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Alghamdi AS, Hazzazi GS, Shaheen MH, Bosaeed KM, Kutubkhana RH, Alharbi RA, Abu-Zaid A, Felemban RA. Nebulized tranexamic acid for treatment of post-tonsillectomy bleeding: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08995-1. [PMID: 39356357 DOI: 10.1007/s00405-024-08995-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 09/14/2024] [Indexed: 10/03/2024]
Abstract
PURPOSE Post-tonsillectomy bleeding (PTB) is a significant complication and common reason for emergency department (ED) visits. Limited literature has investigated the clinical efficacy of nebulized tranexamic acid (TXA) for treating PTB; however, the results were conflicting and not comprehensively summarized. This study aimed to provide the first-ever systematic review encompassing all literature exploring the efficacy and safety of nebulized TXA in treating PTB. METHODS We screened six databases until 01-July-2024, for relevant studies and assessed their quality using validated tools. We provided a qualitative summary of baseline characteristics and clinical data. The primary endpoint was the reoperation rate to manage PTB, and its effect size was aggregated as a proportion or risk ratio (RR) with a 95% confidence interval (CI) using a random-effects model. RESULTS We analyzed nine studies (2 case reports, 4 case series, and 3 retrospective comparative studies), all of which demonstrated good quality and low risk-of-bias. In studies using nebulized TXA for treating PTB (n = 9 studies), the pooled proportion of reoperation to control bleeding was 0.27 (95% CI: 0.08-0.5). The rate of reoperation to control bleeding was significantly lower in the nebulized TXA arm compared to the no-TXA arm (n = 3 studies, RR = 0.55, 95% CI [0.39-0.77], p < 0.001). CONCLUSION Nebulized TXA is safe and promising for treating PTB. This is evidenced by its high efficacy in achieving hemostasis in acute settings during ED visits and reducing the rate of reoperations needed to control PTB. Further high-quality investigations are warranted to corroborate these findings.
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Affiliation(s)
- Abdullah S Alghamdi
- Department of Otorhinolaryngology, Head and Neck Surgery, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia.
| | - Ghaydaa S Hazzazi
- Department of Otorhinolaryngology, Head and Neck Surgery, Hera General Hospital, Makkah, Saudi Arabia
| | - Mohammad H Shaheen
- Department of Otorhinolaryngology, Head and Neck Surgery, Hera General Hospital, Makkah, Saudi Arabia
| | - Khlood M Bosaeed
- Department of Otorhinolaryngology, Head and Neck Surgery, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Rahmah H Kutubkhana
- Department of Otorhinolaryngology, Head and Neck Surgery, Hera General Hospital, Makkah, Saudi Arabia
| | - Ruba A Alharbi
- Department of Otorhinolaryngology, Head and Neck Surgery, Hera General Hospital, Makkah, Saudi Arabia
| | - Ahmed Abu-Zaid
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Roaa A Felemban
- Department of Otorhinolaryngology, Head and Neck Surgery, Hera General Hospital, Makkah, Saudi Arabia
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Nam JS, Oh CS, Kim JY, Choi DK, Oh AR, Park J, Lee JH, Yun SC, Kim KW, Jang MU, Kim TY, Choi IC. A multi-center, double-blind, placebo-controlled, randomized, parallel-group, non-inferiority study to compare the efficacy of goal-directed tranexamic acid administration based on viscoelastic test versus preemptive tranexamic acid administration on postoperative bleeding in cardiovascular surgery (GDT trial). Trials 2024; 25:623. [PMID: 39334224 PMCID: PMC11429631 DOI: 10.1186/s13063-024-08467-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 09/16/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Tranexamic acid (TXA) effectively attenuates hyperfibrinolysis and preemptive administration has been employed to reduce bleeding and blood transfusions in various surgical settings. However, TXA administration could be associated with adverse effects, such as seizures and thromboembolic risks. While patients with fibrinolysis shutdown showed greater thromboembolic complications and mortality, TXA administration may aggravate the degree of shutdown in these patients. Selective TXA administration based on the results of rotational thromboelastometry (ROTEM) would be non-inferior to preemptive TXA administration in reducing postoperative bleeding and beneficial in reducing its risks in patients undergoing cardiovascular surgery. METHODS This non-inferiority, randomized, double-blind, placebo-controlled, multicenter trial will be performed in 3 tertiary university hospitals from August 2023 to March 2025. Seven hundred sixty-four patients undergoing cardiovascular surgery will be randomly allocated to get TXA as a preemptive (Group-P) or goal-directed strategy (Group-GDT) in each institution (with a 1:1 allocation ratio). After anesthesia induction, TXA (10 mg/kg and 2 mg/kg/h) and a placebo are administered after anesthesia induction in Group-P and Group-GDT, respectively. ROTEM tests are performed immediately before weaning from CPB and at the considerable bleeding post-CPB period. After getting the test results, a placebo is administered in Group-P (regardless of the test results). In Group-GDT, placebo or TXA is administered according to the results: placebo is administered if the amplitude at 10 min (A10-EXTEM) is ≥ 40 mm and lysis within 60 min (LI60-EXTEM) of EXTEM assay is ≥ 85%, or TXA (20 mg/kg) is administered if A10-EXTEM is < 40 mm or LI60-EXTEM is < 85%. The primary outcome is inter-group comparisons of postoperative bleeding (for 24 h). The secondary measures include comparisons of perioperative blood transfusion, coagulation profiles, reoperation, thromboembolic complications, seizures, in-hospital mortality, fibrinolysis phenotypes, and hospital costs. DISCUSSION The absence of inter-group differences in postoperative bleeding would support the selective strategy's non-inferiority in reducing postoperative bleeding in these patients. The possible reduction in thromboembolic risks, seizures, and fibrinolysis shutdown in Group-GDT would support its superiority in reducing TXA-induced adverse events and the cost of their management. TRIAL REGISTRATION This trial was registered at ClinicalTrials.gov with the registration number NCT05806346 on March 28, 2023. TRIAL STATUS recruiting. Issue date: 2023 March 28 (by Tae-Yop Kim, MD, PhD). The trial was registered in the clinical registration on March 28, 2023 (ClinicalTrials.gov, NCT05806346) and revised to the latest version of its protocol (version no. 8, August 26, 2024) approved by the institutional review boards (IRBs) of all 3 university hospitals (Konkuk University Medical Center, 2023-07-005-001, Asan Medical Center, 2023-0248, and Samsung Medical Center, SMC 2023-06-048-002). Its recruitment was started on August 1, 2023, and will be completed on December 31, 2024. Protocol amendment number: 08 (protocol version 08, August 26, 2024). Revision chronology: 2023 March 28:Original. 2023 April 10:Amendment No 01. The primary reason for the amendment is the modification of Arms (adding one arm for sub-group analyses) and Interventions, Outcome Measures, Study Design, Study Description, Study Status, Eligibility, and Study Identification. 2023 May 03:Amendment No 02. The primary reason for the amendment is to modify the Outcome Measures and update the study status. 2023 July 06:Amendment No 03. The primary reason for amendment is to update the chronological study status. 2023 July 07:Amendment No 04. The primary reason for the amendment is the modification of study information (the treatment category was changed to diagnostic, and Phase 4 was changed to not applicable) and a chronological update on the study status. 2023 September 12:Amendment No 06. The primary reason for the amendment is a chronological update in the study status and the inclusion of additional information regarding contacts/locations and oversight. 2023 December 29:Amendment No 07. The primary reason for the amendment is to modify the outcome measures (including detailed information on outcome measures, addition of extra secondary measures, and chronological updates in study status). 2024 August 26:Amendment No 08. The primary reason for the amendment is to add detailed descriptions regarding data handling and the names and roles of the participating institutions and to update the chronological process of the trial.
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Affiliation(s)
- Jae-Sik Nam
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chung-Sik Oh
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, and Institution for Patient-Centered Goal-Directed Strategy, Chungju, Republic of Korea
- Institution for Patient-Centered Goal-Directed Strategy, Konkuk University, Chungju, Republic of Korea
| | - Ji-Yoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dae-Kee Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung-Cheol Yun
- Department of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyeng Whan Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Min Uk Jang
- Cheorwon Public Health Center, Cheorwon-Gun, Gangwon-Do, Republic of Korea
| | - Tae-Yop Kim
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, and Institution for Patient-Centered Goal-Directed Strategy, Chungju, Republic of Korea.
- Institution for Patient-Centered Goal-Directed Strategy, Konkuk University, Chungju, Republic of Korea.
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Hannigan A, Bumbak P, Brennan-Jones CG, Hintze J. The use of tranexamic acid in paediatric adenotonsillectomy - A systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol 2024; 186:112110. [PMID: 39341021 DOI: 10.1016/j.ijporl.2024.112110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Revised: 09/06/2024] [Accepted: 09/12/2024] [Indexed: 09/30/2024]
Abstract
BACKGROUND Tonsillectomy and adenoidectomy (AT) are two of the most commonly performed ENT procedures in children, with over 500,000 cases performed annually in the United States. Whilst generally considered a safe and well-tolerated operation, it is not without its risks and complications including pain, nausea, anorexia and most importantly bleeding and post-tonsillectomy haemorrhage (PTH). Whilst tranexamic acid (TXA) has a proven benefit in reducing bleeding and transfusion requirements in patients undergoing trauma, spinal and cardiac surgery; the effectiveness, timing and safety of its application in paediatric tonsillectomy has not yet been established. AIMS, OBJECTIVES & SIGNIFICANCE To date, there has been no published systematic review of the literature specifically looking at paediatric patients undergoing AT, despite a massive surge in popularity of the use of TXA perioperatively. The aim of this study is therefore to systematically review the current literature and collate evidence regarding the efficacy and safety of using TXA to reduce bleeding in children undergoing tonsillectomy and/or adenoidectomy. METHODS A structured search of bibliographic databases (MEDLINE, EMBASE, PubMed, CINAHL, Cochrane CENTRAL) was undertaken to retrieve randomised controlled trials, non-randomised case-control studies and ongoing clinical trials that describe the use of TXA in paediatric patients undergoing AT. The following search terms (and their variations) were used as both medical subject headings (MeSH terms) and text words: tranexamic acid, bleeding, tonsillectomy, adenoidectomy, paediatrics. To ensure that all relevant data was captured, the search did not contain any restrictions on language or publication time. Data extraction and risk of bias assessment was performed independently and in duplicate. RESULTS This review identified and included a total of eight studies (n = 1315). Five studies reported on the intravenous use of TXA (n = 531) whilst three studies reported on the topical use of TXA (n = 784), and these were analysed separately. The intravenous use of TXA did not reduce intraoperative blood loss significantly (95 % CI: -0.1 to 0.33 p = 0.28) and there was not enough information to analyse the effect on PTH in these studies. Topical TXA led to a significant reduction in both intraoperative blood loss (95 % CI 0.11 to 5.31, p = 0.04) and post operative bleeding rates (RR 0.04, 95 % CI 0.01 to 0.08, P = 0.02). CONCLUSION The results of this systematic review and meta-analysis suggest that TXA administered via the intravenous route does not reduce perioperative bleeding associated with AT in paediatric patients. However, when topical TXA is used intraoperatively at the surgical site in paediatric patients undergoing adenoidectomy alone, there was a significant reduction in both intraoperative blood loss and post operative bleeding. TXA appears to be a safe and well-tolerated drug in the paediatric population with no adverse effects reported in this review. Nevertheless, further large and well-designed randomised controlled trials are needed to investigate the risks and benefits of TXA in paediatric AT with a particular focus on its use topically and in association with newly developed surgical equipment.
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Affiliation(s)
- Amy Hannigan
- Department of Otolaryngology, Perth Children's Hospital, Perth, Western Australia, Australia.
| | - Paul Bumbak
- Department of Otolaryngology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Christopher G Brennan-Jones
- Department of Otolaryngology, Perth Children's Hospital, Perth, Western Australia, Australia; Telethon Kids Institute, The University of Western Australia, Australia; Faculty of Health Sciences, Curtin University, Western Australia, Australia
| | - Justin Hintze
- Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, USA
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Park JH, Siddiqui N, Hrebec WK, Szymanski TJ, Uribe-Marquez S, Miletic KG, Krishnan S. Management of Anticoagulation and Antifibrinolytics in Catastrophic Antiphospholipid Syndrome. Semin Cardiothorac Vasc Anesth 2024; 28:181-187. [PMID: 38705843 DOI: 10.1177/10892532241249782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder that presents with hypercoagulability and results in a lab artifact of prolonged PTT. The most severe form is catastrophic antiphospholipid antibody syndrome (CAPS), which manifests as rapidly progressing thromboses in multiple organ systems leading to multi-organ ischemia. The mainstay management CAPS is anticoagulation and systemic corticosteroids. Antifibrinolytic agents have previously been thought to be relatively contraindicated in CAPS due to the pro-thrombotic nature of the disease; the complex coagulation profile of CAPS can make it difficult to assess the risks and benefits of antifibrinolytic therapy. Also, should a patient with CAPS require cardiopulmonary bypass (CPB) for surgery, it poses a unique challenge in providing appropriate anticoagulation in the setting of prolonged ACT. We present a case of a 32-year-old postpartum female with CAPS requiring heart transplant who safely received intraoperative antifibrinolytic therapy and was successfully anticoagulated during CPB after perioperative plasmapheresis.
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Affiliation(s)
- Jee Ha Park
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Nazia Siddiqui
- Department of Anesthesiology, Trinity Health Oakland Hospital, Pontiac, MI, USA
- Department of Anesthesiology, Henry Ford Hospital, Detroit, MI, USA
| | - William K Hrebec
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA
| | | | | | - Kyle G Miletic
- Department of Cardiothoracic Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Sandeep Krishnan
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Anesthesiology, Trinity Health Oakland Hospital, Pontiac, MI, USA
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Hooson E, Hargreaves F, Holdsworth E, Longwell S, Pullinger A, Gill A. Anti-fibrinolytics for mucosal bleeding in adults with life-limiting illnesses: a systematic review. BMJ Support Palliat Care 2024:spcare-2024-005042. [PMID: 39214676 DOI: 10.1136/spcare-2024-005042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 07/31/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Patients with life-limiting illnesses are at increased risk of mucosal bleeding. Usual management includes anticipatory planning and sedation, alongside anti-fibrinolytics, despite a lack of evidence for their use. Anti-fibrinolytic agents (tranexamic acid and aminocaproic acid) produce effective haemostasis in different clinical settings. Our aim was to synthesise the evidence for anti-fibrinolytic medication use in adult patients with life-limiting illnesses at risk of, or experiencing, mucosal bleeding. METHODS We searched MEDLINE, Embase, CINAHL, Web of Science Conference Proceedings Citation Index, Cochrane Library databases and clinical trial registries (inception to January 2024) to identify studies investigating the use of anti-fibrinolytics in patients with life-limiting illnesses. Results were screened against a priori inclusion criteria, data ere extracted, and quality was appraised using a CASP (Critical Appraisal Skills Programme) checklist or BMJ risk of bias assessment. Data were analysed using narrative synthesis. RESULTS Five studies meeting our search criteria (one cohort and four case series) were included. Data relating from 87 patients were used in narrative synthesis. Anti-fibrinolytic therapy was used for active mucosal bleeding in 37 patients, of whom 30 achieved total bleeding cessation. Fifty patients received prophylactic anti-fibrinolytics, of whom 32 experienced no bleeding events. Adverse events were reported in 3 of 87 patients (arterial thrombus, severe thrombocytopenia and stomach cramps). Mortality and quality of life were not reported. CONCLUSION Anti-fibrinolytics are generally well tolerated within this population and may prevent and reduce mucosal bleeding. Further high-quality research is suggested to investigate current practice and to compare anti-fibrinolytic with placebo in the management of bleeding in patients with life-limiting illnesses. PROSPERO REGISTRATION NUMBER CRD42022325529.
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Affiliation(s)
- Emma Hooson
- Palliative Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Fiona Hargreaves
- Palliative Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Emily Holdsworth
- Palliative Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sarah Longwell
- Palliative Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alice Pullinger
- Palliative Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andrew Gill
- Sue Ryder Manorlands Hospice, Oxenhope, West Yorkshire, UK
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Bouras M, Bourdiol A, Rooze P, Hourmant Y, Caillard A, Roquilly A. Tranexamic acid: a narrative review of its current role in perioperative medicine and acute medical bleeding. Front Med (Lausanne) 2024; 11:1416998. [PMID: 39170034 PMCID: PMC11335516 DOI: 10.3389/fmed.2024.1416998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 07/31/2024] [Indexed: 08/23/2024] Open
Abstract
Purpose Tranexamic acid (TXA) is the most widely prescribed antifibrinolytic for active bleeding or to prevent surgical bleeding. Despite numerous large multi-center randomized trials involving thousands of patients being conducted, TXA remains underutilized in indications where it has demonstrated efficacy and a lack of harmful effects. This narrative review aims to provide basic concepts about fibrinolysis and TXA's mode of action and is focused on the most recent and important trials evaluating this drug in different hemorrhagic situations. Methods We selected every low bias RCT, and we highlighted their strengths and limitations throughout this review. Principal findings While TXA appears to have a favorable benefit-risk ratio in most situations (trauma, obstetrics, at-risk for bleeding surgeries) evidence of benefit is lacking in certain medical settings (SAH, digestive bleeding). Conclusion Although in some situations the drug's effect on significant outcomes is modest, its favorable safety profile allows it to be recommended for trauma patients, in obstetrics, and in scheduled surgeries at risk of bleeding. However, it cannot be recommended in cases of spontaneous intracranial bleeding, subarachnoid hemorrhage (SAH), or gastrointestinal bleeding.
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Affiliation(s)
- Marwan Bouras
- CHU Brest, Anesthesiology and Intensive Care Unit, Brest, France
- INSERM UMR 1064 CR2TI, University of Nantes, Nantes, France
| | - Alexandre Bourdiol
- CHU Nantes, Anesthesiology and Intensive Care Unit, CIC Immunology and Infection, Nantes, France
| | - Paul Rooze
- CHU Nantes, Anesthesiology and Intensive Care Unit, CIC Immunology and Infection, Nantes, France
| | - Yannick Hourmant
- CHU Nantes, Anesthesiology and Intensive Care Unit, CIC Immunology and Infection, Nantes, France
| | - Anaïs Caillard
- CHU Brest, Anesthesiology and Intensive Care Unit, Brest, France
| | - Antoine Roquilly
- INSERM UMR 1064 CR2TI, University of Nantes, Nantes, France
- CHU Nantes, Anesthesiology and Intensive Care Unit, CIC Immunology and Infection, Nantes, France
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Mergoum AM, Mergoum AS, Larson NJ, Dries DJ, Cook A, Blondeau B, Rogers FB. Tranexamic Acid Use in the Surgical Arena: A Narrative Review. J Surg Res 2024; 302:208-221. [PMID: 39106732 DOI: 10.1016/j.jss.2024.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/02/2024] [Accepted: 07/07/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION Tranexamic acid (TXA) is a potent antifibrinolytic drug that inhibits the activation of plasmin by plasminogen. While not a new medication, TXA has quickly gained traction across a variety of surgical subspecialties to prevent and treat bleeding. Knowledge on the use of this drug is essential for the modern surgeon to continue to provide excellent care to their patients. METHODS A comprehensive review of the PubMed database was conducted of articles published within the last 10 y (2014-2024) relating to TXA and its use in various surgical subspecialties. Seminal studies regarding the use of TXA older than 10 y were included from the author's archives. RESULTS Indications for TXA are not limited to trauma alone, and TXA is utilized across a variety of surgical subspecialties from neurosurgery to hepatic surgery to control hemorrhage. Overall, TXA is well tolerated with common dose-dependent adverse effects, including headache, nasal symptoms, dizziness, nausea, diarrhea, and fatigue. More severe adverse events are rare and easily mitigated by not exceeding a dose of 50 mg/kg. CONCLUSIONS The administration of TXA as an adjunct to treat trauma saves lives. The ability of TXA to induce seizures is dose dependent with identifiable risk factors, making this serious adverse effect predictable. As for the potential for TXA to cause thrombotic events, uncertainty remains. If this association is proven to be real, the risk will likely be small, since the use of TXA is still advantageous in most situations because of its efficacy for a more common concern, bleeding.
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Affiliation(s)
| | - Adel S Mergoum
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | - Alan Cook
- Department of Surgery, University of Texas at Tyler School of Medicine, Tyler, Texas
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
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Cazes N, Corcostegui SP, Lovi S, Romary E, Desrobert V, Lidzborski L, Derkenne C. Should soldiers take oral tranexamic acid before going into battle? J Trauma Acute Care Surg 2024; 97:S24-S26. [PMID: 38595230 DOI: 10.1097/ta.0000000000004343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
ABSTRACT Tranexamic acid is an inexpensive antifibrinolytic treatment that reduces morbidity and mortality in civilian and military trauma patients. It must be administered within 3 hours of the injury, and its efficacy is greater the earlier it is given. It is already used preventively in the civilian environment in a number of indications to reduce bleeding and bleeding-related mortality. We wondered about the potential benefits of preventive oral administration of tranexamic acid prior to an assault for military personnel with a potential risk of injury.
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Affiliation(s)
- Nicolas Cazes
- From the Emergency Department (N.C.), Laveran Army Teaching Hospital, Marseille; Paris Fire Brigade (S.-P.C.); and French Military Health System (S.L., E.R., V.D., L.L., C.D.), Paris, France
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Sundler Björkman L, Pirouzifard M, Grover SP, Egesten A, Sundquist J, Sundquist K, Zöller B. Increased risk of venous thromboembolism in young and middle-aged individuals with hereditary angioedema: a family study. Blood 2024; 144:435-444. [PMID: 38767511 DOI: 10.1182/blood.2023022996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/23/2024] [Accepted: 04/10/2024] [Indexed: 05/22/2024] Open
Abstract
ABSTRACT Hereditary angioedema (HAE), caused by C1 inhibitor protein deficiency, was recently shown to be associated with an increased risk for venous thromboembolism (VTE). To our knowledge, this is the first national family study of HAE, which aimed to determine the familial risk of VTE. The Swedish Multi-Generation Register was linked to the Swedish National Patient Register for the period of 1964 to 2018. Only patients with HAE with a validated diagnosis were included in the study and were linked to their family members. Hazard ratios (HRs) and 95% confidence intervals (CIs) for VTE were calculated for patients with HAE in comparison with relatives without HAE. Among 2006 individuals (from 276 pedigrees of 365 patients with HAE), 103 individuals were affected by VTE. In total, 35 (9.6%) patients with HAE were affected by VTE, whereas 68 (4.1%) non-HAE relatives were affected (P < .001). The adjusted HR for VTE among patients with HAE was 2.51 (95% CI, 1.67-3.77). Patients with HAE were younger at the first VTE than their non-HAE relatives (mean age, 51 years vs 63 years; P < .001). Before the age of 70 years, the HR for VTE among patients with HAE was 3.62 (95% CI, 2.26-5.80). The HR for VTE for patients with HAE born after 1964 was 8.29 (95% CI, 2.90-23.71). The HR for VTE for patients with HAE who were born in 1964 or earlier was 1.82 (95% CI, 1.14-2.91). HAE is associated with VTE among young and middle-aged individuals in Swedish families with HAE. The effect size of the association is in the order of other thrombophilias. We suggest that HAE may be considered a new rare thrombophilia.
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Affiliation(s)
- Linda Sundler Björkman
- Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
- Division of Hematology, Department of Medicine, UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - MirNabi Pirouzifard
- Department of Clinical Sciences Malmö, Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Steven P Grover
- Division of Hematology, Department of Medicine, UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Arne Egesten
- Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - Jan Sundquist
- Department of Clinical Sciences Malmö, Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Kristina Sundquist
- Department of Clinical Sciences Malmö, Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Bengt Zöller
- Department of Clinical Sciences Malmö, Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
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Girardello C, Carron PN, Dami F, Darioli V, Pasquier M, Ageron FX. Evaluation of the prehospital administration of tranexamic acid for injured patients: a state-wide observational study with sex and age-disaggregated analysis. Emerg Med J 2024; 41:452-458. [PMID: 38876768 PMCID: PMC11287560 DOI: 10.1136/emermed-2023-213806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 04/28/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Tranexamic acid (TXA) decreases mortality in injured patients and should be administered as soon as possible. Despite international guidelines recommending TXA in the prehospital setting, its use remains low. The aim of this study was to assess the prehospital administration of TXA for injured patients in a Swiss region. METHODS We conducted a retrospective observational study in Switzerland between 2018 and 2021. Inclusion criteria were injured patients ≥18 years for whom an ambulance or helicopter was dispatched. The exclusion criterion was minor injury defined by a National Advisory Committee for Aeronautics score <3. The primary outcome was the proportion of patients treated with TXA according to guidelines. The European guidelines were represented by the risk of death from bleeding (calculated retrospectively using the Bleeding Audit for Trauma and Triage (BATT) score). Factors impacting the likelihood of receiving TXA were assessed by multivariate analysis. RESULTS Of 13 944 patients included in the study, 2401 (17.2%) were considered at risk of death from bleeding. Among these, 257 (11%) received prehospital TXA. This represented 38% of those meeting US guidelines. For European guidelines, the treatment rate increased with the risk of death from bleeding: 6% (95% CI 4.4% to 7.0%) for low risk (BATT score 3-4); 13% (95% CI 11.1% to 15.9%) for intermediate risk (BATT score 5-7); and 21% (95% CI 17.6% to 25.6%) for high risk (BATT score ≥8) (p<0.01). Women and the elderly were treated less often than men and younger patients, irrespective of the risk of death from bleeding and the mechanism of injury. CONCLUSION The proportion of injured patients receiving TXA in the prehospital setting of the State of Vaud in Switzerland was low, with even lower rates for women and older patients. The reasons for this undertreatment are probably multifactorial and would require specific studies to clarify and correct them.
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Affiliation(s)
- Camille Girardello
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
- University of Lausanne, Lausanne, Switzerland
| | - Pierre-Nicolas Carron
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
- University of Lausanne, Lausanne, Switzerland
| | - Fabrice Dami
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Vincent Darioli
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
- University of Lausanne, Lausanne, Switzerland
| | - François-Xavier Ageron
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
- University of Lausanne, Lausanne, Switzerland
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11
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Whitley J, Miran SA, Ma P, Saade G, Roberts I, Ahmadzia HK. When Are Pregnant Patients Receiving Tranexamic Acid during Delivery Hospitalization in the United States? Am J Perinatol 2024. [PMID: 38925162 DOI: 10.1055/a-2353-0832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
OBJECTIVE The World Health Organization recommends tranexamic acid (TXA) in the management of postpartum hemorrhage (PPH). However, the role of TXA in PPH prevention and the optimal timing of TXA administration remain unknown. Our objective was to describe the timing of TXA administration, differences in timing of TXA administration by mode of delivery, and current trends in TXA administration in the United States. STUDY DESIGN We conducted a descriptive study of trends in TXA administration using the Cerner Real-World Database. We identified 1,544,712 deliveries occurring at greater than 24 weeks' gestation from January 1, 2016, to February 21, 2023. Demographic data were collected including gestational age, mode of delivery, and comorbidities. The timing of TXA administration and differences in TXA timing by mode of delivery were also collected. RESULTS In our cohort, 21,433 patients (1.39%) received TXA. The majority of patients who received TXA were between ages 25 and 34 years old (55.3%), White (60.7%), and delivered between 37 and 416/7 weeks (81.4%). The TXA group had a higher prevalence of medical comorbidities including obesity (32.9 vs. 19.0%, p < 0.00001), preeclampsia (19.6 vs. 6.81%, p < 0.00001), and pregestational diabetes (3.27 vs. 1.36%, p < 0.00001). Among women who received TXA, 15.4% received it within 3 hours before delivery. Among patients who received TXA after delivery, 23.6% received TXA within 3 hours after delivery, whereas 35.7% received TXA between 10 and 24 hours after delivery. A total of 80.4% of patients who received TXA before delivery had a cesarean delivery. CONCLUSION While TXA is most commonly administered after delivery, many patients are receiving TXA prior to delivery in the United States without clear evidence to guide the timing of administration. A randomized trial is urgently needed to determine the safety and efficacy of TXA when administered prior to delivery. KEY POINTS · TXA is used in the treatment of PPH.. · The role of TXA in prevention of PPH is unclear.. · Fewer than 2% of patients in the United States receive TXA at delivery.. · TXA administration before delivery in the United States is rising..
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Affiliation(s)
- Julia Whitley
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Seyedeh A Miran
- Department of Clinical Research and Leadership, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Phillip Ma
- Department of Clinical Research and Leadership, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - George Saade
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Health System, Falls Church, Virginia
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12
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Sharpe EE, Rose CH, Tweet MS. Obstetric anesthesia considerations in pregnancy-associated myocardial infarction: a focused review. Int J Obstet Anesth 2024:104233. [PMID: 39227292 DOI: 10.1016/j.ijoa.2024.104233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 07/12/2024] [Accepted: 07/14/2024] [Indexed: 09/05/2024]
Abstract
Pregnancy-associated myocardial infarction (PAMI) is a rare but serious complication that can occur either during pregnancy or postpartum. The etiologies of PAMI are atherosclerosis, spontaneous coronary artery dissection, coronary thrombosis, coronary embolism, and coronary vasospasm. Therapy of acute PAMI depends largely on the ECG presentation, hemodynamic stability, and suspected etiology of myocardial infarction. Anesthetic management during delivery in patients with PAMI should consist of early and carefully titrated neuraxial analgesia and anesthesia, maintenance of normal sinus rhythm, preservation of afterload, and monitoring for and avoiding myocardial ischemia. To improve the care of women with PAMI, a multidisciplinary team of cardiologists, maternal fetal medicine specialists, obstetric providers, neonatologists, and anesthesiologists must work collectively to manage these complex patients.
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Affiliation(s)
- E E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1st Street S.W., Rochester, MN, United States.
| | - C H Rose
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mayo Clinic, 200 1st Street S.W., Rochester, MN, United States
| | - M S Tweet
- Department of Cardiovascular Medicine, Mayo Clinic, 200 1st Street S.W., Rochester, MN, United States
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13
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Zhang Y, Han L, Ding W, Gao L, Feng Y, An H. Intravenous tranexamic acid significantly improved visualization and shortened the operation time in microscopic middle ear surgery: a randomized controlled trial. Int J Surg 2024; 110:4170-4175. [PMID: 38518079 PMCID: PMC11254254 DOI: 10.1097/js9.0000000000001366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/10/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND The microscopic middle ear surgery involves a limited operating space and numerous important anatomical structures in which good visualization is crucial, as even a small amount of bleeding can greatly affect the clarity of surgical field. This study aims to investigate whether intravenous 1 g of tranexamic acid can improve surgical visualization and further shorten the operation time in microscopic middle ear surgery. METHODS This study is a prospective, randomized, double-blind, controlled trial conducted from December 2021 to December 2022, enrolling patients who were scheduled for microscopic modified radical mastoidectomy due to chronic otitis media. In addition to standard techniques to optimize the surgical field, participants were randomized into the TXA (tranexamic acid) group (1 g diluted to 20 ml normal saline) and the control group (20 ml normal saline). The primary outcome was assessed based on the clarity of the surgical field using the Modena Bleeding Score. Secondary outcomes included operation time, the surgeon satisfaction with the visual clarity, postoperative 24 h coagulation parameters, and the incidence of adverse events. Student's t -test, χ2 test, and ANOVA of repeated measures were used for statistical analyses. RESULTS A total of 28 patients were enrolled in each group using a 1:1 randomized allocation with similar demographic characteristics, including 24 male and 32 female individuals, and the mean age is 45.6±11.9 years. The surgical visualization in the TXA group was significantly better than that of the control group (2.29±0.46 vs. 2.89±0.31, P <0.001) as assessed by the Modena Bleeding Score. Furthermore, the TXA group demonstrated a shorter operation time compared to the control group (88.61±10.9 vs. 105.2±15.9, P <0.001) and higher surgeon satisfaction with surgical field (7.82±0.55 vs. 6.50±0.64, P <0.001). No statistically significant differences were found in postoperative coagulation parameters in the two groups. No TXA-related adverse events or complications occurred during the 12-month follow-up. CONCLUSION Intravenous 1 g of TXA can further significantly improve the visual clarity in the microscopic middle ear surgery and shorten the operation time based on other standard measures implemented.
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Affiliation(s)
- Yunpeng Zhang
- Department of Anesthesiology, People’s Hospital, Peking University
| | - Lin Han
- Department of Otorhinolaryngology, Head and Neck Surgery, People’s Hospital, Peking University, Beijing, People’s Republic of China
| | - Weisi Ding
- Department of Anesthesiology, People’s Hospital, Peking University
| | - Lan Gao
- Department of Anesthesiology, People’s Hospital, Peking University
| | - Yi Feng
- Department of Anesthesiology, People’s Hospital, Peking University
| | - Haiyan An
- Department of Anesthesiology, People’s Hospital, Peking University
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14
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Samuelson Bannow BT. Management of abnormal uterine bleeding on anticoagulation: the patient-clinician perspective. J Thromb Haemost 2024; 22:1819-1825. [PMID: 38642705 PMCID: PMC11214879 DOI: 10.1016/j.jtha.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/21/2024] [Accepted: 04/04/2024] [Indexed: 04/22/2024]
Abstract
Bleeding is a well-recognized side effect of anticoagulant therapy, which is used to treat venous thromboembolism (VTE) in individuals of all ages, including those of female sex, who commonly experience VTE as a complication of hormonal therapies and/or pregnancy. Heavy menstrual bleeding (HMB) is also extremely common in reproductive-aged individuals of female sex. Despite these overlapping situations, relatively little attention has been paid to the impact of anticoagulant-associated HMB on treatment strategies and the patient experience. In this review, we summarize incidence and complications of HMB in anticoagulated individuals as well as management strategies for HMB in this population. We also address the patient experience, including the impact of HMB on quality of life and the impact of discontinuing hormonal therapies at the time of VTE diagnosis and anticoagulant initiation. We conclude by highlighting specific gaps related to the patient experience of anticoagulant-associated HMB in both the research and clinical settings.
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Affiliation(s)
- Bethany T Samuelson Bannow
- The Hemostasis and Thrombosis Center at Oregon Health & Science University, Portland, Oregon, USA; Division of Hematology & Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA.
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15
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Sawant S, Deshpande SV, Wamborikar H, Jadawala VH, Suneja A, Goel S, Patel V. The Impact of Tranexamic Acid on Blood Loss Management in Primary Total Knee Arthroplasty: A Comprehensive Review. Cureus 2024; 16:e65386. [PMID: 39184800 PMCID: PMC11344607 DOI: 10.7759/cureus.65386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Accepted: 07/25/2024] [Indexed: 08/27/2024] Open
Abstract
Total knee arthroplasty (TKA) is a widely performed surgical procedure to restore function and relieve pain in patients with advanced knee arthritis. One of the key challenges in TKA is managing perioperative blood loss, which can lead to complications such as postoperative anemia and the need for blood transfusions. Tranexamic acid (TXA), an antifibrinolytic agent, has shown promising results in reducing blood loss and transfusion requirements in various surgical settings, including TKA. This comprehensive review synthesizes current evidence regarding the efficacy and safety profile of TXA in primary TKA. Mechanistically, TXA functions by inhibiting the breakdown of fibrin clots, promoting hemostasis, and minimizing blood loss. Clinical studies evaluating TXA in TKA have consistently demonstrated significant reductions in blood loss parameters, including total blood loss, postoperative drain output, and transfusion rates. Key findings highlight the efficacy of TXA across different dosing regimens and administration routes, with minimal associated risks of thromboembolic events or adverse effects. Comparative analyses with other blood conservation strategies underscore TXA's superiority in reducing transfusion requirements and its cost-effectiveness in clinical practice. The review also discusses current clinical guidelines and recommendations for TXA use in TKA, emphasizing optimal dosing strategies and patient selection criteria. Future research directions include exploring the long-term outcomes of TXA administration and its impact on functional recovery, and refining protocols to enhance its efficacy and safety further. In conclusion, TXA represents a valuable adjunct in blood loss management during primary TKA, offering substantial benefits in patient outcomes, healthcare resource utilization, and cost-effectiveness. Continued research efforts are warranted to optimize its use and expand its applicability in orthopedic surgery.
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Affiliation(s)
- Sharad Sawant
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sanjay V Deshpande
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Hitendra Wamborikar
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vivek H Jadawala
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Anmol Suneja
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sachin Goel
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vatsal Patel
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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16
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Roberts I, Murphy MF, Moonesinghe R, Grocott MPW, Kalumbi C, Sayers R, Toh CH. Wider use of tranexamic acid to reduce surgical bleeding could benefit patients and health systems. BMJ 2024; 385:e079444. [PMID: 38866414 PMCID: PMC11170764 DOI: 10.1136/bmj-2024-079444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Affiliation(s)
- Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael F Murphy
- NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Ramani Moonesinghe
- NHS England, London, UK
- Centre for Perioperative Medicine, University College London, London, UK
| | - Michael P W Grocott
- Royal College of Anaesthetists, London, UK
- Southampton Biomedical Research Centre, University of Southampton, Southampton, UK
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17
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Sanusi TD, Momin S, Sachdev B, Leung A. Super-elderly, spinal surgery, evaluating the risks and benefits: a retrospective single-centre cohort study. Acta Neurochir (Wien) 2024; 166:248. [PMID: 38833175 DOI: 10.1007/s00701-024-06135-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/22/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION An increasingly ageing population presents emerging healthcare challenges. Adequate clinical evaluation and understanding of outcome-predicting factors are integral to delivering safe spinal surgery to super-elderly patients. AIM To evaluate spine surgery outcomes in patients aged 80 or above. METHODS We retrospectively evaluated patients 80 years and above who underwent elective or emergency spinal surgery between 2017 and 2022. The Eurospine Surgery Classification (ESC) was used to classify operations into Large, Medium, and Small. We calculated and compared Clinical Frailty Scores (CFS) pre- and post-operatively. RESULTS Two hundred forty-five patients met the inclusion criteria. Most were male (n = 145). The age range was 80 to 99 (mean 83.3). Most operations were elective (n = 151, 62%). In our cohort, 211, 22, 10,2 and 1 patients had degenerative, trauma, tumour, infective and vascular pathologies, respectively. According to the Eurospine classification, 201 (82.0%) had Minor spine surgery (63 emergently and 138 electively), 38 had Medium surgery (15.5% - 30 emergently and 8 electively), and 6 had Large surgery (2.4% - 1 emergently and 5 electively). 163 (66.5%) were discharged or under follow-up. There were 11 in-patient mortalities (4.5%). Outpatient mortality was 51 (20.8%), with the median time from surgery to death being 504.5 days, all the outpatient mortalities were neither non-spinal pathology nor spinal surgical related. CFS improved across the cohort, from 5 pre-operatively to 4 post-operatively (p < 0.001). CONCLUSION Spine surgery in those over the 80s can be performed safely and improve their quality of life, as demonstrated by improvements in the CFS. Good patient selection and adequate pre-operative workup is essential, although it may not be possible in emergencies.
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Affiliation(s)
| | - Sheikh Momin
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Inflammation & Ageing, University of Birmingham, Birmingham, UK
| | - Bobby Sachdev
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Andraay Leung
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
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Eckhof ML, von Hertzberg-Bölch S, Eidmann A, Lüdemann M, Rudert M, Jakuscheit A. Total blood loss and early clinical outcomes under different tranexamic acid regimes in total knee arthroplasty. Arch Orthop Trauma Surg 2024; 144:2795-2802. [PMID: 38819459 DOI: 10.1007/s00402-024-05229-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/15/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Many different regimes of intravenous and local tranexamic acid (TXA) reduce total blood loss (TBL) in patients undergoing total knee arthroplasty (TKA). However, the most effective TXA regime in reducing blood loss might not be most beneficial for the patient. The aim of the present study was to investigate the effect of commonly used TXA regimes on blood loss and on early clinical outcomes. METHODS We performed this monocentric retrospective study in patients undergoing primary TKA. Primary outcome was the estimated TBL. Secondary outcomes were the rates of adverse events (AE) as well as the range of motion (ROM), mobility and pain intensity during the first three physiotherapy sessions (PTS). RESULTS We analysed the data of 1250 TKAs. 5 different TXA regimes were applied. TBL (mean ± SE) was 953 ± 64 ml (2xiv), 999 ± 19 ml (2xiv + 1xlocal), 1075 ± 19 ml (1xiv + 1xlocal), 1191 ± 39 ml (1xlocal) and 1241 ± 48 ml (1xiv) (p < 0.01). In the linear regression model for TBL a lower number of TXA applications was a predictor for increased blood loss (p < 0.01). AE rates were lowest under 2xiv (0%) and 2xiv + 1xlocal (4.8%). Highest mobility and lowest pain intensity were observed under 1x iv and 2x iv. The largest portions of fully mobile patients on day three were observed under 1xiv (100%), 2xiv (100%) and 2xiv + 1local TXA (86.9%). CONCLUSION Our results suggest that multiple applications of TXA are more effective in decreasing blood loss than excessive dosing of TXA. Interestingly, local use of TXA might be associated with higher pain intensity and decreased mobility on the first days after surgery.
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Affiliation(s)
- Mona-Lisa Eckhof
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany.
| | | | - Annette Eidmann
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Martin Lüdemann
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Axel Jakuscheit
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
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Reinhardt ME, Mutyala S, Gerald M, Zhao H, Nova V, Araya Cambronero S, Patel S, Baltodano PA. The Critical Blood-Sparing Effect of Tranexamic Acid (TXA) in Liposuction: A Systematic Review and Meta-Analysis. JPRAS Open 2024; 40:48-58. [PMID: 38425698 PMCID: PMC10904189 DOI: 10.1016/j.jpra.2023.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 01/18/2023] [Indexed: 02/05/2023] Open
Abstract
Introduction Tranexamic acid (TXA) has been used to improve bleeding outcomes in many surgical procedures. However, its blood-sparing effect in liposuction is not well established. Methods A systematic literature search was performed using PubMed, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central, ClinicalTrials.gov, and WorldWideScience.org databases from their inception to October 8, 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors focused on 3 main topics: 1) TXA, 2) liposuction, and 3) complications. We included articles evaluating the potential blood-sparing effects of TXA in liposuction. Studies were excluded if they were systematic review articles or protocol papers, animal studies, conference abstracts, survey studies, or non-English publications. Results A total of 711 articles were identified, with 1 retrospective and 4 prospective (3 randomized) studies meeting our inclusion criteria. TXA was used in various forms: administered intravenously either on induction or after the procedure, mixed into the tumescent solution, or infiltrated into the liposuction sites after lipoaspiration. A significantly smaller reduction in hematocrit was noted in the TXA group compared with that in the non-TXA group (p<0.001) despite a significantly greater amount of lipoaspirate removed in the TXA group (p<0.001). Patients in non-TXA cohorts experienced adverse effects (such as seroma and need for transfusion) that were not seen in TXA cohorts. Conclusion TXA use in patients undergoing liposuction seems to be associated with a beneficial blood-sparing effect, which may enhance safety in this population. Future studies should aim to determine the optimal route and dosing for TXA in liposuction. Evidence Based Medicine Level IV.
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Affiliation(s)
| | | | | | - Huaqing Zhao
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Vitalina Nova
- Temple University, Charles Library, Philadelphia, PA, USA
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Gutierrez RWH, Gobbo HR, Heringer LDFL. Tranexamic Acid in Patients Undergoing Rhinoplasty: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials. Aesthetic Plast Surg 2024; 48:2076-2085. [PMID: 38097691 DOI: 10.1007/s00266-023-03768-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/17/2023] [Indexed: 06/06/2024]
Abstract
BACKGROUND Rhinoplasty is one of the most popular aesthetic plastic surgeries worldwide. The effects of tranexamic acid (TXA) in patients undergoing rhinoplasty are still being studied to guide a better management. METHODS We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) analyzing the effects of TXA in patients undergoing rhinoplasty. The outcomes evaluated were blood loss, postoperative edema, postoperative ecchymosis, surgery duration and surgeon satisfaction. RESULTS Eleven studies comprising 841 patients were included. Overall, TXA reduced total blood loss regardless of dose and administration route (MD = - 39.37 mL; 95% CI = - 62.70 to - 16.05 mL; p = 0.0009; I2 = 92%), using intravenous 10 mg/kg of TXA preoperatively (MD = - 16.30 mL; 95% CI = - 29.49 to - 2.57 mL; p = 0.02; I2 = 61%) and using 1 g of oral TXA preoperatively (MD = - 61.70 mL; 95% CI = - 83.02 to - 40.39 mL; p < 0.00001; I2 = 0%). TXA also decreased edema (MD = - 0.78; 95% CI = - 1.28 to - 0.27 points; p = 0.003; I2 = 80%) and ecchymosis (MD = - 1.13; 95% CI = - 1.99 to -0.28; p = 0.01; I2 = 93%) on postoperative day one (POD 1). Surgeon satisfaction was increased (SMD = 1.55; 95% CI = 0.33 to 2.77; p = 0.01; I2 = 95%). However, there was no difference in surgery duration (SMD = - 0.26; 95% CI = - 0.56 to 0.04; p = 0.09; I2 = 36%). CONCLUSION This study found a significant reduction in blood loss, periorbital edema and periorbital ecchymosis, along with an improvement in surgeon satisfaction. These results hold the potential to optimize the rhinoplasty management by plastic surgeons. LEVEL OF EVIDENCE I This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
| | | | - Luzimagno da Fonseca Lemos Heringer
- Member of the Brazilian Society of Plastic Surgery (SBCP), São Paulo, Brazil
- Head of Plastic Surgery Department, Desembargador Leal Junior Hospital, Itaboraí, Rio de Janeiro, Brazil
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Lindauer KE, Lo BM, Weingart GS, Karpov MV, Gartman GH, Neubauer LE, Kaplan MC. Tranexamic acid for angiotensin converting enzyme inhibitor induced angioedema: A retrospective multicenter study. Am J Emerg Med 2024; 79:33-37. [PMID: 38340480 DOI: 10.1016/j.ajem.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Angiotensin converting enzyme inhibitors (ACE-Is) prevent the breakdown of bradykinin and can lead to life threatening angioedema. Tranexamic acid is an antifibrinolytic that inhibits formation of precursors involved in bradykinin synthesis and, in case reports, has been described as a potential treatment for ACE-I angioedema. METHODS This retrospective study included patients who presented to the emergency department (ED) from January 2018 to August 2021 with angioedema while taking an ACE-I. Patients who received tranexamic acid (treatment group) were compared with patients who did not receive tranexamic acid (control group). Primary outcome was length of stay (LOS). Secondary outcomes evaluated included ICU admissions, intubations, and safety events. RESULTS A total of 262 patients were included in this study (73 treatment; 189 control). Overall, the median ED LOS was longer in the treatment group than controls (20.9 h vs 4.8 h, p < 0.001). ICU admission rates were higher in the treatment group (45% vs 16%, p < 0.001). More patients were intubated in the treatment group (12% vs 3%, p = 0.018). No difference was seen between the treatment group and the controls for return within 7 days, complications related to thrombosis, and death. In patients presenting with severe angioedema symptoms who were admitted to the hospital, median LOS was not different between the two groups (58.7 h vs 55.7 h, p = 0.61). CONCLUSIONS Patients who received tranexamic acid had increased ED LOS, rates of ICU admission, and need for intubation. This finding may be related to the severity of presentation. Administration of tranexamic acid appears safe to use in ACE-I angioedema. Prospective randomized controlled studies should be considered to determine whether tranexamic acid is an effective treatment for ACE-I angioedema.
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Affiliation(s)
| | - Bruce M Lo
- Pharmacy, Sentara Health, Virginia, United States; Department of Emergency Medicine, Eastern Virginia Medical School, 825 Fairfax Ave, Norfolk, United States; Emergency Physicians of Tidewater, Virginia, Norfolk, United States
| | - Gregory S Weingart
- Pharmacy, Sentara Health, Virginia, United States; Department of Emergency Medicine, Eastern Virginia Medical School, 825 Fairfax Ave, Norfolk, United States; Emergency Physicians of Tidewater, Virginia, Norfolk, United States
| | - Matvey V Karpov
- Research and Infrastructure Service Enterprise, Eastern Virginia Medical School, 825 Fairfax Ave, Norfolk, United States
| | - Grace H Gartman
- Department of Emergency Medicine, Eastern Virginia Medical School, 825 Fairfax Ave, Norfolk, United States; Emergency Physicians of Tidewater, Virginia, Norfolk, United States
| | - Lexie E Neubauer
- Department of Emergency Medicine, Eastern Virginia Medical School, 825 Fairfax Ave, Norfolk, United States; Emergency Physicians of Tidewater, Virginia, Norfolk, United States
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22
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Halalmeh DR, Vrana A, Jenkins P, Cranford JA, Wong K, Kristl D, Mercer L, Moisi MD, Sachwani-Daswani GR. Venous Thromboembolic Events in Adult Trauma Patients Receiving Balanced Hemostatic Resuscitation (BHR): An Analysis of Their Incidence, Predictors, and Associated Mortality Rates at a Level 1 Trauma Center. Cureus 2024; 16:e59679. [PMID: 38836163 PMCID: PMC11149781 DOI: 10.7759/cureus.59679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2024] [Indexed: 06/06/2024] Open
Abstract
Background and objective Studies assessing the incidence of venous thromboembolic (VTE) events in the setting of massive balanced transfusions and/or tranexamic acid (TXA) infusion have yielded varied outcomes. In light of this, we conducted this study to examine the incidence of VTEs in trauma patients requiring blood products, and to identify the risk factors for VTE and mortality in this population. Methods We performed a retrospective analysis of trauma patients admitted to our level 1 trauma center from January 2013 to September 2023. Clinical characteristics were compared between patients who developed VTE and those who did not. A regression analysis of potential variables associated with the development of VTEs and mortality was performed. Results Among 1305 patients (mean age: 42.4 ± 18.8 years) receiving blood products within the initial 24 hours, 4.3% (56 patients) developed a VTE. Patients with VTE experienced prolonged ICU and hospital stays and ventilation duration (p<0.001). They were also noted to have delayed initiation of VTE prophylaxis (104.2 vs. 50.3 hours, p<.001). Prolonged ventilation >7 days was the sole significant factor associated with VTE in multivariate regression analysis [odds ratio (OR): 6.2, p=0.004]. Early TXA administration (within four hours) showed a higher association with VTE than TXA within 24 hours (OR: 2.1, p=0.07 vs. OR 1.6, p=0.22). Massive transfusion was found to increase VTE risk (OR: 2.65, p<0.001). Severe head and neck (OR: 6.0, p=0.002) and chest (OR: 3.8, p=0.01) injuries were key predictors of mortality, while TXA was not significantly associated with mortality in the multivariate model. Conclusions Our study revealed an elevated risk of VTE in patients requiring massive transfusion protocol (MTP, ≥6 units). Early TXA administration was neither associated with increased VTE risk in MTP patients nor increased mortality risk. Strategies directed at reducing the risk of VTE in massively transfused patients while maintaining the survival benefits of balanced resuscitation and TXA need to be devised.
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Affiliation(s)
- Dia R Halalmeh
- Trauma and Acute Care Surgery, Hurley Medical Center, Flint, USA
| | - Antonia Vrana
- Trauma and Acute Care Surgery, Hurley Medical Center, Flint, USA
| | | | | | - Kristoffer Wong
- Trauma and Acute Care Surgery, Hurley Medical Center, Flint, USA
| | - Dean Kristl
- Trauma and Acute Care Surgery, Hurley Medical Center, Flint, USA
| | - Leo Mercer
- Surgery, Texas Tech University Health Science Center, Lubbock, USA
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23
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Tan G, Li J, Xu J, Zhu Y, Zhang H. The efficacy and safety of different does of intravenous tranexamic acid on blood loss in fresh foot and ankle fractures: a prospective, randomized controlled study. BMC Musculoskelet Disord 2024; 25:274. [PMID: 38589854 PMCID: PMC11003133 DOI: 10.1186/s12891-024-07410-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/02/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND There are a few studies on the effectiveness and safety of intravenous administration of tranexamic acid(TXA) in patients who underwent foot and ankle surgery, especially for preoperative hidden blood loss in patients with freshfoot and ankle fractures. Thus, the aim of this study was to investigate whether intravenous administration of different doses of TXA can effectively reduce perioperative blood loss and blood loss before surgery and to determine its safety. METHODS A total of 150 patients with fresh closed foot and ankle fractures from July 2021 to July 2023 were randomly divided into a control group (placebo controlled [PC]), standard-dose group (low-dose group [LD], 1 g/24 h; medium-dose group [MD], 2 g/24 h), and high-dose group (HD, 3 g/24 h; ultrahigh-dose group [UD], 4 g/24 h). After admission, all patients completed hematological examinations as soon as possible and at multiple other time points postsurgery. RESULTS There was a significant difference in the incidence of hidden blood loss before the operation between the TXA group and the control group, and the effect was greater in the overdose groups than in the standard-dose groups. There were significant differences in surgical blood loss (intraoperative and postoperative), postoperative HGB changes, and hidden blood loss among the groups. The TXA groups showed a significant decrease in blood loss compared to that of the control group, and the overdose groups had a more significant effect than the standard-dose groups. A total of 9 patients in the control group had early wound infection or poor healing, while only 1 patient in the other groups had this complication, and the difference among the groups was significant. No patients in any group suffered from late deep wound infection, cardiovascular or cerebrovascular events or symptomatic VTE. CONCLUSION This is the first study on whether TXA can reduce preoperative hidden blood loss in patients with freshfoot and ankle fractures. In our study, on the one hand, intravenous application of TXA after foot and ankle fractures as soon as possible can reduce preoperative blood loss and postoperative blood loss. On the other hand, TXA can also lower wound complications, and over-doses of TXA are more effective than standard doses. Moreover, overdoses of TXA do not increase the incidence of DVT.
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Affiliation(s)
- Gang Tan
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37 of Guoxue lane, Wuhou District, Chengdu, Sichuan, 610041, China
- Department of Orthopaedics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jia Li
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37 of Guoxue lane, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Jing Xu
- Operating Room, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yongzhan Zhu
- Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangdong, China.
| | - Hui Zhang
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37 of Guoxue lane, Wuhou District, Chengdu, Sichuan, 610041, China.
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Honda A, Iizuka Y, Michihata N, Uda K, Mieda T, Takasawa E, Ishiwata S, Kakuta Y, Tomomatsu Y, Ito S, Inomata K, Matsui H, Fushimi K, Yasunaga H, Chikuda H. Effect of Intraoperative Tranexamic Acid on Perioperative Major Hemorrhage Requiring Transfusion in Patients Undergoing Elective Spine Surgery: A Propensity Score-Matched Analysis Using a National Inpatient Database. Global Spine J 2024; 14:804-811. [PMID: 36006871 PMCID: PMC11192125 DOI: 10.1177/21925682221123317] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES This study aimed to examine whether the use of intravenous TXA in elective spine surgery is associated with reduced perioperative massive hemorrhage requiring transfusion. METHODS We extracted all patients who underwent decompression with or without fusion surgery for the cervical, thoracic, and lumbar spine between April 2012 and March 2019. The primary outcome was the occurrence of massive hemorrhage requiring transfusion, defined as at least 560 mL of blood transfusion within 2 days of spine surgery or the requirement of additional blood transfusion from 3-7 days postoperatively. Secondary outcomes were the occurrence of thrombotic complications (pulmonary embolism, acute coronary syndrome, and stroke) and postoperative hematoma requiring additional surgery. RESULTS We identified 83,821 eligible patients, with 9747 (12%) patients in the TXA group. Overall, massive hemorrhage requiring transfusion occurred in 781 (.9%) patients. Propensity score matching yielded 8394 pairs. In the matched cohort, the TXA group had a lower proportion of massive hemorrhage requiring transfusion than the control group (.7% vs 1.1%; P = .002). There was no significant difference in the occurrence of thrombotic complications and postoperative hematoma requiring additional surgery between both groups. The multivariable regression analysis also showed that the use of TXA was associated with significantly lower proportions of massive hemorrhage requiring transfusion (odds ratio, .62; 95% confidence interval, .43-.90; P = .012). CONCLUSIONS In this analysis using real-world data, TXA use in elective spinal surgery was associated with reduced perioperative massive hemorrhage requiring transfusion without increasing thrombotic complications. LEVEL OF EVIDENCE Prognostic Level Ⅲ.
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Affiliation(s)
- Akira Honda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yoichi Iizuka
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuaki Uda
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Tokue Mieda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Eiji Takasawa
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Sho Ishiwata
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yohei Kakuta
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yusuke Tomomatsu
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Shunsuke Ito
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Kazuhiro Inomata
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
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O'Donnell O, Gallagher C, Davey MG, Coulter J, Regan M. A systematic review and meta-analysis assessing the use of tranexamic acid (TXA) in acute gastrointestinal bleeding. Ir J Med Sci 2024; 193:705-719. [PMID: 37794272 PMCID: PMC10961292 DOI: 10.1007/s11845-023-03517-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/04/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Gastrointestinal bleeding results in significant morbidity, cost and mortality. TXA, an antifibrinolytic agent, has been proposed to reduce mortality; however, many studies report conflicting results. METHODS The aim of the study was to perform the first systematic review and meta-analysis of RCTs to evaluate the efficacy TXA for both upper and lower gastrointestinal bleeding. This was performed per PRISMA guidelines. PubMed, EMBASE, Cochrane and Scopus databases were searched for RCTs. Dichotomous variables were pooled as risk ratios (RR) with 95% confidence intervals (CI) using the MH method with random effects modelling. RESULTS Fourteen RCTs were identified with 14,338 patients and mean age of 58.4 years. 34.9% (n = 5008) were female and 65.1% (n = 9330) male. There was no significant difference in mortality between TXA and placebo (RR 0.86 95% CI (0.74 to 1.00), P: 0.05). The secondary outcomes, similarly, did not yield significant results. These included rebleeding, need for surgical intervention (RR: 0.75 95% CI (0.53, 1.07)), endoscopic intervention (RR: 0.92 95% CI (0.70, 1.22)), transfusion requirement (RR: 1.01 95% CI (0.94, 10.7)) and length of stay (RR: 0.03 95% CI (- 0.03, 0.08)). There was no increased risk of VTE, RR: 1.29 95% CI (0.53, 3.16). One trial (n = 12,009) reported an increased risk of seizure in the TXA group, RR: 1.73 95% CI (1.03-2.93). CONCLUSION TXA does not reduce mortality in patients with acute upper or lower gastrointestinal bleeding and may confer an increased risk of seizures. The authors do not recommend the use of TXA in acute gastrointestinal bleeding.
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Affiliation(s)
- Oisín O'Donnell
- Department of General and Colorectal Surgery, Galway University Hospitals, Saolta University Health Care Group, Newcastle Road, Galway, H91YR71, Ireland.
- School of Postgraduate Studies, Royal College of Surgeon in Ireland, Dublin, D02YN77, Ireland.
| | - Clodagh Gallagher
- University of Limerick, Sreelane, Castletroy, Co., Limerick, V94 T9PX, Ireland
| | - Matthew G Davey
- Department of General and Colorectal Surgery, Galway University Hospitals, Saolta University Health Care Group, Newcastle Road, Galway, H91YR71, Ireland
- The National University of Ireland Galway, University Rd, Galway, H91TK33, Ireland
| | - Jonathan Coulter
- Department of General and Colorectal Surgery, Galway University Hospitals, Saolta University Health Care Group, Newcastle Road, Galway, H91YR71, Ireland
| | - Mark Regan
- Department of General and Colorectal Surgery, Galway University Hospitals, Saolta University Health Care Group, Newcastle Road, Galway, H91YR71, Ireland
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26
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Provinciatto H, Barbalho ME, da Câmara PM, Donadon IB, Fonseca LM, Bertani MS, Marinho AD, Sirena E, Provinciatto A, Amaral S. Prophylactic tranexamic acid in Cesarean delivery: an updated meta-analysis with a trial sequential analysis. Can J Anaesth 2024; 71:465-478. [PMID: 38453797 DOI: 10.1007/s12630-024-02715-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/29/2023] [Accepted: 11/04/2023] [Indexed: 03/09/2024] Open
Abstract
PURPOSE Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide. Although several studies on the prophylactic use of tranexamic acid (TXA) in parturients undergoing Cesarean delivery have been published, conflicting results raise questions regarding its use. Thus, we aimed to investigate the safety and efficacy of PPH prophylaxis with TXA. SOURCE We searched PubMed®, Embase, Cochrane Central, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing prophylactic TXA with placebo or no treatment in parturients undergoing Cesarean delivery. Our main outcomes were PPH, any blood transfusion, need for additional uterotonics, and adverse events. We performed a trial sequential analysis (TSA) of all outcomes to investigate the reliability and conclusiveness of findings. PRINCIPAL FINDINGS We included 38 RCTs including 22,940 parturients, 11,535 (50%) of whom were randomized to receive prophylactic TXA. Patients treated with TXA had significantly fewer cases of PPH (risk ratio [RR], 0.51; 95% confidence interval [CI], 0.38 to 0.69; P < 0.001); less blood transfusion (RR, 0.43; 95% CI, 0.30 to 0.61; P < 0.001), and less use of additional uterotonics (RR, 0.52; 95% CI, 0.40 to 0.68; P < 0.001). No significant differences were found between the groups in terms of adverse effects and thromboembolic events. CONCLUSION Prophylactic TXA administration for parturients undergoing Cesarean delivery significantly reduced blood loss, without increasing adverse events, supporting its use as a safe and effective strategy for reducing PPH in this population. STUDY REGISTRATION PROSPERO (CRD42023422188); first submitted 27 April 2023.
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Affiliation(s)
- Henrique Provinciatto
- Barao de Maua University Center, Avenida Portugal, 2433, Ribeirao Preto, SP, Brazil.
| | | | | | | | - Luiza M Fonseca
- Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, Brazil
| | | | - Alice D Marinho
- Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Sara Amaral
- Regional Hospital Deputado Afonso Guizzo, Araranguá, Brazil
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27
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Faraoni D, Fenger-Eriksen C. Dosing of tranexamic acid in trauma. Curr Opin Anaesthesiol 2024; 37:125-130. [PMID: 38390911 DOI: 10.1097/aco.0000000000001357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW Tranexamic acid is routinely used as part of the management of traumatic bleeding. The dose recommendation in trauma was extrapolated from other clinical settings and the results of pragmatic randomized trials rather than pharmaco-kinetic and -dynamic evaluations. The review addresses current evidence on dosing of tranexamic acid in traumatized patients with a focus on efficacy, safety and risk-benefit profile. RECENT FINDINGS A majority, but not all, of existing randomized clinical trials reports a reduction in mortality and/or blood loss with tranexamic acid administration. Increasing dose above the general recommendation (1 g bolus + 1 g infusion/8 h intravenously) has not been shown to further increase efficacy and could potentially increase side effects. SUMMARY The benefit of tranexamic acid as adjuvant therapy in the management of bleeding trauma patients on mortality and transfusion requirements is clear and well documented, being most effective if given early and to patients with clinical signs of hemorrhagic shock. Recent reports suggest that in some patients presenting with a shutdown of their fibrinolytic pathway the administration of tranexamic acid could be associated with an increased risk of thromboembolic events and poor outcomes. A more personalized approach based on bedside assessment of fibrinolytic activation and pharmacokinetic-based dose regimen should be developed moving forward.
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Affiliation(s)
- David Faraoni
- Arthur S. Keats Division of Pediatric. Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Christian Fenger-Eriksen
- Department of Anesthesiology and Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Piette N, Beck F, Carella M, Hans G, Maesen D, Kurth W, Lecoq JP, Bonhomme VL. Oral as compared to intravenous tranexamic acid to limit peri-operative blood loss associated with primary total hip arthroplasty: A randomised noninferiority trial. Eur J Anaesthesiol 2024; 41:217-225. [PMID: 38214552 DOI: 10.1097/eja.0000000000001950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND Oral as compared to intravenous tranexamic acid (TXA) is an attractive option, in terms of cost and safety, to reduce blood loss and transfusion in total hip arthroplasty. Exclusion criteria applied in the most recent randomised trials may have limited the generalisability of oral tranexamic acid in this indication. Larger and more inclusive studies are needed to definitively establish oral administration as a credible alternative to intravenous administration. OBJECTIVES To assess the noninferiority of oral to intravenous TXA at reducing intra-operative and postoperative total blood loss (TBL) in primary posterolateral approached total hip arthroplasty (PLTHA). DESIGN Noninferiority, single centre, randomised, double-blind controlled study. SETTING Patients scheduled for primary PLTHA. Data acquisition occurred between May 2021 and November 2022 at the University Hospital of Liège, Belgium. PATIENTS Two hundred and twenty-eight patients, randomised in a 1 : 1 ratio from a computer-generated list, completed the trial. INTERVENTIONS Administration of 2 g of oral TXA 2 h before total hip arthroplasty and 4 h after incision (Group oral) was compared to the intravenous administration of 1 g of TXA 30 min before surgery and 4 h after incision (Group i.v.). MAIN OUTCOME MEASURES TBL (measured intra-operative and drainage blood loss up to 48 h after surgery, primary outcome), decrease in haemoglobin concentration, D-Dimer at day 1 and day 3, transfusion rate (secondary outcomes). RESULTS Analyses were performed on 108 out of 114 participants (Group i.v.) and 104 out of 114 participants (Group oral). Group oral was noninferior to Group i.v. with regard to TBL, with a difference between medians (95% CI) of 35 ml (-103.77 to 33.77) within the noninferiority margins. Median [IQR] of estimated TBL was 480 ml [350 to 565] and 445 ml [323 to 558], respectively. No significant interaction between group and time was observed regarding the evolution of TBL and haemoglobin over time. CONCLUSIONS TXA as an oral premedication before PLTHA is noninferior to its intravenous administration regarding peri-operative TBL. TRIAL REGISTRATION European Clinical Trial Register under EudraCT-number 2020-004167-29 ( https://www.clinicaltrialsregister.eu/ctr-search/trial/2020-004167-29/BE ).
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Affiliation(s)
- Nicolas Piette
- From the Department of Anaesthesia and Intensive Care Medicine (NP, FB, MC, GH, J-PL, VLB), Department of Clinical Pharmacy (DM), Department of Locomotor System Surgery, Liege University Hospital (WK), Inflammation and Enhanced Rehabilitation Laboratory (Regional Anaesthesia and Analgesia), GIGA-I3 Thematic Unit (NP, MC, J-PL), Anaesthesia and Perioperative Neuroscience Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium (FB, VLB)
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29
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Raska A, Kálmán K, Egri B, Csikós P, Beinrohr L, Szabó L, Tenekedjiev K, Nikolova N, Longstaff C, Roberts I, Kolev K, Wohner N. Synergism of red blood cells and tranexamic acid in the inhibition of fibrinolysis. J Thromb Haemost 2024; 22:794-804. [PMID: 38016517 DOI: 10.1016/j.jtha.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. The World Maternal Antifibrinolytic trial showed that antifibrinolytic tranexamic acid (TXA) reduces PPH deaths. Maternal anemia increases the risk of PPH. The World Maternal Antifibrinolytic-2 trial is now assessing whether TXA can prevent PPH in women with anemia. Low red blood cell (RBC) counts promote fibrinolysis by altering fibrin structure and plasminogen activation. OBJECTIVES We explored interactions between RBCs and TXA in inhibiting fibrinolysis. METHODS We used global fibrinolytic assays (ball sedimentation and viscoelasticity) to monitor the lysis of fibrin containing plasminogen and tissue-type plasminogen activator. We applied a fluorogenic kinetic assay to measure plasmin generation in fibrin clots and scanning electron microscopy to study fibrin structure. RESULTS According to parallel-line bioassay analysis of the fibrin lysis-time data, the antifibrinolytic potency of 4-128 μM TXA was increased in the presence of 10% to 40% (v/v) RBCs. Global fibrinolysis assays showed that the joint effect of RBCs and TXA was about 15% larger than the sum of their individual effects in the inhibition of fibrinolysis. In plasminogen activation, TXA added the same increment of inhibition to the effect of RBCs at any cell count in the fibrin clot. Regarding fibrin structure, TXA thickened fibrin fibers, which impaired plasminogen activation, whereas RBCs promoted fine fibers that were more resistant to plasmin. CONCLUSIONS The antifibrinolytic potency of TXA is enhanced in fibrin formed in the presence of RBCs through inhibition of plasminogen activation and fibrin lysis, which correlates with modifications of fibrin structures.
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Affiliation(s)
- Alexandra Raska
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary; HCEMM-SU Thrombosis and Hemostasis Research Group, Department of Biochemistry, Semmelweis University, Budapest, Hungary
| | - Kata Kálmán
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary; HCEMM-SU Thrombosis and Hemostasis Research Group, Department of Biochemistry, Semmelweis University, Budapest, Hungary
| | - Barnabás Egri
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary
| | - Petra Csikós
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary
| | - László Beinrohr
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary
| | - László Szabó
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary; Plasma Chemistry Research Group, Institute of Materials and Environmental Chemistry, Research Centre for Natural Sciences, Budapest, Hungary
| | - Kiril Tenekedjiev
- Australian Maritime College, University of Tasmania, Tasmania, Australia; Nikola Vaptsarov Naval Academy, Varna, Bulgaria
| | - Natalia Nikolova
- Defence Science and Technology Group, Edinburgh, Adelaide, Australia; Australian Maritime College, University of Tasmania, Tasmania, Australia
| | - Colin Longstaff
- Biotherapeutics, Haemostasis Section, National Institute for Biological Standards and Control, South Mimms, Potters Bar, United Kingdom
| | - Ian Roberts
- London School Hygiene and Tropical Medicine, Clinical Trials Unit, London, United Kingdom
| | - Krasimir Kolev
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary
| | - Nikolett Wohner
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary; HCEMM-SU Thrombosis and Hemostasis Research Group, Department of Biochemistry, Semmelweis University, Budapest, Hungary.
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30
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McQuilten ZK, Wood EM, Medcalf RL. When to use tranexamic acid for the treatment of major bleeding? J Thromb Haemost 2024; 22:581-593. [PMID: 37827378 DOI: 10.1016/j.jtha.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 08/15/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic agent originally developed for the management of bleeding in the setting of postpartum hemorrhage (PPH). Over the last 15 years, there has been accumulating evidence on the use of TXA for the treatment of active bleeding in a variety of clinical contexts. Clinical trials have shown that the efficacy and safety of TXA for the treatment of bleeding differ according to the clinical context in which it is being administered, timing of administration, and dose. Early administration is important for efficacy, particularly in trauma and PPH. Further studies are needed to understand the mechanisms by which TXA provides benefit, optimal modes of administration and dosing, and its effect in some clinical settings, such as spontaneous intracerebral hemorrhage. There is no evidence that TXA increases the risk of thrombotic events in patients with major bleeding overall. However, there is evidence of increased risk of venous thrombosis in patients with gastrointestinal bleeding. There is also evidence of increased risk of seizures with the use of higher doses. This review summarizes the current evidence for the use of TXA for patients with active bleeding and highlights the importance of generating evidence of efficacy and safety of hemostatic interventions specific to the bleeding contexts-as findings from 1 clinical setting may not be generalizable to other contexts-and that of individual patient assessment for bleeding, thrombotic, and other risks, as well as important logistical and other practical considerations, to optimize care and outcomes in these settings.
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Affiliation(s)
- Zoe K McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Haematology, Monash Health, Melbourne, Victoria, Australia.
| | - Erica M Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Robert L Medcalf
- Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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Xie W, Jiang S, Donat A, Knapstein PR, Albertsen LC, Kokot JL, Erdmann C, Rolvien T, Frosch KH, Baranowsky A, Keller J. Tranexamic Acid Attenuates the Progression of Posttraumatic Osteoarthritis in Mice. Am J Sports Med 2024; 52:766-778. [PMID: 38305280 PMCID: PMC10905980 DOI: 10.1177/03635465231220855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/25/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Posttraumatic osteoarthritis (OA) is a common disorder associated with a high socioeconomic burden, particularly in young, physically active, and working patients. Tranexamic acid (TXA) is commonly used in orthopaedic trauma surgery as an antifibrinolytic agent to control excessive bleeding. Previous studies have reported that TXA modulates inflammation and bone cell function, both of which are dysregulated during posttraumatic OA disease progression. PURPOSE To evaluate the therapeutic effects of systemic and topical TXA treatment on the progression of posttraumatic OA in the knee of mice. STUDY DESIGN Controlled laboratory study. METHODS OA was induced via anterior cruciate ligament (ACL) transection on the right knee of female mice. Mice were treated with TXA or vehicle intraperitoneally daily or intra-articularly weekly for 4 weeks, starting on the day of surgery. Articular cartilage degeneration, synovitis, bone erosion, and osteophyte formation were scored histologically. Micro-computed tomography evaluation was conducted to measure the subchondral bone microstructure and osteophyte volume. Cartilage thickness and bone remodeling were assessed histomorphometrically. RESULTS Both systemic and topical TXA treatment significantly reduced cartilage degeneration, synovitis, and bone erosion scores and increased the ratio of hyaline to calcified cartilage thickness in posttraumatic OA. Systemic TXA reversed ACL transection-induced subchondral bone loss and osteophyte formation, whereas topical treatment had no effect. Systemic TXA decreased the number and surface area of osteoclasts, whereas those of osteoblasts were not affected. No effect of topical TXA on osteoblast or osteoclast parameters was observed. CONCLUSION Both systemic and topical TXA exerted protective effects on the progression of posttraumatic OA. Drug repurposing of TXA may, therefore, be useful for the prevention or treatment of posttraumatic OA, particularly after ACL surgery. CLINICAL RELEVANCE TXA might be beneficial in patients with posttraumatic OA of the knee.
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Affiliation(s)
- Weixin Xie
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Shan Jiang
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Antonia Donat
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paul Richard Knapstein
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lilly-Charlotte Albertsen
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Judith Luisa Kokot
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cordula Erdmann
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anke Baranowsky
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Keller
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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VanderMeulen H, Tang GH, Sholzberg M. Tranexamic acid for management of heavy vaginal bleeding: barriers to access and myths surrounding its use. Res Pract Thromb Haemost 2024; 8:102389. [PMID: 38623473 PMCID: PMC11017359 DOI: 10.1016/j.rpth.2024.102389] [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: 01/02/2024] [Revised: 03/09/2024] [Accepted: 03/11/2024] [Indexed: 04/17/2024] Open
Abstract
Tranexamic acid is safe and effective for the treatment of heavy vaginal bleeding during menstruation and childbirth. It improves the quality of life, facilitates participation in school and work, and reduces the risk of death from postpartum hemorrhage. Despite its well-established benefits, individual- and structural-level barriers preclude its widespread utilization, hindering effective patient care and perpetuating health inequities in women's health. We first describe the evidence for the use of tranexamic acid in treating heavy menstrual bleeding and postpartum hemorrhage. Barriers to tranexamic acid use, including structural sexism, period poverty, misinformation in product monograph labeling, stigmatization of vaginal blood loss, and drug access, are then discussed. Finally, we summarize relevant data presented during the 2023 International Society on Thrombosis and Haemostasis Congress.
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Affiliation(s)
- Heather VanderMeulen
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Grace H. Tang
- Department of Hematology, Hematology-Oncology Clinical Research Group, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Department of Medicine and Laboratory Medicine & Pathobiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
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Cleveland B, Norling B, Wang H, Gandhi V, Price CL, Borofsky M, Pais V, Dahm P. Tranexamic acid for percutaneous nephrolithotomy: an abridged Cochrane review. BJU Int 2024; 133:259-272. [PMID: 38037865 DOI: 10.1111/bju.16244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
OBJECTIVE To assess the effects of tranexamic acid (TXA) in individuals with kidney stones undergoing percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS We performed a literature search of Cochrane Library, PubMed (including MEDLINE), Embase, Scopus, Global Index Medicus, trials registries, grey literature, and conference proceedings. We included randomised controlled trials (RCTs) that compared treatment with PCNL with administration of TXA to placebo (or no TXA) for patients aged ≥18 years. Two review authors independently classified studies and abstracted data. Primary outcomes were blood transfusion, stone-free rate (SFR), thromboembolic events (TEE). We rated the certainty of evidence (CoE) according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach using a minimally contextualised approach with pre-defined thresholds for minimally clinically important differences (MCID). RESULTS We included 10 RCTs assessing the effect of systemic TXA in PCNL vs placebo (or no TXA). Eight studies were published as full text. Based on an adjusted baseline risk of blood transfusion of 5.7%, systemic TXA may reduce blood transfusions (risk ratio [RR] 0.45, 95% confidence interval [CI] 0.27-0.76). Based on an adjusted baseline SFR of 75.7%, systemic TXA may increase SFR (RR 1.11, 95% CI 0.98-1.27). There is probably no difference in TEEs (risk difference 0.001, 95% CI -0.01 to 0.01). Systemic TXA may increase adverse events (AEs) (RR 5.22, 95% CI 0.52-52.72). Systemic TXA may have little to no effect on secondary interventions (RR 1.15, 95% CI 0.84-1.57). The CoE for most outcomes was assessed as low or very low. CONCLUSIONS Based on a body of evidence of 10 RCTs, we found that systemic TXA in PCNL may reduce blood transfusions, major surgical complications, and hospital length of stay, as well as improve the SFR; however, it may increase AEs. These findings should inform urologists and their patients in making informed decisions about the use of TXA in the setting of PCNL.
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Affiliation(s)
- Brent Cleveland
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
- Urology Section, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Brett Norling
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Hill Wang
- University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Carrie L Price
- Albert S. Cook Library, Towson University, Towson, MD, USA
| | - Michael Borofsky
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
- Urology Section, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Vernon Pais
- Department of Surgery, Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Philipp Dahm
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
- Urology Section, Minneapolis VA Health Care System, Minneapolis, MN, USA
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Lasocki S, Belbachir A, Mertes PM, Le Pelley E, Bosch L, Bezault C, Belarbia S, Capdevila X. Changes in Practices After Implementation of a Patient Blood Management Program in French Surgical Departments: The National Multicenter Observational PERIOPES Study. Anesth Analg 2024:00000539-990000000-00769. [PMID: 38412110 DOI: 10.1213/ane.0000000000006917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Patient blood management (PBM) is an evidence-based approach recommended to improve patient outcomes. Change in practices is often challenging. We report here data from French surgical departments before and after a standardized implementation of a PBM program. METHODS This was a national, multicenter, observational study in surgical centers ("expert" centers with an already established protocol for preoperative anemia or "pilot" centers). Data from consecutive surgical patients of different specialties were retrieved before and after the implementation of a PBM program. Primary outcome variables (preoperative anemia treatment rates, transfusion rates, and length of hospital stay) before and after the implementation of a PBM program were analyzed with segmented regression adjusted on confounders (American Society of Anesthesiologists [ASA] scores and centers). RESULTS A total of 1618 patients (ASA physical status III and IV, 38% in the first period and 45% in the second period) were included in expert (N = 454) or pilot (N = 1164) centers during the first period (January 2017-August 2022) and 1542 (N = 440 and N = 1102, respectively) during the second period (January 2020-February 2023). After implementation of the PBM program, the rate of preoperative anemia treatment increased (odds ratio, 2.37; 95% confidence interval [CI], 1.20-4.74; P = .0136) and length of hospital stay in days decreased (estimate, -0.11; 95% CI, -0.21 to -0.02; P = .0186). Transfusion rate significantly decreased only in expert centers (odds ratio, 0.17; 95% CI, 0.03-0.88; P = .0354). CONCLUSIONS PBM practices in various surgical specialties improved significantly after the implementation of a PBM program. However, too many patients with preoperative anemia remained untreated.
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Affiliation(s)
- Sigismond Lasocki
- From the Département Anesthésie Réanimation, CHU Angers, Angers, France
| | - Anissa Belbachir
- Department of Anesthesia and Critical Care Medicine, Cochin University Paris-Descartes Hospital, Paris, France
| | - Paul-Michel Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, INSERM U1255, FMTS de Strasbourg, Strasbourg, France
| | | | | | | | | | - Xavier Capdevila
- Department of Anesthesia and Critical Care Medicine, Lapeyronie University Hospital and Montpellier University, Montpellier, France
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Steinle AM, Fogel JD, Chen JW, Chanbour H, Vaughan WE, Karwandyar A, Croft AJ, McDonough J, Chandler PJ, Gardocki R, Zuckerman SL, Abtahi AM, Stephens BF. Determining the Effect of Intraoperative TXA on Postoperative Blood Loss in ACDF. Clin Spine Surg 2024; 37:E18-E23. [PMID: 37559204 DOI: 10.1097/bsd.0000000000001508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 06/21/2023] [Indexed: 08/11/2023]
Abstract
STUDY DESIGN Retrospective cohort study using prospectively collected data. OBJECTIVE To determine the effectiveness of intraoperative tranexamic acid (TXA) in anterior cervical discectomy and fusion (ACDF) on postoperative blood loss. SUMMARY OF BACKGROUND DATA TXA has been proven to be a safe and effective agent in reducing blood loss after cervical surgery; however, its efficacy when used intraoperatively for ACDF surgeries had yet to be researched. Currently, there are few studies examining the effects of intraoperative TXA in cervical spinal fusion, and none specifically examining TXA use in ACDF. METHODS A tertiary medical center's prospectively collected spine registry was queried between 1/1/18 and 12/1/21 for all patients who underwent elective ACDF surgery and received a drain postoperatively. Patients were separated into 2 groups; those who had received intraoperative TXA and those who did not. Baseline demographic and operative variables were collected from the registry. The primary outcome was postoperative blood loss over a 24-hour period. Secondary outcomes included total drain output, intraoperative estimated blood loss, operative duration, drain duration, changes in preoperative to postoperative hemoglobin and hematocrit levels, and rate of transfusions, complications, revisions, and reoperations. Univariate and multivariate regression analyses were performed. RESULTS Two hundred eighty-six patients were included. One hundred ninety patients underwent ACDF and did not receive intraoperative TXA, whereas 96 patients underwent ACDF and did receive TXA. There were no differences in any demographic or baseline variables. Multivariate analysis showed intraoperative TXA was associated with shorter drain duration (β=-5.74, 95% CI: -10.9 to -0.53, P =0.031) and reduction in 24-hour drain output (β=-12.2, 95% CI: -19.4 to -4.89, P =0.001) and total drain output (β=-14.0, 95% CI: -22.9 to -5.05, P =0.002). CONCLUSIONS TXA use during ACDF procedures leads to a decrease in perioperative blood loss and faster drain removal. TXA is an effective and safe agent for reducing perioperative blood loss in ACDF surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Anthony M Steinle
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center
| | - Jessa D Fogel
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center
| | | | - Hani Chanbour
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Ayub Karwandyar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center
| | - Andrew J Croft
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center
| | - Judy McDonough
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center
| | - Philip J Chandler
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center
| | - Raymond Gardocki
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center
| | - Scott L Zuckerman
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN
| | - Amir M Abtahi
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN
| | - Byron F Stephens
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN
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Bae J, Lee DDU, Lee KT, Pyon JK, Jeon BJ, Mun GH. The early postoperative effects of rinsing the breast pocket with tranexamic acid in prepectoral prosthetic breast reconstruction. J Plast Reconstr Aesthet Surg 2024; 89:125-133. [PMID: 38181633 DOI: 10.1016/j.bjps.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/27/2023] [Accepted: 12/06/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND The efficacy of tranexamic acid (TXA) has been reported in breast surgery; however, its application and duration have varied across studies. This study aimed to assess the early postoperative outcomes of rinsing the breast pocket with TXA during prepectoral prosthetic breast reconstruction using an acellular dermal matrix (ADM). METHODS A retrospective chart review was conducted in consecutive patients who underwent immediate prosthetic prepectoral reconstruction between August 2021 and December 2022. For cases performed during the earlier part of the study period (up to April 2022), TXA was not administered (non-TXA group), whereas those performed after April 2022 received topical TXA application during surgery (TXA group). Postoperative outcomes including hematoma, seroma, drainage volume, and drain maintenance duration were compared between the two groups using propensity score matching (PSM). RESULTS A total of 674 breasts were analyzed; 280 in the TXA group and 394 were in the non-TXA group. There were 251 breasts in each group after PSM, and their characteristics were similar. The incidence of hematoma in the first 24 hours and total drain output were significantly lower in the TXA group than the non-TXA group. In cases of direct-to-implant cases, the TXA group showed a significantly lower seroma rate. CONCLUSIONS Rinsing the breast pocket with TXA can potentially reduce the occurrence of hematoma and decrease drain output in prepectoral ADM-assisted prosthetic breast reconstruction. Moreover, this approach may be beneficial in lowering the incidence of seroma in direct-to-implant reconstruction.
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Affiliation(s)
- Juyoung Bae
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dianne Dong Un Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jai Kyong Pyon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byung-Joon Jeon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Carabini LM, Koski TR, Bebawy JF. Perioperative Management for Complex Spine Fusion Surgery. Anesthesiology 2024; 140:293-303. [PMID: 38048486 DOI: 10.1097/aln.0000000000004744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
Complex spine surgeries performed worldwide continue to increase in number, as do the age and comorbidity of patients undergoing these operations. Perioperative care protocols related to blood management, postoperative pain control, and intraoperative measures to mitigate morbidity may improve clinical workflows and patient outcomes.
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Affiliation(s)
- Louanne M Carabini
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tyler R Koski
- Departments of Neurological Surgery and Orthopedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John F Bebawy
- Departments of Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Wang S, Yang J, Lin L. Intravenous Application of Tranexamic Acid in Patients Undergoing Plastic Surgery: A Systematic Review and Meta-analysis with GRADE Quality Assessment. Aesthetic Plast Surg 2024; 48:543-558. [PMID: 37721624 DOI: 10.1007/s00266-023-03637-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/07/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is a versatile antifibrinolytic agent that is widely used in modern surgeries. This review assessed the safety and efficacy of intravenous (IV) TXA in plastic surgery versus controls. METHODS This review selected English-language Randomized controlled trials (RCTs) evaluating IV TXA effects in plastic surgery from four electronic databases, PubMed, Web of Science, Embase, and Cochrane Library up to April 9, 2023. Primary outcomes were blood loss volume (BLV) and transfusion occurrence, with operation time and surgical field assessment as secondary outcomes. IV TXA-related complications were also important indicators. Meta-analyses and qualitative analyses were conducted and the quality of the evidence was assessed. RESULTS Thirty RCTs with 2150 patients were included. The total standard mean difference (SMD) of BLV and pooled relative risk of transfusion occurrence between the IV TXA and the control groups were - 1.11 (95% CI, - 1.42 to - 0.80) and 0.36 (95% CI, 0.23 to 0.55) respectively, indicating a significant blood loss reduction with IV TXA treatment, while an ambiguous outcome of operation time was observed, with an SMD of - 0.22 (95% CI, - 0.42 to - 0.02). The quality of evidence for BLV and transfusion occurrence was low and medium, respectively. A quantitative analysis of surgical field assessment was not performed because of the substantial heterogeneity in scoring methods. No IV TXA-related complications were observed. CONCLUSIONS In plastic surgery, IV TXA administration results in less blood loss, reduced need for transfusion and better surgical fields but probably does not increase the risk of adverse events. LEVEL OF EVIDENCE I This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Senmao Wang
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 33 Badachu Road, Shijingshan District, Beijing, 100144, China
| | - Jingwen Yang
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 33 Badachu Road, Shijingshan District, Beijing, 100144, China
| | - Lin Lin
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 33 Badachu Road, Shijingshan District, Beijing, 100144, China.
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Franchini M, Focosi D, Zaffanello M, Mannucci PM. Efficacy and safety of tranexamic acid in acute haemorrhage. BMJ 2024; 384:e075720. [PMID: 38176733 DOI: 10.1136/bmj-2023-075720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy
| | - Marco Zaffanello
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Evans HG, Murphy MF, Foy R, Dhiman P, Green L, Kotze A, von Neree L, Palmer AJ, Robinson SE, Shah A, Tomini F, Trompeter S, Warnakulasuriya S, Wong WK, Stanworth SJ. Harnessing the potential of data-driven strategies to optimise transfusion practice. Br J Haematol 2024; 204:74-85. [PMID: 37964471 DOI: 10.1111/bjh.19158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/24/2023] [Accepted: 10/03/2023] [Indexed: 11/16/2023]
Abstract
No one doubts the significant variation in the practice of transfusion medicine. Common examples are the variability in transfusion thresholds and the use of tranexamic acid for surgery with likely high blood loss despite evidence-based standards. There is a long history of applying different strategies to address this variation, including education, clinical guidelines, audit and feedback, but the effectiveness and cost-effectiveness of these initiatives remains unclear. Advances in computerised decision support systems and the application of novel electronic capabilities offer alternative approaches to improving transfusion practice. In England, the National Institute for Health and Care Research funded a Blood and Transplant Research Unit (BTRU) programme focussing on 'A data-enabled programme of research to improve transfusion practices'. The overarching aim of the BTRU is to accelerate the development of data-driven methods to optimise the use of blood and transfusion alternatives, and to integrate them within routine practice to improve patient outcomes. One particular area of focus is implementation science to address variation in practice.
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Affiliation(s)
- H G Evans
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - M F Murphy
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | - R Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - P Dhiman
- Centre for Statistics in Medicine, Botnar Research Centre, Oxford, UK
| | - L Green
- Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
- NHS Blood and Transplant, London, UK
| | - A Kotze
- Leeds Teaching Hospitals, Leeds, UK
| | - L von Neree
- University College London Hospitals NHS Foundation Trust, London, UK
| | - A J Palmer
- Nuffield Orthopaedic Centre, Oxford University NHS Foundation Trust, Oxford, UK
| | - S E Robinson
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Shah
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - F Tomini
- Queen Mary University of London, London, UK
| | - S Trompeter
- University College London Hospitals NHS Foundation Trust, London, UK
- University College London, London, UK
| | - S Warnakulasuriya
- University College London Hospitals NHS Foundation Trust, London, UK
- University College London, London, UK
| | - W K Wong
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S J Stanworth
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
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Ferrarin DA, Schwab ML, Wrzesinski MR, Rauber JDS, Chaves JNF, Ripplinger A, Mazzanti A. Tranexamic Acid in Reducing Intraoperative Bleeding in Dogs Undergoing Thoracolumbar and Lumbar Hemilaminectomy and Intervertebral Disc Fenestration. Top Companion Anim Med 2024; 58:100820. [PMID: 37802243 DOI: 10.1016/j.tcam.2023.100820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/23/2023] [Accepted: 10/01/2023] [Indexed: 10/08/2023]
Abstract
Hemilaminectomy associated with intervertebral disc fenestration (HF) is the most used spinal decompression surgical technique for the treatment of intervertebral disc extrusion (IVDE). The surgical procedure can be hampered by excessive bleeding from the venous sinuses; however, tranexamic acid intravenously (IV) is a possible adjunct to hemostasis in these patients. This study aimed to verify the effectiveness of tranexamic acid in reducing intraoperative bleeding in dogs with thoracolumbar and lumbar IVDE submitted to HF. Sixteen dogs with IVDE undergoing HF were included. These were distributed into a TXA group (tranexamic acid 20 mg/kg IV bolus, followed by 2 mg/kg/h IV continuous infusion) (n = 8) and a control group, with saline solution (n = 8). Blood loss was measured using the gravimetric method. The difficulty of operative visualization due to bleeding was classified by the surgeon. Median blood loss (%) in patients in the TXA group was lower than those in the control group (2.75 ± 1.23 and 4.99 ± 4.44, respectively) (P = .028). Intraoperative visualization difficulty due to bleeding occurred in 10 patients in the control group, and in no patients in the TXA group. A severe arterial thromboembolic complication was recorded, potentially due to tranexamic acid. The use of intraoperative tranexamic acid was effective in reducing bleeding and facilitating operative visualization in dogs with IVDE undergoing hemilaminectomy and intervertebral disc fenestration.
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Affiliation(s)
| | - Marcelo Luís Schwab
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Mathias Reginatto Wrzesinski
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Júlia da Silva Rauber
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Julya Nathalya Felix Chaves
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Angel Ripplinger
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, Universidade do Oeste de Santa Catarina, SC, Brazil
| | - Alexandre Mazzanti
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil.
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Eaton V, Braaten M, Schissel M, Wallace M. Assessing the Safety and Efficacy of Tranexamic Acid Usage in Osteogenesis Imperfecta Patients. J Pediatr Orthop 2024; 44:e73-e78. [PMID: 37750572 PMCID: PMC10702696 DOI: 10.1097/bpo.0000000000002524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND Osteogenesis Imperfecta (OI) usually causes an increased fracture burden and bone deformity, with subsequent operations common. In addition to skeletal manifestations, there is a potential increase in bleeding susceptibility due to the increased frequency of orthopedic procedures, warranting investigation into methods to mitigate this risk. This study aims to evaluate the safety and efficacy of tranexamic acid (TXA) usage to reduce intraoperative blood loss in children with OI. We want to assess the potential benefits, risks, and complications involved with TXA use in this patient population. METHODS TXA-receiving patients (cases) were matched 1:1 with non-TXA-receiving controls on the following criteria: age within 2 years, bone category, and OI Type. Descriptive statistics were used to summarize the data. Fisher Exact Test was performed to compare transfusion status between groups. A Wilcoxon Rank Sum test was performed to assess differences between the groups in days of stay, length of surgery, and estimated blood loss (EBL). All analyses were conducted using SAS version 9.4. P <0.05 was considered statistically significant. RESULTS Our TXA-receiving population of 30 patients consisted of 11 females and 19 males. One patient was OI type I, 13 were OI type III, 14 were OI type IV, and 2 were categorized as Other (not Type I through Type IV). We found a significant difference in transfusion status ( P =0.02), with zero TXA patients requiring a transfusion compared with 20% of the control cases. There is also a significant difference in median EBL ( P =0.0004) between groups, with TXA patients having decreased intraoperative EBL (20 vs. 62.5 mL). There was also a difference in median days of postoperative stay between TXA-receiving and non-TXA-receiving patients ( P =0.001; 2.6 vs. 4 d). CONCLUSIONS Our study concluded that TXA use in OI patients is associated with lower perioperative transfusions and intraoperative blood loss rates. These results support the standard usage of TXA in these patients to reduce intraoperative blood loss. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | | | - Maegen Wallace
- University of Nebraska Medical Center
- Children’s Hospital & Medical Center, Omaha, NE
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Retter A, Hunt BJ. Consumptive coagulopathy in the ICU. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:754-760. [PMID: 38066939 PMCID: PMC10727004 DOI: 10.1182/hematology.2023000502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
A consumptive coagulopathy describes a situation where there is a loss of hemostatic factors, which leads to an increased risk of bleeding. Some recent studies have used the term interchangeably with disseminated intravascular coagulation (DIC), but we have reverted to the older definition, which covers a broader range of issues where there is loss of hemostatic factors due to multiple causes, which includes systemic activation of coagulation as seen in DIC. Therefore, the term consumptive coagulopathy covers conditions from the hemostatic effects of major hemorrhage to the use of extracorporeal circuits to true DIC. We review the current understanding of the pathophysiology, diagnosis, and management of common consumptive coagulopathy in critical care patients, focusing on recent advances and controversies. Particular emphasis is given to DIC because it is a common and often life-threatening condition in critical care patients and is characterized by the simultaneous occurrence of widespread microvascular thrombosis and bleeding. Second, we focus on the effect of modern medical technology, such as extracorporeal membrane oxygenation, on hemostasis.
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Affiliation(s)
- Andrew Retter
- Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Beverley J Hunt
- Kings Healthcare Partners and Thrombosis & Haemophilia Centre, GSTT, London, UK
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Brenner A, Shakur-Still H, Chaudhri R, Muganyizi P, Olayemi O, Arribas M, Kayani A, Javid K, Bello A, Roberts I. Tranexamic acid by the intramuscular or intravenous route for the prevention of postpartum haemorrhage in women at increased risk: a randomised placebo-controlled trial (I'M WOMAN). Trials 2023; 24:782. [PMID: 38044460 PMCID: PMC10694937 DOI: 10.1186/s13063-023-07687-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/28/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) causes about 70,000 maternal deaths every year. Tranexamic acid (TXA) is a life-saving treatment for women with PPH. Intravenous (IV) TXA reduces deaths due to PPH by one-third when given within 3 h of childbirth. Because TXA is more effective when given early and PPH usually occurs soon after childbirth, giving TXA just before childbirth might prevent PPH. Although several randomised trials have examined TXA for PPH prevention, the results are inconclusive. Because PPH only affects a small proportion of births, we need good evidence on the balance of benefits and harms before using TXA to prevent PPH. TXA is usually given by slow IV injection. However, recent research shows that TXA is well tolerated and rapidly absorbed after intramuscular (IM) injection, achieving therapeutic blood levels within minutes of injection. METHODS The I'M WOMAN trial is an international, multicentre, three-arm, randomised, double-blind, placebo-controlled trial to assess the effects of IM and IV TXA for the prevention of PPH in women with one or more risk factors for PPH giving birth vaginally or by caesarean section. DISCUSSION The trial will provide evidence of the benefits and harms of TXA for PPH prevention and the effects of the IM and IV routes of administration. The IM route should be as effective as the IV route for preventing bleeding. There may be fewer side effects with IM TXA because peak blood concentrations are lower than with the IV route. IM TXA also has practical advantages as it is quicker and simpler to administer. By avoiding the need for IV line insertion and a slow IV injection, IM administration would free up overstretched midwives and doctors to focus on looking after the mother and baby and expand access to timely TXA treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT05562609. Registered on 3 October 2022. ISRCTN Registry ISRCTN12590098. Registered on 20 January 2023. Pan African Clinical Trial Registry PACTR202305473136570. Registered on 18 May 2023.
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Affiliation(s)
- Amy Brenner
- London School of Hygiene & Tropical Medicine, London, United Kingdom.
| | | | | | | | | | - Monica Arribas
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Aasia Kayani
- Shifa Tameer-E-Millat University, Islamabad, Pakistan
| | - Kiran Javid
- Shifa Tameer-E-Millat University, Islamabad, Pakistan
| | | | - Ian Roberts
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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Pai B H P, Patel S, Lai YH. Updated Clinical Review: Perioperative Use of Tranexamic Acid in Orthopedics and Other Surgeries. Adv Anesth 2023; 41:1-15. [PMID: 38251612 DOI: 10.1016/j.aan.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Tranexamic acid is a well-known antifibrinolytic that has numerous clinical indications, and it is efficacious and safe in many perioperative scenarios including patients with some thrombotic risks. However, further studies that characterize clinical outcomes concerning dosing, timing, and routes in combination are needed in ultra high-risk populations.
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Affiliation(s)
- Poonam Pai B H
- Department of Anesthesiology and Perioperative Pain Medicine, Mount Sinai West-Morningside Hospitals, 1000 Tenth Avenue, Suite 1G, New York, NY 10019, USA.
| | - Shivani Patel
- Department of Anesthesiology and Perioperative Pain Medicine, Mount Sinai West-Morningside Hospitals, 1000 Tenth Avenue, Suite 1G, New York, NY 10019, USA
| | - Yan H Lai
- Department of Anesthesiology and Perioperative Pain Medicine, Mount Sinai West-Morningside Hospitals, 1000 Tenth Avenue, Suite 1G, New York, NY 10019, USA
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Abu-Zaid A, Baradwan S, Albouq B, Ghazi A, Khadawardi K, Bukhari IA, Alyousef A, Abdulmalik NA, Alblewi H, Alsehaimi SO, Albadawi MI, Abuzaid M, Alomar O, Salem H. Tranexamic acid versus misoprostol for management of postpartum hemorrhage: A systematic review and meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2023; 291:61-69. [PMID: 37832480 DOI: 10.1016/j.ejogrb.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 10/15/2023]
Abstract
AIM To conduct the first-ever systematic review and meta-analysis of randomized controlled trials (RCTs) on the antihemorrhagic utility and safety of tranexamic acid (TXA) versus misoprostol for management (prevention and/or treatment) of postpartum hemorrhage (PPH). METHODS Six databases were screened from inception until May 2023 and updated in September 2023. The RCTs were assessed for quality according to the Cochrane's risk of bias tool. The endpoints were summarized as mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI) in a random-effects model. RESULTS Ten RCTs with 2121 patients (TXA = 1061 and misoprostol = 1060) were analyzed. There was no significant difference between TXA and misoprostol groups regarding the mean intraoperative blood loss (n = 9 RCTs, MD = 17.32 ml, 95% CI [-40.43, 75.07], p = 0.56), mean change in hemoglobin (n = 6 RCTs, MD = 0.11 mg/dl, 95% CI [-0.1, 0.31], p = 0.30), mean hospital stay (n = 2 RCTs, MD = -0.3 day, 95% CI [-0.61, 0.01], p = 0.06), blood transfusion rate (n = 4 RCTs, RR = 0.49, 95% CI [0.16, 1.47], p = 0.2), and rate of additional uterotonic agents (n = 4 RCTs, RR = 1.05, 95% CI [0.72, 1.53], p = 0.81). Leave-one-out sensitivity analysis showed robustness of the results, and there was no evidence of publication bias. Regarding safety endpoints, there was no significant difference between both groups regarding the rates of minor side effects, such as diarrhea, fever, nausea, and vomiting. No patient developed thromboembolic events in the TXA group. CONCLUSION There was no significant antihemorrhagic efficacy between adjunct TXA and misoprostol for the management of PPH. The safety profile was comparable between both agents.
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Affiliation(s)
- Ahmed Abu-Zaid
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Saeed Baradwan
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Bayan Albouq
- Department of Obstetrics and Gynecology, Prince Mohammed Bin Abdulaziz National Guard Hospital, Madinah, Saudi Arabia
| | - Ahmed Ghazi
- Department of Obstetrics and Gynecology, College of Medicine, Jeddah University, Jeddah, Saudi Arabia
| | - Khalid Khadawardi
- Department of Obstetrics and Gynecology, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Ibtihal Abdulaziz Bukhari
- Department of Obstetrics and Gynecology, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Abdullah Alyousef
- Department of Obstetrics and Gynecology, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Nadia Ahmed Abdulmalik
- Department of Obstetrics and Gynecology, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Hedaya Alblewi
- Department of Obstetrics and Gynecology, National Guard Hospital, Riyadh, Saudi Arabia
| | - Saud Owaimer Alsehaimi
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Mohammed Abuzaid
- Department of Obstetrics and Gynecology, Muhayil General Hospital, Muhayil, Saudi Arabia
| | - Osama Alomar
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hany Salem
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Wheeler DR, Bucci F, Vaccari S, di Giuli R, Vinci V, Klinger M. Topical Tranexamic Acid: Risks, Benefits and Novel Complications in Aesthetic Plastic Surgery. Aesthetic Plast Surg 2023; 47:2880-2888. [PMID: 37069351 DOI: 10.1007/s00266-023-03346-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 03/27/2023] [Indexed: 04/19/2023]
Abstract
Antifibrinolytics, particularly tranexamic acid (TXA), are agents used to reduce bleeding. TXA is a synthetic reversible competitive inhibitor to the lysine receptor found on plasminogen. By reversibly binding to this site, it leads to plasminogen being unable to bind to fibrin and so prevents fibrinolysis, this stabilizes the clot and thus prevents hemorrhage. (Pekrul in Der Anaesth 70:515-521, 2021) It can be used either intravenously or topically but has never entered mainstream use in plastic surgery. (Pekrul in Der Anaesth 70:515-521, 2021) This is most likely due to understandable fears of thromboembolic events. On the other hand, the tempting benefits are reduced bleeding (perioperatively) decreased bruising and swelling, and thus increased aesthetic, important for obvious reasons. A review of the literature was done to go deeper on this issue, examining topical use in aesthetic surgery. Clear benefit was shown in the literature, it could be postulated that it would not be unwise to consider more research on topical use of TXA in certain cases, the benefits could greatly outweigh the risks. Old fears and conceptions, unsupported by the literature at the time of writing, should not hold back further research, and the benefits shown could even potentially justify the topical use of these agents in the near future. Further studies evaluating the utility of TXA in Panniculectomy and Abdominoplasty surgery should be performed especially, since only one was found which reported no significant benefit. Minor complications were present, such as minor delayed post-auricular skin healing, temporary unilateral marginal mandibular neuropraxia and increased cumulative seroma volume. These were novel findings and could warrant further investigation as well. After performing a review of the literature, it was seen that topical TXA generally adds benefit in aesthetic plastic surgery, with no particularly significant complications. We would like to bring more attention to the issue and support more studies on TXA use. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Dakota Russell Wheeler
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy.
| | - Flavio Bucci
- Plastic Surgery Unit, Department of Medical Biotechnology and Translational Medicine BIOMETRA, Humanitas Clinical and Research Hospital, Reconstructive and Aesthetic Plastic Surgery School, University of Milan, Via Manzoni 56, 20090, Rozzano, MI, Italy
| | - Stefano Vaccari
- Plastic Surgery Unit, Department of Medical Biotechnology and Translational Medicine BIOMETRA, Humanitas Clinical and Research Hospital, Reconstructive and Aesthetic Plastic Surgery School, University of Milan, Via Manzoni 56, 20090, Rozzano, MI, Italy
| | - Riccardo di Giuli
- Plastic Surgery Unit, Department of Medical Biotechnology and Translational Medicine BIOMETRA, Humanitas Clinical and Research Hospital, Reconstructive and Aesthetic Plastic Surgery School, University of Milan, Via Manzoni 56, 20090, Rozzano, MI, Italy
| | - Valeriano Vinci
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Marco Klinger
- Plastic Surgery Unit, Department of Medical Biotechnology and Translational Medicine BIOMETRA, Humanitas Clinical and Research Hospital, Reconstructive and Aesthetic Plastic Surgery School, University of Milan, Via Manzoni 56, 20090, Rozzano, MI, Italy
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48
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Abdallah Z, Staibano P, Zhou K, Khalife S, Nguyen TBV, Sommer DD. Tranexamic acid in endoscopic sinus and skull base surgery: A systematic review and meta-analysis. Int Forum Allergy Rhinol 2023; 13:2187-2204. [PMID: 37259887 DOI: 10.1002/alr.23203] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/24/2023] [Accepted: 05/26/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Endoscopic sinus surgery (ESS) and endoscopic skull base surgery (ESBS) approaches have revolutionized the management of sinonasal and intracranial pathology. Maintaining surgical hemostasis is essential as bleeding can obscure the visibility of the surgical field, thus increasing surgical duration, risk of complications, and procedural failure. Tranexamic acid (TXA) acts to reduce bleeding by inhibiting fibrin degradation. This review aims to assess whether TXA improves surgical field quality and reduces intraoperative blood loss compared with control. METHODS We searched PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library from inception until September 1, 2022. Two reviewers independently screened citations, extracted data, and assessed methodological quality using the Cochrane risk-of-bias tool for randomized trials. Data were pooled using a random-effect model, with continuous data presented as mean differences and dichotomous data presented as odds ratios. RESULTS Seventeen ESS randomized controlled trials (n = 1377) and one ESBS randomized controlled trial (n = 50) were reviewed. Significant improvement in surgical field quality was achieved with both systemic TXA (six studies, p < 0.00001) and topical TXA (six studies, p = 0.01) compared with the control. Systemic TXA (eight studies) and topical TXA (three studies) both achieved a significant reduction in intraoperative blood loss compared with the control (p < 0.00001). There were significant differences in operative times (p < 0.001) but no significant difference in perioperative outcomes (p = 0.30). CONCLUSION This meta-analysis demonstrated that the administration of TXA in ESS can improve surgical field quality and reduce intraoperative blood loss. TXA use did not result in increased perioperative complications including thrombotic events.
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Affiliation(s)
- Zahra Abdallah
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Phillip Staibano
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kelvin Zhou
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Khalife
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Thomas B V Nguyen
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Doron D Sommer
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
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Wolf Y, Skorochod R, Kwartin S, Shapira L. Tranexamic Acid Irrigation in Liposuction: A Double-Blind, Half-Body, Randomized, Placebo-Controlled Trial. Aesthetic Plast Surg 2023; 47:2525-2532. [PMID: 37488309 DOI: 10.1007/s00266-023-03499-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/30/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Hematomas are common complications following plastic and esthetic surgeries. Large and complex hematomas might result in prolonged hospitalization, further interventions, additional expenses, and poor esthetic outcome. Tranexamic acid (TXA), an antifibrinolytic agent, has long been used to reduce blood loss. Its use in the field of plastic surgery has gained popularity recently. Several studies have presented the ability of TXA to reduce blood loss, hematomas, and ecchymoses after liposuctions. However, the proper dose and the route of administration remained controversial. OBJECTIVE The objective of the study was to quantify the effect of a low dose of TXA in an irrigation method in reducing hematomas and ecchymoses following liposuction. METHODS A prospective randomized controlled trial was conducted. Following liposuction, 400 mg of TXA were administered in an irrigation protocol to one side of the body in each patient, while the other side was administered with saline. The patients were photographed on 1, 2, 4, and 11 post-operative days. Ecchymosis and hematoma were measured and rated. RESULTS No statistical difference was observed between the intervention and control groups in terms of RBC in liposuction area (p = 0.11), RBC in lipoaspirate (p = 0.79), bruising size on days 1, 2, 4, and 11 (p = 0.68, 0.21, 0.42, and 0.75), and average ecchymosis score on the same days (p = 0.34, 0.72, 0.09, and 1) CONCLUSIONS: The use of a low-dose TXA irrigation solution did not demonstrate a statistically significant difference in post-operative hematoma formations rates and subsequent ecchymosis size and scale. LEVEL OF EVIDENCE II This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Yoram Wolf
- Plastic Surgery Unit, Hillel Yaffe Medical Center, P.O.B 169, 38100, Hadera, Israel.
| | - Ron Skorochod
- Plastic Surgery Unit, Hillel Yaffe Medical Center, P.O.B 169, 38100, Hadera, Israel
| | - Shmuel Kwartin
- Plastic Surgery Unit, Hillel Yaffe Medical Center, P.O.B 169, 38100, Hadera, Israel
| | - Liran Shapira
- Plastic Surgery Unit, Hillel Yaffe Medical Center, P.O.B 169, 38100, Hadera, Israel
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50
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Huynh MNQ, Wong CR, McRae MC, Voineskos S, McRae MH. The Effects of Tranexamic Acid in Breast Surgery: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2023; 152:993e-1004e. [PMID: 36995174 DOI: 10.1097/prs.0000000000010479] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is used in trauma and surgical settings. Its role in reducing postoperative blood loss in breast surgery remains unclear. The primary objective of this study was to determine the effect of TXA on postoperative blood loss in breast surgery. METHODS Searches of the PubMed, Ovid MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases were performed from inception to April 3, 2020. Inclusion criteria were any retrospective reviews, prospective cohort studies, and randomized controlled trials that administered TXA (topical or intravenously) in the context of breast surgery. Quality of studies were evaluated using the risk of bias in randomized trials tool and the risk of bias in nonrandomized studies of interventions tool. Data were pooled, and a meta-analysis was performed. RESULTS In total, seven studies were included, representing 1226 patients (TXA, 632 patients; control, 622 patients). TXA was administered as follows: topically (20 mL of 25 mg/mL TXA intraoperatively; n =258 patients), intravenously (1 to 3 g perioperatively; n = 743 patients), or both (1 to 3 g daily up to 5 days postoperatively; n = 253 patients). TXA administration reduced hematoma formation in breast surgery (risk ratio, 0.48; 95% CI, 0.32 to 0.73), with no effect on drain output (mean difference, -84.12 mL; 95% CI, -206.53 to 38.29 mL), seroma formation (risk ratio, 0.92; 95% CI, 0.60 to 1.40), or infection rates (risk ratio, 1.01; 95% CI, 0.46 to 2.21). No adverse effects were reported. CONCLUSION The use of TXA in breast surgery is a safe and effective modality with low-level evidence that it reduces hematoma rates without affecting seroma rates, postoperative drain output, or infection rates.
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Affiliation(s)
| | - Chloe R Wong
- Michael G. DeGroote School of Medicine, McMaster University
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