after inducing the anesthesia as loading dose followed by 0.5 mg/kg/h until skin closure and the control group received equal amounts of normal saline as placebo. Intraoperative blood loss was recorded by estimating blood with the suction tube plus the number of bloody gasses. The amounts compared between the 2 groups and analyzed. Results: Forty patients were enrolled in this study in the first group intraoperative, the 1st and 2nd postoperative days, the mean blood loss were 574 ml, 80.5 ml, and 669.5 ml while in the second group were 797 ml, 124 ml, and 921.5 ml. Conclusion: TA seems to be safe and can be considered in spinal surgeries with significant excepted blood loss especially in female patients and instrumental procedures. We suggest further studies on TAs efficacy and safety in larger scales.
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Affiliation(s)
- Afsoun Seddighi
- Functional Neurosurgery Research Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Nikouei
- Functional Neurosurgery Research Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Saeid Seddighi
- Departement of Neurosurgery, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Zali
- Functional Neurosurgery Research Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Mahmood Tabatabaei
- Functional Neurosurgery Research Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Yourdkhani
- Functional Neurosurgery Research Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shoeib Naimian
- Functional Neurosurgery Research Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Iman Razavian
- Functional Neurosurgery Research Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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419
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Cochrane in CORR ®: Topical Application of Tranexamic Acid for the Reduction of Bleeding (Review). Clin Orthop Relat Res 2017; 475:21-26. [PMID: 27709420 PMCID: PMC5174059 DOI: 10.1007/s11999-016-5112-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 09/28/2016] [Indexed: 01/31/2023]
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420
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Williams B, McNeil J, Crabbe A, Tanaka KA. Practical Use of Thromboelastometry in the Management of Perioperative Coagulopathy and Bleeding. Transfus Med Rev 2017; 31:11-25. [DOI: 10.1016/j.tmrv.2016.08.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 08/23/2016] [Accepted: 08/23/2016] [Indexed: 12/23/2022]
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421
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Estcourt LJ, Birchall J, Allard S, Bassey SJ, Hersey P, Kerr JP, Mumford AD, Stanworth SJ, Tinegate H. Guidelines for the use of platelet transfusions. Br J Haematol 2016; 176:365-394. [DOI: 10.1111/bjh.14423] [Citation(s) in RCA: 266] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Lise J. Estcourt
- NHSBT and Radcliffe Department of Medicine; University of Oxford; Oxford UK
| | - Janet Birchall
- NHSBT and Department of Haematology; North Bristol NHS Trust; Bristol UK
| | - Shubha Allard
- NHSBT and Department of Haematology; Royal London Hospital; London UK
| | - Stephen J. Bassey
- Department of Haematology; Royal Cornwall Hospital Trust; Cornwall UK
| | - Peter Hersey
- Department of Critical Care Medicine & Anaesthesia; City Hospitals Sunderland NHS Foundation Trust; Sunderland UK
| | - Jonathan Paul Kerr
- Department of Haematology; Royal Devon & Exeter NHS Foundation Trust; Exeter UK
| | - Andrew D. Mumford
- School of Cellular and Molecular Medicine; University of Bristol; Bristol UK
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422
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Bansal A, Arora A. A double-blind, placebo-controlled randomized clinical trial to evaluate the efficacy of tranexamic acid in irrigant solution on blood loss during percutaneous nephrolithotomy: a pilot study from tertiary care center of North India. World J Urol 2016; 35:1233-1240. [PMID: 27995302 DOI: 10.1007/s00345-016-1980-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 11/29/2016] [Indexed: 01/22/2023] Open
Abstract
PURPOSE To evaluate the efficacy and safety of 0.1% tranexamic acid in irrigant fluid in reducing blood loss during PCNL. MATERIALS AND METHODS The study involved 400 patients who were planned for PCNL and were prospectively randomized into two equal groups. In tranexamic group, 0.1% tranexamic acid was given in irrigant fluid, while in placebo group, distilled water was added to irrigant fluid during surgery. Operative data were recorded which included fall in hemoglobin, total blood loss, operative time, irrigation fluid, length of stay in hospital, requirement of blood transfusion, complications related to PCNL and adverse events of tranexamic acid. RESULTS Baseline parameters were comparable between two groups. The fall in hemoglobin and total blood loss in the tranexamic group was significantly lower than placebo group (1.71 vs. 2.67 gm/dL, 154.55 vs. 212.61 mL, respectively, p < 0.0001). Operative time, amount of irrigation fluid used and hospital stay of tranexamic group were significantly less compared to placebo (p < 0.05). Complete stone clearance rate was 88% in tranexamic group versus 82% in placebo (p = 0.12). The blood transfusion requirement was significantly lower in the tranexamic group versus placebo (5 vs. 12.5%, p = 0.012), as was the complication rate (19 vs. 28%, p = 0.044). The requirement of angioembolization in the tranexamic group was significantly less as compared to placebo (0.5 vs. 4%, p = 0.03). No adverse events related to administration of tranexamic acid were noted. CONCLUSIONS 0.1% tranexamic acid in irrigant fluid is safe and significantly reduces perioperative blood loss and requirement of blood transfusion during percutaneous nephrolithotomy. It is associated with lower perioperative complication rates.
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Affiliation(s)
| | - Aditi Arora
- Janak Surgicare Centre, Patiala, Punjab, India
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423
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Shakur H, Fawole B, Kuti M, Olayemi O, Bello A, Ogunbode O, Kotila T, Aimakhu CO, Huque S, Gregg M, Roberts I. Effect of tranexamic acid on coagulation and fibrinolysis in women with postpartum haemorrhage (WOMAN-ETAC): protocol and statistical analysis plan for a randomized controlled trial. Wellcome Open Res 2016; 1:31. [PMID: 28317031 PMCID: PMC5351844 DOI: 10.12688/wellcomeopenres.10383.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Postpartum haemorrhage (PPH) is a leading cause of maternal death. Tranexamic acid has the potential to reduce bleeding and a large randomized controlled trial of its effect on maternal health outcomes in women with PPH (The WOMAN trial) is ongoing. We will examine the effect of tranexamic acid on fibrinolysis and coagulation in a subset of WOMAN trial participants. Methods: Adult women with clinically diagnosed primary PPH after vaginal or caesarean delivery are eligible for inclusion in the WOMAN trial. In a sub-group of trial participants, blood samples will be collected at baseline and 30 minutes after the first dose of tranexamic acid or matching placebo. Our primary objective is to evaluate the effect of tranexamic acid on fibrinolysis. Fibrinolysis will be assessed by measuring D-dimers and by rotational thromboelastometry (ROTEM). Secondary outcomes are international normalized ratio (INR), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen, haemoglobin and platelets. We aim to include about 180 women from the University College Hospital, Ibadan in Nigeria. Discussion: This sub-study of WOMAN trial participants should provide information on the mechanism of action of tranexamic acid in women with postpartum haemorrhage. We present the trial protocol and statistical analysis plan. The trial protocol was registered prior to the start of patient recruitment. The statistical analysis plan was completed before un-blinding. Trial registration: The trial was registered:
ClinicalTrials.gov, Identifier NCT00872469
https://clinicaltrials.gov/ct2/show/NCT00872469; ISRCTN registry, Identifier ISRCTN76912190
http://www.isrctn.com/ISRCTN76912190 (Registration date: 22/03/2012).
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Affiliation(s)
- Haleema Shakur
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Bukola Fawole
- Department of Obstetrics & Gynaecology National Institute of Maternal and Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Modupe Kuti
- Department of Chemical Pathology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Oladapo Olayemi
- Department of Obstetrics & Gynaecology National Institute of Maternal and Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Adenike Bello
- Department of Obstetrics & Gynaecology National Institute of Maternal and Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Olayinka Ogunbode
- Department of Obstetrics & Gynaecology National Institute of Maternal and Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Taiwo Kotila
- Department of Haematology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Chris O Aimakhu
- Department of Obstetrics & Gynaecology National Institute of Maternal and Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Sumaya Huque
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Meghann Gregg
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
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424
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Farrow LS, Smith TO, Ashcroft GP, Myint PK. A systematic review of tranexamic acid in hip fracture surgery. Br J Clin Pharmacol 2016; 82:1458-1470. [PMID: 27492116 PMCID: PMC5099561 DOI: 10.1111/bcp.13079] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 12/14/2022] Open
Abstract
AIM To systematically examine and quantify the efficacy and safety of tranexamic acid in hip fracture surgery. METHODS A systematic literature search was conducted using Medline, EMBASE, AMED, CiNAHL, and the Cochrane Central Registry of Controlled Trials. Two assessors independently screened search outputs for potentially relevant articles which met the eligibility criteria. The primary outcome measure was requirement of post-operative blood transfusion. Risk of bias assessment was performed using the Cochrane Collaboration's risk of bias tool for randomized controlled trials (RCTs) and the ROBINS-I tool for observational studies. Meta-analysis was performed to estimate risk ratio (RR), risk difference (RD) and mean difference (MD) values for dichotomous and continuous data outcomes, respectively. The interpretation of each outcome was made using the GRADE approach. RESULTS Of 102 studies identified, seven met the inclusion criteria including a total of 770 participants (TXA: 341; Control: 429). On meta-analysis, intravenous TXA resulted in a 46% risk reduction in blood transfusion requirement compared to a placebo/control group (RR: 0.54; 95% CI: 0.35-0.85; I2 : 78%; Inconsistency (χ2 ) P = <0.0001; n = 750). There was also a significantly higher post-operative haemoglobin for TXA versus placebo/control (MD: 0.81; 95% CI: 0.45-1.18; I2 : 46%; Inconsistency (χ2 ) P = 0.10; n = 638). There was no increased risk of thromboembolic events (RD: 0.01; 95% CI: -0.03, 0.05; I2 : 68%; Inconsistency (χ2 ) P = 0.007, n = 683). CONCLUSION There is moderate quality evidence that TXA reduces blood transfusion in hip fracture surgery, with low quality evidence suggesting no increased risk of thrombotic events. These findings are consistent with TXA use in other orthopaedic procedures.
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Affiliation(s)
- Luke S. Farrow
- Institute of Medical SciencesUniversity of AberdeenForesterhillAberdeenAB25 2ZDUK
| | - Toby O. Smith
- School of Health SciencesUniversity of East AngliaQueen's Building, Norwich Research ParkNorwichNR4 7TJUK
| | - George P. Ashcroft
- Institute of Medical SciencesUniversity of AberdeenForesterhillAberdeenAB25 2ZDUK
| | - Phyo K. Myint
- Epidemiology Group, Institute of Applied Health SciencesUniversity of AberdeenForesterhillAberdeenAB25 2ZDUK
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425
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Karanicolas PJ, Lin Y, Tarshis J, Law CHL, Coburn NG, Hallet J, Nascimento B, Pawliszyn J, McCluskey SA. Major liver resection, systemic fibrinolytic activity, and the impact of tranexamic acid. HPB (Oxford) 2016; 18:991-999. [PMID: 27765582 PMCID: PMC5144548 DOI: 10.1016/j.hpb.2016.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/19/2016] [Accepted: 06/21/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hyperfibrinolysis may occur due to systemic inflammation or hepatic injury that occurs during liver resection. Tranexamic acid (TXA) is an antifibrinolytic agent that decreases bleeding in various settings, but has not been well studied in patients undergoing liver resection. METHODS In this prospective, phase II trial, 18 patients undergoing major liver resection were sequentially assigned to one of three cohorts: (i) Control (no TXA); (ii) TXA Dose I - 1 g bolus followed by 1 g infusion over 8 h; (iii) TXA Dose II - 1 g bolus followed by 10 mg/kg/hr until the end of surgery. Serial blood samples were collected for thromboelastography (TEG), coagulation components and TXA concentration. RESULTS No abnormalities in hemostatic function were identified on TEG. PAP complex levels increased to peak at 1106 μg/L (normal 0-512 μg/L) following parenchymal transection, then decreased to baseline by the morning following surgery. TXA reached stable, therapeutic concentrations early in both dosing regimens. There were no differences between patients based on TXA. CONCLUSIONS There is no thromboelastographic evidence of hyperfibrinolysis in patients undergoing major liver resection. TXA does not influence the change in systemic fibrinolysis; it may reduce bleeding through a different mechanism of action. Registered with ClinicalTrials.gov: NCT01651182.
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Affiliation(s)
- Paul J Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Yulia Lin
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Calvin H L Law
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Natalie G Coburn
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Julie Hallet
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Barto Nascimento
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Janusz Pawliszyn
- Department of Chemistry, University of Waterloo, Waterloo, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
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426
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The Efficacy and Safety of Tranexamic Acid in Cranio-Maxillofacial and Plastic Surgery. J Craniofac Surg 2016; 27:374-9. [PMID: 26967076 DOI: 10.1097/scs.0000000000002250] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The antifibrinolytic drug tranexamic acid (TXA) is effective in reducing blood loss and transfusion requirements in other fields of elective surgery and its use is emerging in a number of plastic surgical subspecialties. This systematic review and meta-analysis evaluates the current evidence for the efficacy and safety of TXA in craniomaxillofacial, head and neck, breast, aesthetic, burns, and reconstructive microsurgery. We searched PubMed, EMBASE, Medline, The Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials for randomized controlled trials of TXA in plastic surgery. Studies were analyzed using standard methodology. A total of 7965 records were screened, of which 14 met the inclusion criteria. Seven were suitable for meta-analysis. In craniofacial surgery, TXA was associated with a mean reduction in blood loss of 18.2 mL/kg (P = 0.00001) and a mean reduction in blood transfusion of 8.7 mL/kg (P = 0.0001). In orthognathic surgery, TXA was associated with a mean reduction in blood loss of 156 mL (P = 0.001). Tranexamic acid may also have a role in reducing drainage output volumes in oncological breast excision and lymph node dissection of the neck. Level-1 evidence for efficacy in aesthetic surgery, burns, and reconstructive microsurgery is lacking. Although no reported complications were attributable to TXA, there remain no phase IV trials published. Level-1 evidence supports the use of TXA in craniofacial and orthognathic surgery. There exists an unmet need for studies in areas, including burns, aesthetic surgery, and reconstructive microsurgery. Phase IV trials in areas of proven efficacy are also required.
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427
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Logan JK, Pantle H. Role of topical tranexamic acid in the management of idiopathic anterior epistaxis in adult patients in the emergency department. Am J Health Syst Pharm 2016; 73:1755-1759. [DOI: 10.2146/ajhp150829] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Jill K. Logan
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | - Hardin Pantle
- Department of Emergency Medicine, Johns Hopkins University, Johns Hopkins Bayview Medical Center, Baltimore, MD
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428
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Hallstrom B, Singal B, Cowen ME, Roberts KC, Hughes RE. The Michigan Experience with Safety and Effectiveness of Tranexamic Acid Use in Hip and Knee Arthroplasty. J Bone Joint Surg Am 2016; 98:1646-1655. [PMID: 27707851 DOI: 10.2106/jbjs.15.01010] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion requirements in total hip and knee arthroplasty has been well established in small controlled clinical trials and meta-analyses. The purpose of the current study was to determine the risks and benefits of TXA use in routine orthopaedic surgical practice on the basis of data from a large, statewide arthroplasty registry. METHODS From April 18, 2013, to September 30, 2014, there were 23,236 primary total knee arthroplasty cases and 11,489 primary total hip arthroplasty cases completed and registered in the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI). We evaluated the association between TXA use and hemoglobin drop, transfusion, length of stay (LOS), venous thromboembolism (VTE), readmission, and cardiovascular events by fitting mixed-effects generalized linear and mixed-effects Cox models. We used inverse probability of treatment weighting to enhance causal inference. RESULTS For total hip arthroplasty, TXA use was associated with a smaller drop in hemoglobin (mean difference = -0.65 g/dL; 95% confidence interval [CI] = -0.60 to -0.71 g/dL), decreased odds of blood transfusion (odds ratio [OR] = 0.72; 95% CI = 0.60 to 0.86), and decreased readmissions (OR = 0.77; 95% CI = 0.64 to 0.93) compared with no TXA use. There was no effect on VTE (hazard ratio [HR] = 0.91; 95% CI = 0.62 to 1.33), LOS (incident rate ratio [IRR] = 1.00; 95% CI = 0.97 to 1.03), or cardiovascular events (OR = 0.85; 95% CI = 0.47 to 1.52). For total knee arthroplasty, TXA was associated with a smaller drop in hemoglobin (mean difference = -0.68 g/dL; 95% CI = -0.64 to -0.71 g/dL) and one-fourth the odds of blood transfusion (OR = 0.26; 95% CI = 0.21 to 0.31). There was an association with decreased risk of VTE within 90 days after surgery (HR = 0.56; 95% CI = 0.42 to 0.73), slightly decreased LOS (IRR = 0.93; 95% CI = 0.92 to 0.95), and no association with readmissions (OR = 0.90; 95% CI = 0.79 to 1.04) or cardiovascular events (OR = 1.12; 95% CI = 0.74 to 1.71). CONCLUSIONS In routine orthopaedic surgery practice, TXA use was associated with decreased blood loss and transfusion risk for both total knee and total hip arthroplasty, without evidence of increased risk of complications. TXA use was also associated with reduced risk of readmission among total hip arthroplasty patients and reduced risk of VTE among total knee arthroplasty patients, and did not have an adverse effect on cardiovascular complications in either group. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Brian Hallstrom
- Department of Orthopaedic Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Bonita Singal
- Department of Orthopaedic Surgery, MARCQI Coordinating Center, University of Michigan, Ann Arbor, Michigan
| | - Mark E Cowen
- Quality Institute, St. Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Karl C Roberts
- West Michigan Orthopaedics, GRMEP-MSU Orthopaedic Surgery Residency Program, Spectrum Health Hospitals, Grand Rapids, Michigan
| | - Richard E Hughes
- Department of Orthopaedic Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
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429
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Abildgaard JT, McLemore R, Hattrup SJ. Tranexamic acid decreases blood loss in total shoulder arthroplasty and reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2016; 25:1643-8. [PMID: 27106116 DOI: 10.1016/j.jse.2016.02.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/26/2016] [Accepted: 02/12/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Efficacy of tranexamic acid (TXA) remains unproven in the setting of shoulder arthroplasty. The purpose of this study was to determine the effects of TXA on perioperative blood loss and drain output in patients undergoing primary total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). METHODS We conducted a retrospective comparison of 77 TSAs and 94 RTSAs performed in 168 patients. TXA was administered intravenously in 35 TSA and 42 RTSA patients. Changes in hemoglobin (Hgb), hematocrit (Hct), drain output, and total blood loss were reviewed with univariate analysis and additional multivariate regression examining the cofactors of age, body mass index, American Society of Anesthesiologists status, and gender of each patient. RESULTS Use of TXA in TSA led to a significant decrease in total blood loss (679 mL vs. 910 mL; P < .001), change in Hgb (1.8 mg/dL vs. 2.6 mg/dL; P < .001), and drop in Hct (5.2 vs. 7.0; P < .001). Similarly, RTSA also had significantly less total blood loss with the use of TXA (791 mL vs. 959 mL; P < .001), change in Hgb (2.3 mg/dL vs. 2.9 mg/dL; P < .001), and change in Hct (6.4 vs. 8.3; P < .001). TXA also significantly decreased drain output in both TSA (99 mL vs. 235 mL; P < .001) and RTSA (180 mL vs. 370 mL; P < .001). CONCLUSIONS Use of TXA perioperatively among patients undergoing primary shoulder arthroplasty can decrease perioperative blood loss, change in Hgb and Hct, and postoperative drain output.
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Affiliation(s)
| | - Ryan McLemore
- Department of Health Science Research, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Steven J Hattrup
- Department of Orthopedics, Mayo Clinic Arizona, Phoenix, AZ, USA
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430
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Research Waste in Atopic Eczema Trials—Just the Tip of the Iceberg. J Invest Dermatol 2016; 136:1930-1933. [DOI: 10.1016/j.jid.2016.06.614] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 06/20/2016] [Indexed: 11/24/2022]
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431
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Morris S, Yudin MH, Callum J, Alam A, Herold J, Lin Y. Obstetrical transfusion medicine knowledge among faculty and trainee obstetricians: a prospective knowledge assessment study. Transfus Med 2016; 26:440-447. [DOI: 10.1111/tme.12360] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 08/31/2016] [Accepted: 09/01/2016] [Indexed: 11/28/2022]
Affiliation(s)
- S. Morris
- Department of Obstetrics and Gynecology; Health Sciences North; Sudbury Canada
| | - M. H. Yudin
- Department of Obstetrics and Gynecology; St. Michael's Hospital and University of Toronto; Toronto Canada
| | - J. Callum
- Department of Clinical Pathology; Sunnybrook Health Sciences Centre; Toronto Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto Canada
| | - A. Alam
- Department of Anesthesia; Sunnybrook Health Sciences Centre and University of Toronto; Toronto Canada
| | - J. Herold
- Department of Medicine; University of Toronto; Toronto Canada
| | - Y. Lin
- Department of Clinical Pathology; Sunnybrook Health Sciences Centre; Toronto Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto Canada
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432
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Desborough MJR, Smethurst PA, Estcourt LJ, Stanworth SJ. Alternatives to allogeneic platelet transfusion. Br J Haematol 2016; 175:381-392. [PMID: 27650431 DOI: 10.1111/bjh.14338] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Allogeneic platelet transfusions are widely used for the prevention and treatment of bleeding in thrombocytopenia. Recent evidence suggests platelet transfusions have limited efficacy and are associated with uncertain immunomodulatory risks and concerns about viral or bacterial transmission. Alternatives to transfusion are a well-recognised tenet of Patient Blood Management, but there has been less focus on different strategies to reduce bleeding risk by comparison to platelet transfusion. Direct alternatives to platelet transfusion include agents to stimulate endogenous platelet production (thrombopoietin mimetics), optimising platelet adhesion to endothelium by treating anaemia or increasing von Willebrand factor levels (desmopressin), increasing formation of cross-linked fibrinogen (activated recombinant factor VII, fibrinogen concentrate or recombinant factor XIII), decreasing fibrinolysis (tranexamic acid or epsilon aminocaproic acid) or using artificial or modified platelets (cryopreserved platelets, lyophilised platelets, haemostatic particles, liposomes, engineered nanoparticles or infusible platelet membranes). The evidence base to support the use of these alternatives is variable, but an area of active research. Much of the current randomised controlled trial focus is on evaluation of the use of thrombopoietin mimetics and anti-fibrinolytics. It is also recognised that one alternative strategy to platelet transfusion is choosing not to transfuse at all.
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Affiliation(s)
- Michael J R Desborough
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK. .,Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, UK.
| | | | - Lise J Estcourt
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK.,Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Simon J Stanworth
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK.,Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
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433
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Affiliation(s)
- Kang-Il Kim
- Department of Orthopaedic Surgery, Kyung Hee University School of Medicine, Seoul, Korea
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434
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Castro-Menéndez M, Pena-Paz S, Rocha-García F, Rodríguez-Casas N, Huici-Izco R, Montero-Viéites A. Efficacy of 2 grammes of intravenous transexamic acid in the reduction of post-surgical bleeding after total hip and knee replacement. Rev Esp Cir Ortop Traumatol (Engl Ed) 2016. [DOI: 10.1016/j.recote.2016.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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435
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Ker K, Shakur H, Roberts I. Does tranexamic acid prevent postpartum haemorrhage? A systematic review of randomised controlled trials. BJOG 2016; 123:1745-52. [DOI: 10.1111/1471-0528.14267] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2016] [Indexed: 11/26/2022]
Affiliation(s)
- K Ker
- Clinical Trials Unit; London School of Hygiene & Tropical Medicine; London UK
| | - H Shakur
- Clinical Trials Unit; London School of Hygiene & Tropical Medicine; London UK
| | - I Roberts
- Clinical Trials Unit; London School of Hygiene & Tropical Medicine; London UK
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436
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Nilsson CU, Strandberg K, Engström M, Reinstrup P. Coagulation during elective neurosurgery with hydroxyethyl starch fluid therapy: an observational study with thromboelastometry, fibrinogen and factor XIII. Perioper Med (Lond) 2016; 5:20. [PMID: 27540479 PMCID: PMC4989364 DOI: 10.1186/s13741-016-0046-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 07/26/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Several studies have described hypercoagulability in neurosurgery with craniotomy for brain tumor resection. In this study, hydroxyethyl starch (HES) 130/0.42 was used for hemodynamic stabilization and initial blood loss replacement. HES can induce coagulopathy with thromboelastographic signs of decreased clot strength. The aim of this study was to prospectively describe perioperative changes in coagulation during elective craniotomy for brain tumor resection with the present fluid regimen. METHODS Forty patients were included. Perioperative whole-blood samples were collected for EXTEM and FIBTEM assays on rotational thromboelastometry (ROTEM) and plasma fibrinogen analysis immediately before surgery, after 1 L of HES infusion, at the end of surgery and in the morning after surgery. Factor (F)XIII activity, thrombin-antithrombin complex (TAT) and plasmin-α2-antiplasmin complex (PAP) were analysed in the 25 patients receiving ≥1 L of HES. RESULTS Most patients (37 of 40) received HES infusion (0.5-2 L) during surgery. Preoperative ROTEM clot formation/structure, plasma fibrinogen and FXIII levels were generally within normal range but approached a hypocoagulant state during and at end of surgery. ROTEM variables and fibrinogen levels, but not FXIII, returned to baseline levels in the morning after surgery. Low perioperative fibrinogen levels were common. TAT levels were increased during and after surgery. PAP levels mostly remained within the reference ranges, not indicating excessive fibrinolysis. There were no differences in ROTEM results and fibrinogen levels in patients receiving <1 L HES and ≥1 L HES. CONCLUSIONS Only the increased TAT levels indicated an intra- and postoperative activation of coagulation. On the contrary, all other variables deteriorated towards hypocoagulation but were mainly normalized in the morning after surgery. Although this might be an effect of colloid-induced coagulopathy, we found no dose-dependent effect of HES. The unactivated fibrinolysis indicates that prophylactic use of tranexamic acid does not seem warranted under normal circumstances in elective neurosurgery. Individualized fluid therapy and coagulation factor substitution is of interest for future studies.
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Affiliation(s)
| | - Karin Strandberg
- Department of Laboratory Medicine, Skåne University Hospital Malmö, Lund University, Malmö, Sweden
| | - Martin Engström
- Department of Anaesthesia and Intensive Care, Lund University, Lund, Sweden
| | - Peter Reinstrup
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden
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437
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Mahla E, Tantry US, Gurbel PA. To stop or continue aspirin before aortocoronary bypass operations-do we have enough evidence to adequately guide us? J Thorac Dis 2016; 8:E578-80. [PMID: 27501008 DOI: 10.21037/jtd.2016.05.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Udaya S Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Paul A Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, USA
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438
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Bignami E, Cattaneo M, Crescenzi G, Ranucci M, Guarracino F, Cariello C, Baldassarri R, Isgrò G, Baryshnikova E, Fano G, Franco A, Gerli C, Crivellari M, Zangrillo A, Landoni G. Desmopressin after cardiac surgery in bleeding patients. A multicenter randomized trial. Acta Anaesthesiol Scand 2016; 60:892-900. [PMID: 27117753 DOI: 10.1111/aas.12740] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/05/2016] [Accepted: 04/06/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous studies showed that desmopressin decreases post-operative blood loss in patients undergoing cardiac surgery. These studies were small and never studied the effect of desmopressin in patients with active bleeding. Objective of the study was to determine whether desmopressin reduces red blood cells transfusion requirements in patients with active bleeding after cardiac surgery who had been pre-treated with tranexamic acid. METHODS This multicenter, randomized, double-blind, placebo-controlled, parallel-group study randomized elective patients with bleeding after cardiac surgery despite pre-treatment with tranexamic acid, to receive placebo (saline solution) or a single administration of desmopressin (0.3 μg/kg in saline solution). The primary endpoint was the number of patients requiring red blood cells transfusion after randomization and during hospital stay. Secondary end points were: blood loss from chest tubes during the first 24 h after study drug administration, hours of mechanical ventilation, intensive care unit stay, and in-hospital mortality. RESULTS The study was interrupted after inclusion of 67% of the planned patients for futility. The number of patients requiring red blood cells transfusion after randomization was 37/68 (54%) in desmopressin group and 33/67 (49%) in placebo group (P = 0.34) with no difference in blood loss: 575 (interquartile 422-770) ml in desmopressin group and 590 (476-1013) ml in placebo group (P = 0.42), mechanical ventilation, intensive care unit stay or mortality. CONCLUSIONS This multicenter randomized trial demonstrated that, in patients pre-treated with tranexamic acid, desmopressin should not be expected to improve treatment of patients who experience bleeding after cardiac surgery.
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Affiliation(s)
- E. Bignami
- Department of Anesthesia and Intensive Care; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - M. Cattaneo
- ASST Santi Paolo e Carlo; Dipartimento di Scienze della Salute; Università degli Studi di Milano
| | - G. Crescenzi
- Department of Anesthesia and Intensive Care; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - M. Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care; IRCCS Policlinico San Donato; Milan Italy
| | - F. Guarracino
- Department of Anesthesia and Intensive Care; University Hospital of Pisa; Pisa Italy
| | - C. Cariello
- Department of Anesthesia and Intensive Care; University Hospital of Pisa; Pisa Italy
| | - R. Baldassarri
- Department of Anesthesia and Intensive Care; University Hospital of Pisa; Pisa Italy
| | - G. Isgrò
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care; IRCCS Policlinico San Donato; Milan Italy
| | - E. Baryshnikova
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care; IRCCS Policlinico San Donato; Milan Italy
| | - G. Fano
- Department of Anesthesia and Intensive Care; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - A. Franco
- Department of Anesthesia and Intensive Care; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - C. Gerli
- Department of Anesthesia and Intensive Care; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - M. Crivellari
- Department of Anesthesia and Intensive Care; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - A. Zangrillo
- Department of Anesthesia and Intensive Care; IRCCS San Raffaele Scientific Institute; Milan Italy
- Vita-Salute San Raffaele University; Milan Italy
| | - G. Landoni
- Department of Anesthesia and Intensive Care; IRCCS San Raffaele Scientific Institute; Milan Italy
- Vita-Salute San Raffaele University; Milan Italy
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439
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Godier A, Parmar K, Manandhar K, Hunt BJ. An in vitro study of the effects of t-PA and tranexamic acid on whole blood coagulation and fibrinolysis. J Clin Pathol 2016; 70:154-161. [PMID: 27445340 DOI: 10.1136/jclinpath-2016-203854] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 06/23/2016] [Accepted: 06/27/2016] [Indexed: 11/03/2022]
Abstract
AIMS Acute traumatic coagulopathy is characterised by fibrinolysis and low fibrinogen. It is unclear how much fibrinogenolysis contributes to reduce fibrinogen levels. The study aim was to: investigate in vitro the effects of tissue-plasminogen activator (t-PA) and tranexamic acid (TXA) on coagulation and fibrinolysis. METHODS Whole blood was spiked with varying t-PA concentrations. Clauss fibrinogen levels and thrombelastography (TEG, Haemonetics) were performed, including functional fibrinogen level (FLEV). TXA effects were assessed using four TXA concentrations. Recorded parameters from kaolin activated TEG included maximal amplitude (MA), clot strength (G), percentage lysis (LY). Plasmin-antiplasmin complex (PAP), endogenous thrombin potential (ETP), prothrombin fragment 1+2 (PF1+2), factor V and factor VIII levels were all measured. RESULTS t-PA induced fibrinolysis: it increased PAP and LY, but decreased MA and G. t-PA induced fibrinogenolysis, with a concentration-dependant decrease in fibrinogen from 2.7 (2.6-3.1) to 0.8 (0.8-0.9) g/L with 60 nM t-PA. FLEV and fibrinogen levels were well correlated. High t-PA doses increased PF1+2, decreased ETP of 19% and FVIII of 63% but not FV. TXA had no effect on plasmin generation as evidenced by no change in PAP. It corrected LY, MA and G and partly protected fibrinogen against fibrinogenolysis: 0.03 mg/mL TXA reduced the fibrinogen fall induced by t-PA 20 nM from 43% to 14%. TXA halved the FVIII fall and increased ETP. CONCLUSIONS t-PA induced plasminogen activation and fibrinogenolysis in a concentration-dependant manner. TXA did not affect plasmin activation but reduced fibrinogenolysis. These results suggest that TXA given early in bleeding patients may prevent fibrinogenolysis.
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Affiliation(s)
- Anne Godier
- Department of Anesthesia and Critical Care, Fondation Ophtalmologique Rothschild, Paris, France.,Faculté de Pharmacie, INSERM UMR-S1140, Université Paris Descartes, Paris, France.,Department of Thrombosis and Vascular Biology, Rayne Institute, London, UK
| | - Kiran Parmar
- Department of Thrombosis and Vascular Biology, Rayne Institute, London, UK
| | - Karuna Manandhar
- Department of Thrombosis and Vascular Biology, Rayne Institute, London, UK
| | - Beverley J Hunt
- Department of Thrombosis and Vascular Biology, Rayne Institute, London, UK.,Thrombosis and Haemostasis Centre, Guy's and St Thomas's NHS Foundation Trusts, and King's College, London, UK
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440
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Topsoee MF, Bergholt T, Ravn P, Schouenborg L, Moeller C, Ottesen B, Settnes A. Anti-hemorrhagic effect of prophylactic tranexamic acid in benign hysterectomy-a double-blinded randomized placebo-controlled trial. Am J Obstet Gynecol 2016; 215:72.e1-8. [PMID: 26829509 DOI: 10.1016/j.ajog.2016.01.184] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 12/15/2015] [Accepted: 01/22/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Hysterectomy is one of the most frequently performed major gynecological surgical procedures. Even when the indication for the procedure is benign, relatively high complication rates have been reported. Perioperative bleeding seems to represent the most common cause of complications and in 2004, 8% of all women in Denmark undergoing benign hysterectomy experienced a bleeding complication. Tranexamic acid is an antifibrinolytic agent that has shown to effectively reduce bleeding complications within other surgical and medical areas. However, knowledge about the drug's effect in relation to benign hysterectomy is still missing. OBJECTIVE To investigate the antihemorrhagic effect of prophylactic tranexamic acid in elective benign hysterectomy. STUDY DESIGN A double-blinded randomized placebo-controlled trial was conducted at 4 gynecological departments in Denmark from April 2013 to October 2014. A total of 332 women undergoing benign abdominal, laparoscopic, or vaginal hysterectomy were included in the trial, randomized to either 1 g of intravenous tranexamic acid or placebo at start of surgery. Chi-square test and Student t test statistical analyses were applied. RESULTS The primary outcome of intraoperative total blood loss was reduced in the group treated with tranexamic acid compared to the placebo group when estimated both subjectively by the surgeon and objectively by weight (98.4 mL vs 134.8 mL, P = .006 and 100.0 mL vs 166.0 mL, P = .004). The incidence of blood loss ≥500 mL was also significantly reduced (6 vs 21, P = .003), as well as the use of open-label tranexamic acid (7 vs 18, P = .024). Furthermore, the risk of reoperations owing to postoperative hemorrhage was significantly reduced in the tranexamic acid group compared to the placebo group (2 vs 9, P = .034). This corresponds to an absolute risk reduction of 4.2% and number needed to treat of 24. No incidence of thromboembolic events or death was observed in any of the groups. CONCLUSION The results support the hypothesis that prophylactic treatment with tranexamic acid reduces the overall total blood loss, the incidence of substantial blood loss, and the need for reoperations owing to postoperative hemorrhage in relation to benign hysterectomy. No incidences of serious adverse events occurred. Thus, tranexamic acid should be considered as a prophylactic treatment prior to elective benign hysterectomy.
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441
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Abstract
Postpartum Haemorrhage (PPH) is a major cause of maternal morbidity and mortality. Treatment of acquired coagulopathy observed in severe PPH is an important part of PPH management, but is mainly based on literature in trauma patients, and data thus should be interpreted with caution. This review describes recent advances in transfusion strategy and in the use of tranexamic acid and fibrinogen concentrates in women with PPH.
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Affiliation(s)
- Marie Pierre Bonnet
- Department of Anaesthesia and Intensive Care Medicine, Paris Descartes University, Paris, France
| | - Dan Benhamou
- Department of Anaesthesia and Intensive Care Medicine, Paris Sud University, Paris, France
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442
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Cleland S, Corredor C, Ye JJ, Srinivas C, McCluskey SA. Massive haemorrhage in liver transplantation: Consequences, prediction and management. World J Transplant 2016; 6:291-305. [PMID: 27358774 PMCID: PMC4919733 DOI: 10.5500/wjt.v6.i2.291] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 03/16/2016] [Accepted: 04/11/2016] [Indexed: 02/05/2023] Open
Abstract
From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity (need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both pro- and anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shown improvements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back technique and avoiding veno-veno bypass has been shown to reduced blood loss.
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443
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Castro-Menéndez M, Pena-Paz S, Rocha-García F, Rodríguez-Casas N, Huici-Izco R, Montero-Viéites A. Efficacy of 2 grammes of intravenous transexamic acid in the reduction of post-surgical bleeding after total hip and knee replacement. Rev Esp Cir Ortop Traumatol (Engl Ed) 2016; 60:315-24. [PMID: 27342383 DOI: 10.1016/j.recot.2016.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 02/23/2016] [Accepted: 05/05/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There is currently sufficient clinical evidence to recommend tranexamic acid (TXA) for reducing post-operative blood loss in total knee and hip arthroplasty, however, its optimal dose and administration regimes are unknown. OBJECTIVE Analyse effectiveness and safety of TXA in total hip and knee arthroplasty using 2 grammes (g) intravenously in two different regimes. MATERIAL AND METHODS A prospective randomised intervention study was conducted on a total of 240 patients. The patients were divided into 3 groups: 1) control; 2) 1g of TXA intraoperative, followed by another postoperative; and 3): 2g preoperative. Each group consisted of 40 patients undergoing total knee arthroplasty, and 40 total hip arthroplasty. Postoperative blood loss, transfusion rate, and thromboembolic complications were studied. RESULTS There were significant differences (p<.005) when comparing mean total blood loss and transfusion between group 1 and 2, and between group 1 and 3, but not between the two TXA groups (2 and 3). The authors only recorded one complication in group 1 (deep vein thrombosis). DISCUSION This study was not performed to investigate the already well established effectiveness of TXA, but to confirm if 2 empirical intravenous g is safe, and what is most beneficial regimen. In conclusion, according to the literature, both proven patterns of 2g intravenous of TXA are effective in reducing blood loss and transfusion requirements, without increasing the complication rate.
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Affiliation(s)
- M Castro-Menéndez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital de Monforte de Lemos, Lugo, España.
| | - S Pena-Paz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Lucus Augusta, Lugo, España
| | - F Rocha-García
- Servicio de Anestesia y Reanimación, Hospital de Monforte de Lemos, Lugo, España
| | - N Rodríguez-Casas
- Servicio de Cirugía Ortopédica y Traumatología, Hospital de Monforte de Lemos, Lugo, España
| | - R Huici-Izco
- Servicio de Cirugía Ortopédica y Traumatología, Hospital de Monforte de Lemos, Lugo, España
| | - A Montero-Viéites
- Servicio de Cirugía Ortopédica y Traumatología, Hospital de Monforte de Lemos, Lugo, España
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444
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Segrelles Calvo G, De Granda-Orive I, López Padilla D. Inhaled Tranexamic Acid as an Alternative for Hemoptysis Treatment. Chest 2016; 149:604. [PMID: 26867844 DOI: 10.1016/j.chest.2015.10.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 10/17/2015] [Accepted: 10/20/2015] [Indexed: 10/22/2022] Open
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445
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Abstract
Half of all patients with acute venous thromboembolism are aged over 70 years; they then face the added hazard of an age-related increase in the incidence of major bleeding. This makes it even more important to weigh the balance of benefit and risk when considering anticoagulant treatment and treatment duration. Traditional treatment with a heparin (usually low molecular weight) followed by a vitamin K antagonist such as warfarin is effective but is often complicated, especially in the elderly. The direct-acting oral anticoagulants (DOACs), i.e. the thrombin inhibitor dabigatran and the factor Xa inhibitors rivaroxaban, apixaban and edoxaban, are given in fixed doses, do not need laboratory monitoring, have fewer drug-drug interactions and are therefore much easier to take. Randomised trials, their meta-analyses and 'real-world' data indicate the DOACs are no less effective than warfarin (are non-inferior) and probably cause less major bleeding (especially intracranial). It seems the relative safety of DOACs extends to age above 65 or 70 years, although bleeding becomes more likely regardless of the chosen anticoagulant. Renal impairment, comorbidities (especially cancer) and interventions are special hazards. Ways to minimise bleeding include patient selection and follow-up, education about venous thromboembolism, anticoagulants, drug interactions, regular checks on adherence and avoiding needlessly prolonged treatment. The relatively short circulating half-lives of DOACs mean that time, local measures and supportive care are the main response to major bleeding. They also simplify the management of invasive interventions. An antidote for dabigatran, idarucizumab, was recently approved by regulators, and a general antidote for factor Xa inhibitors is in advanced development.
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Affiliation(s)
- Jir Ping Boey
- Department of Haematology, SA Pathology, Flinders Medical Centre, Flinders Dr, Bedford Park, SA, 5042, Australia
| | - Alexander Gallus
- Department of Haematology, SA Pathology, Flinders Medical Centre, Flinders Dr, Bedford Park, SA, 5042, Australia.
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446
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Iorio-Morin C, Blanchard J, Richer M, Mathieu D. Tranexamic Acid in Chronic Subdural Hematomas (TRACS): study protocol for a randomized controlled trial. Trials 2016; 17:235. [PMID: 27150916 PMCID: PMC4857422 DOI: 10.1186/s13063-016-1358-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 04/13/2016] [Indexed: 01/20/2023] Open
Abstract
Background Chronic subdural hematoma (CSDH) is one of the most frequent reason for cranial neurosurgical consultation. There is no widely accepted medical treatment for this condition. Herein, we present the protocol for the Tranexamic Acid (TXA) in Chronic Subdural Hematomas (TRACS) trial aiming at determining whether TXA can increase the rate of CSDH resolution following conservative management, lower the number of required surgical procedures and decrease the rate of CSDH recurrence following surgical evacuation. Methods TRACS is a multicenter, double-blind, randomized, parallel-design, placebo-controlled, phase IIB study designed to provide preliminary efficacy data as well as feasibility, safety and incidence data required to plan a larger definitive phase III trial. Consecutive patients presenting with a diagnosis of chronic subdural hematoma will be screened for eligibility. Exclusion criteria include: specific risk factors for thromboembolic disease, anticoagulant use or contraindication to TXA. A total of 130 patients will be randomized to receive either 750 mg of TXA daily or placebo until complete radiological resolution of the CSDH or for a maximum of 20 weeks. CSDH volume will be measured on serial computed tomography (CT) scanning. Cognitive function tests, quality of life questionnaires as well as functional autonomy assessments will be performed at enrollment, at 10 weeks following randomization and at 3 months following treatment cessation. During the treatment period, patients will undergo standard CSDH management with surgery being performed at the discretion of the treating physician. If surgery is performed, the CSDH and its outer membrane will be sampled for in vitro analysis. The primary outcome is the rate of CSDH resolution by 20 weeks without intervening unplanned surgical procedure. Secondary outcomes include: CSDH volume, incidence of surgical evacuation procedures, CSDH recurrence, cognitive functions, functional autonomy, quality of life, incidence of complications and length of hospital stay. Planned subgroup analyses will be performed for conservatively versus surgically managed subjects and highly versus poorly vascularized CSDH. Discussion CSDH is a frequent morbidity for which an effective medical treatment has yet to be discovered. The TRACS trial will be the first prospective study of TXA for CSDH. Trial registration NCT ID: NCT02568124. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1358-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Iorio-Morin
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke, 3001, 12e avenue Nord, Sherbrooke, QC, J1H 5N4, Canada.
| | - Jocelyn Blanchard
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke, 3001, 12e avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Maxime Richer
- Department of Pathology, Centre Hospitalier Universitaire de Sherbrooke, 3001, 12e avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - David Mathieu
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke, 3001, 12e avenue Nord, Sherbrooke, QC, J1H 5N4, Canada.,Centre de recherche du CHUS, Sherbrooke, QC, Canada
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447
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Jawa RS, Singer A, Mccormack JE, Huang EC, Rutigliano DN, Vosswinkel JA. Tranexamic Acid Use in United States Trauma Centers: A National Survey. Am Surg 2016. [DOI: 10.1177/000313481608200520] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic agent that is listed as an essential medication by the World Health Organization for traumatic hemorrhage. We determined United States–based surgeons’ familiarity with TXA and their use of TXA. An online survey was sent to the 1291 attending surgeon members of a national trauma organization. The survey was organized into three general parts: respondent demographics, perceptions of TXA, and experience with TXA. The survey was completed by 35 per cent of members. TXA was available at 89.1 per cent of centers. Experience with TXA was variable: 38.0 per cent use regularly, 24.9 per cent use it 1 to 2 times per year, 12.3 per cent use it rarely, and 24.7 per cent had never used it. Among surgeons who had used TXA, 77.1 per cent noted that TXA had reduced bleeding, but 22.9 per cent indicated that it had not. Reasons for not routinely using TXA included uncertain clinical benefit (47.7%) and unfamiliarity (31.5%). Finally, 90.5 per cent of respondents indicated that are looking toward national organizations to develop practice guidelines. TXA is widely available in civilian United States trauma centers. Although a majority of surveyed surgeons had used TXA, only 38 per cent use TXA regularly for significant traumatic hemorrhage; principal reasons for this are uncertainty regarding clinical benefit and unfamiliarity with the drug. National guidelines are sought.
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Affiliation(s)
- Randeep S. Jawa
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine and Stony Brook University Medical Center, Stony Brook, New York
| | - Adam Singer
- Department of Emergency Medicine, Stony Brook University School of Medicine, Stony Brook, New York
| | - Jane E. Mccormack
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine and Stony Brook University Medical Center, Stony Brook, New York
| | - Emily C. Huang
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine and Stony Brook University Medical Center, Stony Brook, New York
| | - Daniel N. Rutigliano
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine and Stony Brook University Medical Center, Stony Brook, New York
| | - James A. Vosswinkel
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine and Stony Brook University Medical Center, Stony Brook, New York
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448
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Winter SF, Santaguida C, Wong J, Fehlings MG. Systemic and Topical Use of Tranexamic Acid in Spinal Surgery: A Systematic Review. Global Spine J 2016; 6:284-95. [PMID: 27099820 PMCID: PMC4836933 DOI: 10.1055/s-0035-1563609] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 07/13/2015] [Indexed: 01/17/2023] Open
Abstract
Study Design Combination of narrative and systematic literature reviews. Objectives Massive perioperative blood loss in complex spinal surgery often requires blood transfusions and can negatively affect patient outcome. Systemic use of the antifibrinolytic agent tranexamic acid (TXA) has become widely used in the management of surgical bleeding. We review the clinical evidence for the use of intravenous TXA as a hemostatic agent in spinal surgery and discuss the emerging role for its complementary use as a topical agent to reduce perioperative blood loss from the surgical site. Through a systematic review of published and ongoing investigations on topical TXA for spinal surgery, we wish to make spine practitioners aware of this option and to suggest opportunities for further investigation in the field. Methods A narrative review of systemic TXA in spinal surgery and topical TXA in surgery was conducted. Furthermore, a systematic search (using PRISMA guidelines) of PubMed (MEDLINE), EMBASE, and Cochrane CENTRAL databases as well as World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov (National Institutes of Health), and International Standard Randomized Controlled Trial Number registries was conducted to identify both published literature and ongoing clinical trials on topical TXA in spinal surgery. Results Of 1,631 preliminary search results, 2 published studies were included in the systematic review. Out of 285 ongoing clinical trials matching the search criteria, a total of 4 relevant studies were included and reviewed. Conclusion Intravenous TXA is established as an efficacious hemostatic agent in spinal surgery. Use of topical TXA in surgery suggests similar hemostatic efficacy and potentially improved safety as compared with intravenous TXA. For spinal surgery, the literature on topical TXA is sparse but promising, warranting further clinical investigation and consideration as a clinical option in cases with significant anticipated surgical site blood loss.
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Affiliation(s)
| | - Carlo Santaguida
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Jean Wong
- Department of Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada,Krembil Neuroscience Centre, University Health Network, Toronto, Ontario, Canada,Address for correspondence Michael G. Fehlings, MD Suite 4W449, Toronto Western Hospital399 Bathurst Street, Toronto M5T 2S8, OntarioCanada
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449
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Efficacy of tranexamic acid in reducing allogeneic blood products in adolescent idiopathic scoliosis surgery. BMC Musculoskelet Disord 2016; 17:187. [PMID: 27117696 PMCID: PMC4847368 DOI: 10.1186/s12891-016-1006-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 04/01/2016] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Adolescent idiopathic scoliosis (AIS) surgery usually require prolonged operative times with extensive soft tissue dissection and significant perioperative blood loss, and allogeneic blood products are frequently needed. Methods to reduce the requirement for transfusion would have a beneficial effect on these patients. Although many previous studies have revealed the efficacy of tranexamic acid (TXA) in spinal surgery, there is still a lack of agreement concerning the reduction of both blood loss and transfusion requirements of large dose tranexamic acid (TXA) in surgery for adolescent idiopathic scoliosis (AIS). The objective of this study was to elevate the efficacy and safety of a large dose tranexamic acid (TXA) in reducing transfusion requirements of allogeneic blood products in adolescent idiopathic scoliosis (AIS) surgery using a retrospective study designed with historical control group. METHODS One hundred thirty seven consecutive AIS patients who underwent surgery treatment with posterior spinal pedicle systems from August 2011 to March 2015 in our scoliosis center were retrospectively reviewed. Patients were divided into two groups, the TXA group and the historical recruited no TXA group (NTXA). Preoperative demographics, radiographic parameters, operative parameters, estimated blood loss (EBL), total irrigation fluid, number of patients requiring blood transfusion, mean drop of Hb (Pre-op Hb-Post-op Hb), haematocrit pre and post-surgery, mean volume of blood transfusion, hospitalization time, and adverse effect were recorded and compared. RESULTS All the patients were successfully treated with satisfied clinical and radiographic outcomes. There were 71 patients in the TXA group and 66 patients in the NTXA group. The preoperative demographics were homogeneity between two groups (P > 0.05). There were no significant difference in average operative time between two groups (209 min vs 215 min, p >0.05). Number of patients in the TXA group showed a significant decrease in transfusion requirements with an associated reduced intraoperative blood loss of nearly 45% compared with those in NTXA group (8 vs 37, 619 ml vs 1125 ml, P < 0.05). There were no significant difference in total irrigation fluid between two groups (540 vs 550, p >0.05). Additional, patients in NTXA group showed significant decrease of Hb compared with patients in TXA group (5.2 g/dL vs 3.3 g/dL, P < 0.05), No significant difference were found in hospitalization time between two groups (6.3 vs 7.2 days, P > 0.05). No minor adverse effects associated with use of TXA were noted. CONCLUSIONS Use of large dose tranexamic acid routinely seems to be effective and safe in reducing allogenic blood transfusion and blood loss in adolescent idiopathic scoliosis surgery.
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Roberts I. Fibrinolytic shutdown: fascinating theory but randomized controlled trial data are needed. Transfusion 2016; 56 Suppl 2:S115-8. [DOI: 10.1111/trf.13490] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/05/2015] [Accepted: 11/05/2015] [Indexed: 02/05/2023]
Affiliation(s)
- Ian Roberts
- Clinical Trials Unit; London School of Hygiene & Tropical Medicine; London UK
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