Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion

Role of tranexamic acid (TXA) in plastic and reconstructive surgery: A national perspective

PURPOSE

Despite the widespread use of tranexamic acid (TXA) in plastic surgery, guidelines for the safe and effective administration have yet to be established. The present study reports the current practices of TXA usage in plastic and reconstructive surgery procedures among members of the American Society of Plastic Surgeons (ASPS).

METHODS

An online survey was distributed to all active members of the ASPS. The survey was organized into three general parts: (1) demographic data and practice profiles; (2) familiarity, perceptions, and experience with TXA in various plastic surgery fields including craniofacial surgery, aesthetic surgery, burn care, microsurgery, and Mohs surgery; and (3) TXA dosage, mode, and time of administration.

RESULTS

Five hundred two ASPS members completed the survey (21% response rate). Among the respondents, TXA use was most common in aesthetic surgery (90.3%), craniofacial surgery (78.2%), and breast reconstruction (61.8%). The most common procedures performed under TXA were facial procedures, including facelift (83.6%), neck lift (77.1%), forehead and browlift (54.8%), and rhinoplasty (55.0%). TXA administration protocols in aesthetic procedures included IV bolus (52.3%) and topical administration (50.5%). The most common IV bolus dose was 1 g (43.2%) and the most common TXA solution concentration was 3% (36.0). A total of 92.4% of respondents reported that they had never observed any TXA-related complications.

CONCLUSIONS

The results reflect the widespread use of TXA among ASPS members, the preferred administration protocols in plastic surgery, and TXA's efficacy and favorable safety profile across a wide range of procedures.

Tranexamic acid for reducing blood loss in bipolar transurethral resection of the prostate: a systematic review of literature

OBJECTIVE

To study the efficacy of tranexamic acid at reducing bleeding during bipolar prostate resection surgery (B-TURP) in patients with benign prostatic hyperplasia.

METHODS

We searched registers with MESH terms "prostate hyperplasia," "prostate surgery," and "tranexamic acid." Studies available in full and online, published from 2013 to 2023, in Portuguese, English, Spanish, and French were included; review articles were excluded. Information sources: Portal Regional da Biblioteca Virtual em Saúde and PubMed Central. The Cochrane RoB2 tool was used to analyze risk of bias in randomized clinical trials.

RESULTS

Two randomized clinical trials involving 256 patients were included. Both groups had minimal risk of bias. Both studies showed a positive effect of tranexamic acid on blood loss parameters. Only one study in the tranexamic acid group had a lower transfusion rate, and another had a lower irrigation fluid volume and operation time in the tranexamic acid group. A meta-analysis was not performed because of the limited number of eligible studies.

CONCLUSION

For patients undergoing B-TURP for benign prostatic hyperplasia symptoms, the use of tranexamic acid reduced blood loss. However, a limited number of patients were studied, and the available randomized clinical trials presented conflicting conclusions. Therefore, further studies are needed to explore this aspect in detail.

PROSPERO DATABASE REGISTRATION

(www.crd.york.ac.uk/prospero) under registration ID CRD42023416383.

Cost analysis study comparing the impact of treatment with aprotinin versus tranexamic acid in cardiac surgery under cardiopulmonary bypass

OBJECTIVES

An increased risk of mortality and postoperative side effects led to aprotinin (Trasylol®) withdrawal from the market in 2008, but since 2018 aprotinin has again been used in France. The French retrospective multicentre APACHE study (AProtinin versus tranexamic Acid in Cardiac surgery patients with High-risk for Excessive bleeding) compared the efficacy of tranexamic acid versus half-dose aprotinin. The aim of this study, ancillary to the APACHE study, is to carry out a medico-economic analysis of the use of these two antifibrinolytics on an APACHE subpopulation.

METHODS

Economic data on reimbursement by the French health insurance system were extracted from the program for the data processing of medical information, and quantitative data on the cost of healthcare products were obtained from the hospital pharmacy software.

RESULTS

The main analysis of costs for the population shows that the global valuation was not significantly different between the two treatment groups (P=0.60), but the costs of blood products included in the related hospital stay group (Groupe Homogène de séjour [GHS]) (whole blood, platelets and plasma) were higher for the tranexamic acid group (P=0.007). In a sub-analysis of patients alive at discharge, the costs of blood products in addition to GHS (blood-derived medicines) and the costs of blood products in the GHS were higher for the tranexamic acid group (P=0.04 and 0.001, respectively).

CONCLUSIONS

The additional cost of aprotinin at the time of purchase is offset by the additional costs of blood products in the tranexamic acid group.

Effect of early tranexamic acid treatment on fatigue in patients with mild traumatic brain injury: data from the CRASH-3 clinical trial

Background

Each year world-wide about 65 million people sustain a mild traumatic brain injury (mTBI). Fatigue is a common and distressing symptom after mTBI. We examine the effect of tranexamic acid (TXA) on fatigue in patients with mTBI using data from the CRASH-3 trial.

Methods

The CRASH-3 trial randomised 9,202 patients with traumatic brain injury and no significant extracranial bleeding to receive TXA or placebo within 3 hours of injury. The primary outcome was death from head injury within 28 days of injury. The methods and results are presented elsewhere. Fatigue was recorded as "None", "Moderate" or "Extreme." This study examines the effect of TXA on extreme fatigue in the 2,632 patients with mTBI (Glasgow Coma Scale [GCS] score≥13). Our analyses were not prespecified.

Results

Our study primary outcome, extreme fatigue, was reported for 10 (0.8%) of 1,328 patients receiving TXA and 19 (1.5%) of 1,288 patients receiving placebo (risk ratio [RR]=0.51, 95% confidence interval [CI] 0.24-1.09). Death within 28 days of injury was reported for 34 (2.6%) of 1,328 patients receiving TXA versus 47 (3.6%) of 1,288 patients receiving placebo (RR=0.70, 95% CI 0.45-1.08). Among patients allocated to TXA, 44 (3.3%) patients either died or reported extreme fatigue versus 66 (5.1%) patients among those allocated to placebo (RR=0.65, 95% CI 0.44-0.94). This composite outcome is disproportionately influenced by deaths which account for 74% (81 from 110) of events.

Conclusions

We found no evidence that tranexamic acid reduces fatigue in patients with mTBI. Given, 1) our analyses were not prespecified, 2) our outcome measure is not based on a validated fatigue severity scale, and 3) TBI patients can suffer from hospital-induced delirium, which hinders clinician assessment, these results need to be replicated in another study.

Registration

ISRCTN (ISRCTN15088122, 19/07/2011), ClinicalTrials.gov (NCT01402882, 26/07/2011), EudraCT (2011-003669-14, 25/07/2011), Pan African Clinical Trial Registry (PACTR20121000441277, 30/10/2012).

Development of a Methodology Based on Optical Interferometry for Measuring Fibrinolytic Activity

Fibrinolytic activity assay is particularly important for the detection, diagnosis, and treatment of cardiovascular disease and the development of fibrinolytic drugs. A novel efficacious strategy for real-time and label-free dynamic detection of fibrinolytic activity based on ordered porous layer interferometry (OPLI) was developed. Fibrin or a mixture of fibrin and plasminogen (Plg) was loaded into the highly ordered silica colloidal crystal (SCC) film scaffold to construct a fibrinolytic response interference layer to measure fibrinolytic activity with different mechanisms of action. Fibrinolytic enzyme-triggered fibrinolysis led to the migration of interference fringes in the interferogram, which could be represented by optical thickness changes (ΔOT) tracked in real time by the OPLI system. The morphology and optical property of the fibrinolytic response interference layer were characterized, and the Plg content in the fibrinolytic response interference layer and experimental parameters of the system were optimized. The method showed adequate sensitivity for the fibrinolytic activity of lumbrokinase and streptokinase, with wide linear ranges of 12-6000 and 10-2000 U/mL, respectively. Compared with the traditional fibrin plate method, it has a lower detection limit and higher linearity. The whole kinetic process of fibrinolysis by these two fibrinolytic drug models was recorded in real time, and the Michaelis constant and apparent kinetic parameters were calculated. Importantly, some other blood proteins were less interfering with this system, and it showed reliability in fibrin activity detection in real whole blood samples. This study established a better and more targeted research method of in vitro fibrinolysis and provided dynamic monitoring data for the analysis of fibrinolytic activity of whole blood.

Tranexamic acid versus oxytocin prophylaxis in reducing post-partum blood loss, in low-risk pregnant women: TRANOXY STUDY, a phase III randomized clinical trial

Background

To assess the equivalence of tranexamic acid (TRAN) versus synthetic oxytocin (OXY) in reducing post-partum blood loss, in full-term patients (37-42 weeks), at low risk of post-partum hemorrhage, with vaginal childbirth.

Methods

Phase III, randomized (1:1), open-label, longitudinal, multi-center, prospective clinical trial (Prot. n 63209, ClinicalTrials.gov Identifier: NCT02775773). From January 7, 2020, to June 30, 2023, a total of 256 women were enrolled at two general urban community hospitals in Italy, serving a multi-ethnic patient population with National Health Insurance. The primary outcome was to explore a potential equivalence between the two treatments (OXY and TRAN) in preventing total blood loss. Therefore, we randomized 231 women into two groups: Group A (OXY), 127 women who were administered 10UI intramuscularly within 5 min from childbirth; Group B (TRAN), 104 women to whom 1-g slow intravenous infusion was administered within 5 min from childbirth.

Findings

At the time of delivery, mean blood loss for OXY group versus TRAN group was 269.12 mL versus 263.88 mL, respectively, with equivalence between the two groups. Similarly, there was equivalence in total blood loss between the OXY and the TRAN group (397.66 mL versus 405.64 mL, respectively. No statistical differences between Hb levels at admission and discharge in the two groups were reported. No difference was found in terms of additional uterotonic and surgical therapies between the two groups of patients. Neither group showed thrombotic complications at check-up performed after 7 days or after a questionnaire regarding adverse effects, subjected after 40 days.

Interpretation

The study shows the equivalence of tranexamic acid versus synthetic oxytocin in post-partum blood loss prophylaxis in term patients at low risk of PPH with vaginal childbirth. The safety profiles of OXY and TRAN were similar.

Funding

None.

Topical Tranexamic Acid in Primary Breast Augmentation Surgery: Short- and Long-term Outcomes

BACKGROUND

Breast augmentation mammaplasty (BAM) remains the most popular cosmetic procedure done worldwide. Bleeding in this procedure increases the chance of capsular contracture. Tranexamic acid (TXA), an antifibrinolytic, has been widely used by other surgical specialties to reduce bleeding.

OBJECTIVES

We aimed to evaluate the use of TXA in BAM surgery.

METHODS

This was a single-surgeon case series of all patients who underwent primary BAM from March 2017 to March 2018 and received topical TXA spray to the implant pocket before implant insertion. Early postoperative complications and long-term outcomes, such as capsular contracture and revisional surgery, were recorded and described.

RESULTS

Two hundred and eighty-eight patients were included in the study with an overall complication rate of 2.8% over 5 years. No patients had postoperative bleeding or hematoma formation. One patient had a seroma, managed with ultrasound drainage. Complications requiring reoperation included rippling (3, 1.0%), pocket revision (2, 0.7%), capsule contracture (1, 0.3%) and rupture (1, 0.3%).

CONCLUSIONS

This study highlights the safety and potential benefits of the use of topical TXA in breast augmentation, with low bleeding and capsular contracture rates.

LEVEL OF EVIDENCE: 4

Patient Blood Management and Its Role in Supporting Blood Supply

Blood donors and voluntary blood donations are essential for ensuring the blood supply that can be maintained by good patient blood management (PBM) practices. This review article explores the role of blood donation in PBM and highlights the importance of donor screening and selection processes in different regions worldwide. The donor health questionnaires and the focused physical examination guidelines have changed in the last decade to increase donor and recipient safety. This article also discusses the status of transfusion practices, including the challenges of ensuring a safe blood supply. Significant among these are the effects of the COVID-19 pandemic on the blood supply chain and the impact of an aging donor population, especially. Promoting autologous donations and other blood conservation strategies are suggested to mitigate these issues. The role of replacement donors and the upper age limit for voluntary blood donation may be decided based on the demography and donor pool. The involvement of C-suite executives is also critical in implementing and running a successful PBM program. The review highlights how these different aspects of blood donation are integral to a successful PBM program and the safety of patients who receive blood transfusions.

Perioperative hemostatic management of patients with type A aortic dissection

Coagulopathy is common in patients undergoing thoracic aortic repair for Stanford type A aortic dissection. Non-critical administration of blood products may adversely affect the outcome. It is therefore important to be familiar with the pathologic conditions that lead to coagulopathy in complex cardiac surgery. Adequate care of these patients includes the collection of the medical history regarding the use of antithrombotic and anticoagulant drugs, and a sophisticated diagnosis of the coagulopathy with viscoelastic testing and subsequently adapted coagulation therapy with labile and stable blood products. In addition to the above-mentioned measures, intraoperative blood conservation measures as well as good interdisciplinary coordination and communication contribute to a successful hemostatic management strategy.

Is Tranexamic Acid an Effective Prevention in the Formation of Epidural Fibrosis? Histological Evaluation in the Rats

OBJECTIVE

The present study aimed to determine the topical and systemic efficacy of tranexamic acid (TXA) on epidural fibrosis in a rat laminectomy model.

METHODS

Thirty-two 12-month-old adult Sprague-Dawley rats were used in this study. Each rat underwent bilateral laminectomy at the L1 and L2 vertebral levels. Rats were divided into four groups : in group I (control group, n=8), a laminectomy was performed and saline solution was applied into the surgical space. In group II (topical group, n=8), laminectomy was performed and 30 mg/ kg TXA was applied to the surgical site before skin closure. In group III (systemic group, n=8), 30 mg/kg TXA was administered intravenously via the tail vein in the same session as the surgical procedure. In group IV (topical and systemic group, n=8), TXA was administered 30 mg/kg both topical and intravenous. The rats were sacrificed at 4 weeks postoperatively. Masson's trichrome and hematoxylin and eosin were used to assess acute inflammatory cells, chronic inflammatory cells, vascular proliferation, and epidural fibrosis.

RESULTS

Epidural fibrosis, acute inflammation, chronic inflammation, and sum histologic score value were significantly lower in the systemic TXA group, systemic and topical TXA groups than in the control group (p<0.05). In addion, the sum histologic score was significantly lower in the topical TXA group than in the control group (p<0.05).

CONCLUSION

In this study, epidural fibrosis formation was prevented more by systemic application, but the topical application was found to be effective when compared to the control group. As a result, we recommend the systemic and topical use of TXA to prevent epidural fibrosis during spinal surgery.

The Optimal Dosing and Timing of Tranexamic Acid in Reducing Perioperative Bleeding and Transfusion Requirements in Vascular Surgery Patients: A Systematic Review

Tranexamic acid (TXA) has been widely investigated as an antifibrinolytic agent to minimize perioperative bleeding and transfusion requirements in various surgical settings. This systematic review aims to assess the optimal dosing and timing of TXA administration for reducing perioperative bleeding and transfusion requirements, specifically in vascular surgery patients. A comprehensive search was conducted using multiple databases, and relevant articles were selected based on predefined inclusion criteria. A total of 20 studies were identified and analyzed, including randomized controlled trials (RCTs), systematic reviews, and meta-analyses. Findings from these studies were synthesized to provide a comprehensive overview of the evidence regarding the use of TXA in vascular surgery.

Analysis of the efficacy of prophylactic tranexamic acid in preventing postpartum bleeding: systematic review with meta-analysis of randomized clinical trials

BACKGROUND

Postpartum Hemorrhage (PPH) is one of the main causes of maternal mortality, mainly in the poorest regions of the world, drawing attention to the need for strategies for preventing it. This study aims to evaluate the efficacy of prophylactic administration of Tranexamic Acid (TXA) in decreasing blood loss in pregnant women in delivery, preventing PPH.

METHODS

Systematic review of randomized clinical trials. We searched for publications in PubMed, EMBASE and Cochrane Library databases, with the uniterms "postpartum, puerperal hemorrhage" and "tranexamic acid", published between January of 2004 and January of 2020. The eligibility criteria were trials published in English with pregnant women assessed during and after vaginal or cesarean delivery about the effect of prophylactic use of TXA on bleeding volume. The random-effects model was applied with the DerSimonian-Laird test and the Mean Difference (MD) was calculated for continuous variables together with each 95% CI. This systematic review was previously registered in the PROSPERO platform under the registration n° CRD42020187393.

RESULTS

Of the 630 results, 16 trials were selected, including one with two different doses, performing a total of 6731 patients. The intervention group received a TXA dose that varied between 10 mg.kg^-1 and 1g (no weight calculation). The TXA use was considered a protective factor for bleeding (MD: -131.07; 95% CI: -170.00 to -92.78; p = 0.000) and hemoglobin variation (MD: -0.417; 95% CI: -0.633 to -0.202; p = 0.000). In the subgroup analysis related to the cesarean pathway, the effect of TXA was even greater.

CONCLUSION

The prophylactic use of tranexamic acid is effective in reducing the post-partum bleeding volume.

PROSPERO REGISTRATION ID

CRD42020187393.

Current Clinical Trials in Traumatic Brain Injury

Traumatic brain injury (TBI) is one of the leading causes of morbidity, disability and mortality across all age groups globally. Currently, only palliative treatments exist, but these are suboptimal and do little to combat the progressive damage to the brain that occurs after a TBI. However, multiple experimental treatments are currently available that target the primary and secondary biochemical and cellular changes that occur after a TBI. Some of these drugs have progressed to clinical trials and are currently being evaluated for their therapeutic benefits in TBI patients. The aim of this study was to identify which drugs are currently being evaluated in clinical trials for TBI. A search of ClinicalTrials.gov was performed on 3 December 2021 and all clinical trials that mentioned “TBI” OR “traumatic brain injury” AND “drug” were searched, revealing 362 registered trials. Of the trials, 46 were excluded due to the drug not being mentioned, leaving 138 that were completed and 116 that were withdrawn. Although the studies included 267,298 TBI patients, the average number of patients per study was 865 with a range of 5–200,000. Of the completed studies, 125 different drugs were tested in TBI patients but only 7 drugs were used in more than three studies, including amantadine, botulinum toxin A and tranexamic acid (TXA). However, previous clinical studies using these seven drugs showed variable results. The current study concludes that clinical trials in TBI have to be carefully conducted so as to reduce variability across studies, since the severity of TBI and timing of therapeutic interventions were key aspects of trial success.

Effect of early tranexamic acid treatment on fatigue in patients with mild traumatic brain injury: data from the CRASH-3 clinical trial

Background: Each year world-wide about 65 million people sustain a mild traumatic brain injury (mTBI). Fatigue is a common and distressing symptom after mTBI. We examine the effect of tranexamic acid (TXA) on fatigue in patients with mTBI using data from the CRASH-3 trial. Methods: The CRASH-3 trial randomised 9,202 patients with traumatic brain injury and no significant extracranial bleeding to receive TXA or placebo within 3 hours of injury. The primary outcome was death from head injury within 28 days of injury. The methods and results are presented elsewhere. Fatigue was recorded as “None”, “Moderate” or “Extreme.” This study examines the effect of TXA on extreme fatigue in the 2,632 patients with mTBI (Glasgow Coma Scale [GCS] score≥13). Our analyses were not prespecified. Results: Our study primary outcome, extreme fatigue, was reported for 10 (0.8%) of 1,328 patients receiving TXA and 19 (1.5%) of 1,288 patients receiving placebo (risk ratio [RR]=0.51, 95% confidence interval [CI] 0.24-1.09). Death within 28 days of injury was reported for 34 (2.6%) of 1,328 patients receiving TXA versus 47 (3.6%) of 1,288 patients receiving placebo (RR=0.70, 95% CI 0.45-1.08). Among patients allocated to TXA, 44 (3.3%) patients either died or reported extreme fatigue versus 66 (5.1%) patients among those allocated to placebo (RR=0.65, 95% CI 0.44-0.94). Conclusions: Early tranexamic acid treatment may reduce fatigue in mTBI patients, but these results need to be confirmed in a larger trial. Registration: ISRCTN (ISRCTN15088122, 19/07/2011), ClinicalTrials.gov (NCT01402882, 26/07/2011), EudraCT (2011-003669-14, 25/07/2011), Pan African Clinical Trial Registry (PACTR20121000441277, 30/10/2012).

Efficacy of antifibrinolytics in reducing blood loss during hip reconstruction surgery in cerebral palsy children. A systematic review and meta-analysis

BACKGROUND

Cerebral palsy (CP) children undergoing hip reconstruction are more prone to blood loss during surgery due to poor nutritional status, antiepileptic medication intake, depletion of clotting factors, and the extent of surgery involved. We conducted this present review to analyze whether antifibrinolytics during hip surgery in CP children would reduce surgical blood loss and transfusion requirements.

METHODS

Three databases (PubMed, EMBASE, and Cochrane library) were searched independently for publications mentioning the use of antifibrinolytics during hip reconstruction surgery in CP children. The primary outcome was to compare the surgical blood loss with and without antifibrinolytics use. Secondary outcomes were transfusion requirements, drop in hemoglobin level, length of hospital stay, and complication rates.

RESULTS

All five studies (reporting 478 patients) published on this topic were found eligible based on inclusion criteria and were included for final analysis. Primary outcome: In three of the included studies, antifibrinolytics use resulted in a significant reduction in total blood loss with a mean difference (MD) of -151.05 mL (95% CI -272.30 to -29.80, p = 0.01). In the other two studies although statistically not significant, antifibrinolytics use reduces estimated blood loss (MD: 3.27, 95% CI -21.44 to 14.91, p = 0.72). Secondary outcomes: We observed that in the antifibrinolytics group, there was a reduction in total blood transfusion requirements (OD: 0.70, 95% CI 0.35 to 1.37, p = 0.29), and a drop in haemoglobin level (MD: 0.16, 95% CI -0.62 to 0.30, p = 0.49) but statistically not significant. No adverse effects related directly to antifibrinolytics were noticed in all five studies.

CONCLUSION

Only two out of five included studies favored the use of antifibrinolytics in CP children undergoing hip reconstruction. The evidence synthesized on this meta-analysis is also not sufficient enough to support its routine use in this cohort of children for hip reconstruction surgery. High-quality studies with adequate sample size to determine the effective and safe dosage, timing, and cost involved of different antifibrinolytics are the need of the hour.

LEVEL OF EVIDENCE

Ⅲ.

A Systematic Review of Tranexamic Acid in Plastic Surgery: What's New?

BACKGROUND

Blood loss associated with surgical interventions can lead to several complications. Therefore, minimizing perioperative bleeding is critical to improve overall survival. Several interventions have been found to successfully reduce surgical bleeding, including the antifibrinolytic agent. After aprotinin was withdrawn from the market in 2008, TXA remained the most commonly used medication. The safety and efficacy of TXA has been well studied in other specialties. TXA has been rarely used in plastic surgery, except in craniofacial procedures. Since the last review, the number of articles examining the use of TXA has doubled; so the aim of this systematic review is to update the readers on the current knowledge and clinical recommendations regarding the efficacy of TXA in plastic surgical procedures.

METHODS

A systematic literature search was conducted in Medline, SciELO, Cochrane, and Google Scholar to evaluate all articles that discussed the use of TXA in plastic surgery in the fields of aesthetic surgery, burn care, and reconstructive microsurgery.

RESULTS

A total of 233 publications were identified using the search criteria defined above. After examination of titles and abstracts, and exclusion of duplicates, a total of 23 articles were selected for analysis.

CONCLUSIONS

The literature shows a clear benefit of using TXA to decrease blood loss regardless of the administration route, with no risk of thrombosis events. Also, TXA elicits a potent anti-inflammatory response with a decrease in postoperative edema and ecchymosis, which improves recovery time. Further investigations are needed to standardize the optimal administration route and dosage of TXA.

A randomized, double-blinded trial comparing the effectiveness of tranexamic acid and epsilon-aminocaproic acid in reducing bleeding and transfusion in cardiac surgery

Objectives:

To compare the effectiveness of epsilon aminocaproic acid (EACA) to tranexamic acid (TA) in reducing blood loss and transfusion requirements in patients undergone cardiac surgery under cardiopulmonary bypass.

Design:

Randomized, double blinded study. Outcome variables collected included; baseline demographic characteristics, type of surgery, amount of 24 hour chest tube drainage, amount of 24 hour blood products administered, 30 day mortality and morbidity and length of stay. We analyzed the data using parametric and non-parametric tests as appropriate.

Setting:

Single center tertiary-care university hospital setting.

Participants:

114 patients who had undergone cardiac surgery under cardiopulmonary bypass.

Interventions:

Standard dose of intra-operative EACA or TA was compared in patients undergone cardiac surgery under cardiopulmonary bypass.

Results:

There was no statistically significant difference between groups when analyzing chest tube drainage. However, there was a significant difference in the administration of any transfusion (PRBC's, FFP, platelets) intra-operatively to 24 hours postoperatively, with less transfusion in patients receiving EACA compared to TA (25% vs. 44.8%, respectively P = 0.027). Additionally, there was no significant difference in terms of adverse events during the one month follow up period.

Conclusion:

The findings of this study suggest that EACA and TA have similar effects on chest tube drainage but EACA is associated with fewer transfusions in CABG alone surgeries. Our results suggest that EACA can be used in a similar fashion to TA which may result in a cost and morbidity advantage.

Tranexamic Acid in Aesthetic Facial Plastic Surgery: A Systematic Review of Evidence, Applications, and Outcomes

Background

Tranexamic acid (TXA) is an antifibrinolytic that has become widely used in aesthetic facial plastic surgery, although its efficacy has not been well investigated.

Objectives

To evaluate the existing evidence for use of TXA in aesthetic facial plastic surgery, highlighting routes of administration, dosing, surgical applications, and clinical outcomes.

Methods

Systematic review of primary literature evaluating TXA in aesthetic facial plastic surgery.

Results

Eleven studies met inclusion criteria: 8 prospective randomized controlled trials, 2 retrospective case series/cohort studies, and 1 clinical opinion. Six studies evaluated TXA in rhinoplasty, 4 in rhytidectomy, and 1 in blepharoplasty. Significant reductions in intraoperative blood loss were found in 5 rhinoplasty studies. Three rhinoplasty and 2 rhytidectomy studies found significantly reduced postoperative edema and ecchymosis. One rhinoplasty and 1 rhytidectomy study reported reduced operative time and time to achieve hemostasis. One rhytidectomy study reported reduced postoperative drain output and faster time to drain removal. No studies reported an adverse outcome directly related to TXA.

Conclusions

Existing literature investigating TXA in aesthetic facial plastic surgery is sparse with varying levels of evidence and heterogeneous data. Literature suggests systemic TXA reduces intraoperative blood loss during rhinoplasty, although the clinical significance of this blood loss reduction is unclear. TXA may also reduce postoperative edema and/or ecchymosis in rhytidectomy and rhinoplasty, although the lack of validated grading scales yields insufficient evidence to support this claim. Topical and subcutaneously injected TXA are emerging administration routes in rhytidectomy, with evidence suggesting TXA mixed with tumescent may reduce postoperative drain output, thereby expediting drain removal.

Level of Evidence: 2

Introduction of a standardised protocol, including systematic use of tranexamic acid, for management of severe adult trauma patients in a low-resource setting: the MSF experience from Port-au-Prince, Haiti

BACKGROUND

Bleeding is an important cause of death in trauma victims. In 2010, the CRASH-2 study, a multicentre randomized control trial on the effect of tranexamic acid (TXA) administration to trauma patients with suspected significant bleeding, reported a decreased mortality in randomized patients compared to placebo. Currently, no evidence on the use of TXA in humanitarian, low-resource settings is available. We aimed to measure the hospital outcomes of adult patients with severe traumatic bleeding in the Médecins Sans Frontières Tabarre Trauma Centre in Port-au-Prince, Haiti, before and after the implementation of a Massive Haemorrhage protocol including systematic early administration of TXA.

METHODS

Patients admitted over comparable periods of four months (December2015- March2016 and December2016 - March2017) before and after the implementation of the Massive Haemorrhage protocol were investigated. Included patients had blunt or penetrating trauma, a South Africa Triage Score ≥ 7, were aged 18-65 years and were admitted within 3 h from the traumatic event. Measured outcomes were hospital mortality and early mortality rates, in-hospital time to discharge and time to discharge from intensive care unit.

RESULTS

One-hundred and sixteen patients met inclusion criteria. Patients treated after the introduction of the Massive Haemorrhage protocol had about 70% less chance of death during hospitalization compared to the group "before" (adjusted odds ratio 0.3, 95%confidence interval 0.1-0.8). They also had a significantly shorter hospital length of stay (p = 0.02).

CONCLUSIONS

Implementing a Massive Haemorrhage protocol including early administration of TXA was associated with the reduced mortality and hospital stay of severe adult blunt and penetrating trauma patients in a context with poor resources and limited availability of blood products.

Comparing the efficacy of intravenous or intra-articular tranexamic acid in reducing blood loss in simultaneous bilateral knee replacement surgery without the use of tourniquet

PURPOSE

To compare the effect of intravenous or intra-articular route of administration of tranexamic acid in reducing the blood loss in simultaneous bilateral total knee replacement surgeries performed without the use of tourniquets.

METHODS

Prospective cohort study of 30 consecutive patients grouped into two groups; Group 1: intravenous group and group 2: intra-articular group. Two outcome measures were studied; mean drop in post-operative haemoglobin and need for blood transfusion in both groups.

RESULTS

No significant difference in mean drop of haemoglobin and need for blood transfusion in both groups.

CONCLUSION

Route of administration of tranexamic acid does not influence on the mean drop of haemoglobin and need for blood transfusion in simultaneous bilateral total knee replacement surgeries performed without the use of tourniquet.

Tranexamic Acid Use in Prehospital Uncontrolled Hemorrhage

The use of tranexamic acid (TXA) in the treatment of trauma patients was relatively unexplored until the landmark Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage-2 (CRASH-2) trial in 2010 demonstrated a reduction in mortality with the use of TXA. Although this trial was a randomized, double-blinded, placebo-controlled study incorporating >20,000 patients, numerous limitations and weaknesses have been described. As a result, additional studies have followed, delineating the potential risks and benefits of TXA administration. A systematic review of the literature to date reveals a mortality benefit of early (ideally <1 hour and no later than 3 hours after injury) TXA administration in the treatment of severely injured trauma patients (systolic blood pressure <90 mm Hg, heart rate >110). Combined with abundant literature showing a reduction in bleeding in elective surgery, the most significant benefit may be administration of TXA before the patient goes into shock. Those trials that failed to show a mortality benefit of TXA in the treatment of hemorrhagic shock acknowledged that most patients received blood products before TXA administration, thus confounding the results. Although the use of prehospital TXA in the severely injured trauma patient will become more clear with the trauma studies currently underway, the current literature supports the use of prehospital TXA in this high-risk population. We recommend considering a 1 g TXA bolus en route to definitive care in high-risk patients and withholding subsequent doses until hyperfibrinolysis is confirmed by thromboelastography.

Blood utilization in revision versus first-time cardiac surgery: an update in the era of patient blood management

BACKGROUND

Relative to first-time (primary) cardiac surgery, revision cardiac surgery is associated with increased transfusion requirements, but studies comparing these cohorts were performed before patient blood management (PBM) and blood conservation measures were commonplace. The current study was performed as an update to determine if this finding is still evident in the PBM era.

STUDY DESIGN AND METHODS

Primary and revision cardiac surgery cases were compared in a retrospective database analysis at a single tertiary care referral center. Two groups of patients were assessed: 1) those having isolated coronary artery bypass (CAB) or valve surgery and 2) all other cardiac surgeries. Intraoperative and whole hospital transfusion requirements were assessed for the four major blood components.

RESULTS

Compared to the primary cardiac surgery patients, the revision surgery patients required approximately twofold more transfused units intraoperatively (p < 0.0001) and approximately two- to threefold more transfused units for the whole hospital stay (p < 0.0001). Intraoperative massive transfusion (>10 red blood cell [RBC] units) was substantially more frequent with revision versus primary cardiac surgery (2.6% vs. 0.1% [p < 0.0001] for isolated CAB or valve and 6.1% vs. 1.9% [p < 0.0001] for all other cardiac surgeries). Revision surgery was an independent risk factor for both moderate (6-10 RBC units) and massive intraoperative transfusion.

CONCLUSIONS

In the era of PBM, with restrictive transfusion strategies and a variety of methods for blood conservation, revision cardiac surgery patients continue to have substantially greater transfusion requirements relative to primary cardiac surgery patients. This difference in transfusion requirement was greater than what has been previously reported in the pre-PBM era.

USE OF TRANEXAMIC ACID IN TRAUMA PATIENTS: AN ANALYSIS OF COST-EFFECTIVENESS FOR USE IN BRAZIL

Introduction:

Use of tranexamic acid (TXA) in trauma has been the subject of growing interest by researchers and health professionals. However, there are still several open questions regarding its use. In some aspects medical literature is controversial. The points of disagreement among experts include questions such as: Which patients should receive TXA in trauma? Should treatment be performed in the pre-hospital environment? Is there any need for laboratory parameters before starting TXA treatment? What is the drug safety profile? The main issue on which there is still no basis in literature is: What is the indication for treatment within massive transfusion protocols?

Objective:

Answer the questions proposed based on critical evaluation of the evidence gathered so far and carry out a study of cost-effectiveness of TXA use in trauma adapted to the Brazilian reality.

Methods:

A literature review was performed through searching Pubmed.com, Embase and Cab Abstract by headings "tranexamic AND trauma", in all languages, yielding 426 articles. Manuscripts reporting on TXA utilization for elective procedures were excluded, remaining 79 articles. Fifty-five articles were selected, and critically evaluated in order to answer study questions. The evaluation of cost effectiveness was performed using CRASH-2 trial data and Brazilian official population data.

Results:

TXA is effective and efficient, and should be administered to a wide range of patients, including those with indication evaluated in research protocols and current indication criteria for TXA should be expanded. As for the cost-effectiveness, the TXA proved to be cost-effective with an average cost of R$ 61.35 (currently US$16) per year of life saved.

Conclusion:

The use of TXA in trauma setting seems to be effective, efficient and cost-effective in the various groups of polytrauma patients. Its use in massive transfusion protocols should be the subject of further investigations.

Effectiveness of tranexamic acid for decreasing bleeding in prostate surgery: a systematic review and meta-analysis

Introduction

The objective of this study was to determine the effectiveness of tranexamic acid in decreasing bleeding in patients undergoing prostate surgery.

Material and methods

All clinical experiments were included without language restrictions. The inclusion criteria were as follows: men over 18 years of age who underwent prostate surgery (transurethral, prostate adenectomy, and radical prostatectomy) and received tranexamic acid prior to prostate surgery as a preventive measure for perioperative hemorrhage. Prophylactic tranexamic acid vs. no intervention or placebo were compared. The primary outcomes were as follows: 1) intraoperative blood loss and 2) the need for red blood cell transfusion. A systematic search was performed in MEDLINE, EMBASE, CENTRAL and LILACS. Other sources were used to discover published and unpublished literature sources. The statistical analysis was performed in Review Manager v.5.3.

Results

Four studies were included with a total of 436 patients. Three of the four studies had small sample sizes. There was a low risk of attrition bias and reporting bias. Unclear risk of selection bias, performance bias, or detection bias was presented. A mean difference (MD) of -174.49 [95% CI (-248.43 to -100.56)] was found for perioperative blood loss (the primary outcome). At the end of the procedure, the hemoglobin concentration had a MD of -1.19 [95% CI (-4.37 to 1.99)].

Conclusions

Tranexamic acid is effective at preventing perioperative blood loss compared with the placebo in patients undergoing transurethral resection of the prostate (TURP). However, this treatment was not effective neither at preventing the need for transfusions nor at increasing hemoglobin values at the end of the procedure.

Antifibrinolytic therapy to reduce haemoptysis from any cause

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Role of Tranexamic Acid in Reducing Blood Loss in Vaginal Delivery

INTRODUCTION

Anti-fibrinolytic agents are used to reduce obstetric blood loss as the fibrinolytic system is known to get activated after placental delivery.

OBJECTIVES

To evaluate the efficacy of parenteral tranexamic acid in reducing blood loss during normal labour and to compare it with the amount of blood loss in patients who received placebo in the third stage of labour.

METHODOLOGY

Patients with spontaneous labour or planned for induction of labour and fulfilling the inclusion criteria were recruited for the study. In each patient, the pre-delivery pulse rate, blood pressure, Hb gm% and PCV% were noted. Labour was monitored carefully using a partogram. The study group received Inj. Oxytocin and Inj. Tranexamic acid. The control group received Inj. Oxytocin and Placebo injection. Immediately after delivery of the baby, when all the liquor was drained, the patient was placed over a blood drape-a disposable conical, graduated plastic collection bag. The amount of blood collected in the blood drape was measured. Then the patient was given pre-weighed pads, which were weighed 2 h post-partum. The blood loss was measured by measuring the blood collected in the drape and by weighing the swabs before and after delivery.

RESULTS

The total number of patients studied was 100-equally distributed in both the groups. The age group of the patients and BMI were comparable. There was a significant increase in the pulse rate and decrease in blood pressure in the control group as compared with the study group. The post-delivery haemoglobin and haematocrit were significantly reduced in the control group as compared to the study group. The mean blood loss at the end of 2 h was 105 ml in the study group and 252 ml in the control group. There was a significant increase in the usage of uterotonics and also in the need for blood transfusion in the control group; 12 % of the patients in the control group had to stay for more than 3 days compared to 2 % in the study group.

CONCLUSION

Tranexamic acid injection, an antifibrinolytic agent when given prophylactically after the delivery of the baby, by intravenous route appears to reduce the blood loss and maternal morbidity during normal labour effectively.

Placental Blood Drainage as a Part of Active Management of Third Stage of Labour After Spontaneous Vaginal Delivery

AIM

The third stage of labour commences after the delivery of the foetus and ends with the delivery of the placenta and its membranes. Postpartum haemorrhage is the most common cause of maternal mortality and accounts for about 25 % of maternal deaths in India.

OBJECTIVES

The present study was designed to evaluate the effectiveness of placental blood drainage after spontaneous vaginal delivery as part of active management of third stage of labour in decreasing the duration, blood loss, and complications of the third stage, against no drainage of placental blood.

METHODOLOGY

Two hundred pregnant patients with 37 or more weeks of gestation, with single live foetus in cephalic presentation, who underwent a spontaneous vaginal delivery, were included in the study. The patients were prospectively randomized equally into two groups (100 each in the study and control groups). Placental blood was drained in all the patients in the study group, whereas in the control group the cord blood was not drained. Blood lost in the third stage of labour was measured by collecting in a disposable conical measuring bag, and blood from the episiotomy was mopped, and the mops were discarded separately.

RESULTS

The baseline statistics in both the group were comparable. The duration of third stage of labour was 210.5 s in the study group and 302.5 s in the control group. The 'p' value was statistically significant (p ≤ 0.0001). The mean blood loss in study group was 227.5 ml and was 313.3 ml in the control group (p ≤ 0.0001). The incidence of postpartum haemorrhage was 1 % in study group and 9 % in control group. The mean drop in Hb % level was 0.6 gm/dl in study group and 1.1 gm/dl in control group. These above differences were both statistically significant.

CONCLUSION

Placental blood drainage as part of active management of third stage of labour was effective in reducing the duration, the blood loss, and also the incidence of PPH. Placental blood drainage is a simple, safe, and non-invasive method of managing the third stage of labour, which can be practiced in both tertiary care centres as well as rural setup in addition to the routine uterotonics.

Active Bleeding after Cardiac Surgery: A Prospective Observational Multicenter Study

MAIN OBJECTIVES

To estimate the incidence of active bleeding after cardiac surgery (AB) based on a definition directly related on blood flow from chest drainage; to describe the AB characteristics and its management; to identify factors of postoperative complications.

METHODS

AB was defined as a blood loss > 1.5 ml/kg/h for 6 consecutive hours within the first 24 hours or in case of reoperation for hemostasis during the first 12 postoperative hours. The definition was applied in a prospective longitudinal observational study involving 29 French centers; all adult patients undergoing cardiac surgery with cardiopulmonary bypass were included over a 3-month period. Perioperative data (including blood product administration) were collected. To study possible variation in clinical practice among centers, patients were classified into two groups according to the AB incidence of the center compared to the overall incidence: "Low incidence" if incidence is lower and "High incidence" if incidence is equal or greater than overall incidence. Logistic regression analysis was used to identify risk factors of postoperative complications.

RESULTS

Among 4,904 patients, 129 experienced AB (2.6%), among them 52 reoperation. Postoperative bleeding loss was 1,000 [820;1,375] ml and 1,680 [1,280;2,300] ml at 6 and 24 hours respectively. Incidence of AB varied between centers (0 to 16%) but was independent of in-centre cardiac surgical experience. Comparisons between groups according to AB incidence showed differences in postoperative management. Body surface area, preoperative creatinine, emergency surgery, postoperative acidosis and red blood cell transfusion were risk factors of postoperative complication.

CONCLUSIONS

A blood loss > 1.5 ml/kg/h for 6 consecutive hours within the first 24 hours or early reoperation for hemostasis seems a relevant definition of AB. This definition, independent of transfusion, adjusted to body weight, may assess real time bleeding occurring early after surgery.

Effectiveness of pericardial lavage with or without tranexamic acid in cardiac surgery patients receiving intravenous tranexamic acid: a randomized controlled trial

OBJECTIVES

Pericardial lavage with saline, with or without tranexamic acid (TA), is still not evidence-based within current clinical practice as a part of a blood conservation strategy in cardiac surgery patients receiving intravenous TA administration. The objective was to determine whether intravenous TA combined with pericardial lavage with saline, with or without TA, reduces blood loss by 25% after cardiac surgery measured in the first 12 h postoperatively.

METHODS

In this single-centre, randomized controlled, multiple-armed, parallel study, individual patients were randomly assigned to receive either topical administration of 2 g TA diluted in 200 ml of saline (TA group), 200 ml of saline (placebo group) or no topical administration at all (control group). Eligible participants were all adults aged 18 or older and scheduled for elective cardiac surgery on cardiopulmonary bypass. All patients received 2 g TA intravenously before sternal incision and 2 g TA after cardiopulmonary bypass. The main outcome measure was the 12-h postoperative blood loss.

RESULTS

In total, 739 individuals were analysed according to intention-to-treat analyses (TA group, n = 245 patients; placebo group, n = 249 patients; control group, n = 245 patients). There was no difference in the median 12-h postoperative blood loss between the three groups [TA group, 290 (IQR 190-430) ml; placebo group, 290 (IQR 210-440) ml; control group, 300 (IQR 190-450) ml, P= 0.759].

CONCLUSIONS

Pericardial lavage, with or without TA, does not result in a statistically significant difference in the 12-h postoperative blood loss in cardiac surgery patients receiving intravenous TA administration. Pericardial lavage with saline, with or without TA, should not be a part of a blood conservation strategy.

The impact of mild peri-operative hypothermia on the effectiveness of tranexamic acid in total hip arthroplasty

PURPOSE

Surgical patients experience inadvertent hypothermia as a result of anaesthesia-induced thermoregulatory impairment. Previous studies have found that hypothermia is associated with increased blood loss and transfusion requirements. This study examined the incidence of hypothermia in patients undergoing total hip arthroplasty (THA), whether hypothermia is associated with increased blood loss, and whether any such association is modified by tranexamic acid (TXA) administration.

METHODS

An observational prospective study was performed in 941 consecutive patients undergoing elective THA, with and without intra-operative administration of TXA. The presence of hypothermia on post-anaesthesia care unit admission was determined, and the post-operative bleeding index calculated. Transfusions and complications were documented.

RESULTS

The incidence of peri-operative inadvertent hypothermia was 84.2 %. TXA was administered to 751 (79.8 %) patients. The bleeding index was 2.6 (95 % confidence interval [CI] 2.6-2.7) in patients treated with TXA and 3.1 (95 % CI 2.8-3.4) in patients who did not receive TXA (p = 0.012). Mild hypothermia did not have a significant impact on the bleeding index (difference, -0.4; 95 % CI, -1.1 to +0.2; p = 0.190), nor on the effectiveness of TXA (difference, 0.4; 95 % CI, -0.3 to +1.1; p = 0.250).

CONCLUSION

The incidence of hypothermia in our THA population was high, despite peri-operative air warming. However, mild hypothermia was not significantly associated with increased blood loss and did not reduce the effectiveness of TXA.

Tranexamic acid-associated seizures: Causes and treatment

Antifibrinolytic drugs are routinely used worldwide to reduce the bleeding that results from a wide range of hemorrhagic conditions. The most commonly used antifibrinolytic drug, tranexamic acid, is associated with an increased incidence of postoperative seizures. The reported increase in the frequency of seizures is alarming, as these events are associated with adverse neurological outcomes, longer hospital stays, and increased in‐hospital mortality. However, many clinicians are unaware that tranexamic acid causes seizures. The goal of this review is to summarize the incidence, risk factors, and clinical features of these seizures. This review also highlights several clinical and preclinical studies that offer mechanistic insights into the potential causes of and treatments for tranexamic acid–associated seizures. This review will aid the medical community by increasing awareness about tranexamic acid–associated seizures and by translating scientific findings into therapeutic interventions for patients. ANN NEUROL 2016;79:18–26

The Advantages and Disadvantages of Methods Used to Control Liver Bleeding: A Review

Context:

Despite advancements in the science of surgery, minimizing bleeding from parenchymal tissue of the liver continues to be one of the challenges surgeons are facing to protect patients’ lives. However, the number of surgeries needing incisions in the liver tissue, e.g. metastatectomy, is constantly increasing.

Evidence Acquisition:

A MEDLINE and conventional search of the past 50 years of the medical literature was performed to identify relevant articles on hemostasis in the liver parenchymal tissue.

Results:

The studies that have been published on hemostasis in the liver parenchymal tissue can be classified into 3 categories: 1. surgical procedures; 2. methods affecting body hemodynamic; 3. pharmacological methods. The purpose of these studies are to identify the best therapeutic approaches that not only minimize the bleeding, but also save the maximum amount of the liver tissue and minimize the use of partial liver resections.

Conclusions:

The excessive blood loss and the long time needed to control the bleeding during liver surgery impose several side effects and complications on patients. Topical hemostatic agents such as ferric chloride, potassium aluminum sulfate (alum) and aluminum chloride are safely applicable in patients. These agents might be used along with other current methods to minimize the blood loss and the need for blood products during liver surgeries.

A Comparison of Two Different Dosing Protocols for Tranexamic Acid in Posterior Spinal Fusion for Spinal Deformity: A Prospective, Randomized Trial

BACKGROUND

Multilevel spinal fusions have typically been associated with significant blood loss. Previous studies have shown a reduction in blood loss with antifibrinolytics in both adolescent and adult spinal deformity patients. While this has been mirrored in other subspecialties as well, the dosing of TXA remains highly variable. To date, there remains a paucity of data guiding dosing for TXA in spine surgery and orthopedic surgery as a whole.

METHODS/DESIGN

One hundred and fifty patients from 3 institutions (50 each site) will be consecutively enrolled and randomized to either a high dose of TXA (50mg/kg loading followed by 20mg/kg hourly) or a lose dose (10mg/kg, then 1mg/kg hourly). Both surgeons and patients will be blinded to the treatment group. Primary outcomes will be perioperative blood loss, drain output, and transfusion rate. Secondary outcomes will be length of stay, complications, and overall cost.

DISCUSSION

The primary goal of this study is to provide level-1 comparative data for two TXA dosing regimens in adult spinal deformity surgery. Management of blood loss remains a critical factor in reducing complications during spinal deformity surgery. The null hypothesis is that there is no difference between high- and low-dose TXA with respect to any of the primary or secondary outcomes.

CRASH-2 Study of Tranexamic Acid to Treat Bleeding in Trauma Patients: A Controversy Fueled by Science and Social Media

This paper reviews the application of tranexamic acid, an antifibrinolytic, to trauma. CRASH-2, a large randomized controlled trial, was the first to show a reduction in mortality and recommend tranexamic acid use in bleeding trauma patients. However, this paper was not without controversy. Its patient recruitment, methodology, and conductance in moderate-to-low income countries cast doubt on its ability to be applied to trauma protocols in countries with mature trauma networks. In addition to traditional vetting in scientific, peer-reviewed journals, CRASH-2 came about at a time when advances in communication technology allowed debate and influence to be leveraged in new forms, specifically through the use of multimedia campaigns, social media, and Internet blogs. This paper presents a comprehensive view of tranexamic acid utilization in trauma from peer-reviewed evidence to novel multimedia influences.

Study protocol. TRAAP - TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery: a multicenter randomized, double-blind, placebo-controlled trial

Background

Postpartum hemorrhage (PPH) is a major cause of maternal mortality, accounting for one quarter of all maternal deaths worldwide. Estimates of its incidence in the literature vary widely, from 3 % to 15 % of deliveries. Uterotonics after birth are the only intervention that has been shown to be effective in preventing PPH. Tranexamic acid (TXA), an antifibrinolytic agent, has been investigated as a potentially useful complement to uterotonics for prevention because it has been proved to reduce blood loss in elective surgery, bleeding in trauma patients, and menstrual blood loss. Randomized controlled trials for PPH prevention after cesarean (n = 10) and vaginal (n = 2) deliveries show that women who received TXA had significantly less postpartum blood loss without any increase in their rate of severe adverse effects. However, the quality of these trials was poor and they were not designed to test the effect of TXA on the reduction of PPH incidence. Large, adequately powered, multicenter randomized controlled trials are required before the widespread use of TXA to prevent PPH can be recommended.

Methods and design

A multicenter, double-blind, randomized controlled trial will be performed. It will involve 4000 women in labor for a planned vaginal singleton delivery, at a term ≥ 35 weeks. Treatment (either TXA 1 g or placebo) will be administered intravenously just after birth. Prophylactic oxytocin will be administered to all women. The primary outcome will be the incidence of PPH, defined by blood loss ≥500 mL, measured with a graduated collector bag. This study will have 80 % power to show a 30 % reduction in the incidence of PPH, from 10.0 % to 7.0 %.

Discussion

In addition to prophylactic uterotonic administration, a complementary component of the management of third stage of labor acting on the coagulation process may be useful in preventing PPH. TXA is a promising candidate drug, inexpensive, easy to administer, and simple to add to the routine management of deliveries in hospitals. This large, adequately powered, multicenter, randomized placebo-controlled trial seeks to determine if the risk-benefit ratio favors the routine use of TXA after delivery to prevent PPH.

Trial registration

ClinicalTrials.gov NCT02302456 (November 17, 2014)

WITHDRAWN: Haemostatic drugs for traumatic brain injury

May 2015: The authors have asked for this review to be withdrawn. The information contained in this review has been included in the review 'Antifibrinolytic drugs for acute traumatic injury'.

The editorial group responsible for this previously published document have withdrawn it from publication.

Antifibrinolytic drugs for acute traumatic injury

BACKGROUND

Uncontrolled bleeding is an important cause of death in trauma victims. Antifibrinolytic treatment has been shown to reduce blood loss following surgery and may also be effective in reducing blood loss following trauma.

OBJECTIVES

To assess the effect of antifibrinolytic drugs in patients with acute traumatic injury.

SEARCH METHODS

We ran the most recent search in January 2015. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (OvidSP), PubMed and clinical trials registries.

SELECTION CRITERIA

Randomised controlled trials of antifibrinolytic agents (aprotinin, tranexamic acid [TXA], epsilon-aminocaproic acid and aminomethylbenzoic acid) following acute traumatic injury.

DATA COLLECTION AND ANALYSIS

From the results of the screened electronic searches, bibliographic searches, and contacts with experts, two authors independently selected trials meeting the inclusion criteria, and extracted data. One review author assessed the risk of bias for key domains.Outcome measures included: mortality at end of follow-up (all-cause); adverse events (specifically vascular occlusive events [myocardial infarction, stroke, deep vein thrombosis or pulmonary embolism] and renal failure); number of patients undergoing surgical intervention or receiving blood transfusion; volume of blood transfused; volume of intracranial bleeding; brain ischaemic lesions; death or disability.We rated the quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach.

MAIN RESULTS

Three trials met the inclusion criteria.Two trials (n = 20,451) assessed the effect of TXA. The larger of these (CRASH-2, n = 20,211) was conducted in 40 countries and included patients with a variety of types of trauma; the other (n = 240) restricted itself to those with traumatic brain injury (TBI) only.One trial (n = 77) assessed aprotinin in participants with major bony trauma and shock.The pooled data show that antifibrinolytic drugs reduce the risk of death from any cause by 10% (RR 0.90, 95% CI 0.85 to 0.96; P = 0.002) (quality of evidence: high). This estimate is based primarily on data from the CRASH-2 trial of TXA, which contributed 99% of the data.There is no evidence that antifibrinolytics have an effect on the risk of vascular occlusive events (quality of evidence: moderate), need for surgical intervention or receipt of blood transfusion (quality of evidence: high). There is no evidence for a difference in the effect by type of antifibrinolytic (TXA versus aprotinin) however, as the pooled analyses were based predominantly on trial data concerning the effects of TXA, the results can only be confidently applied to the effects of TXA. The effects of aprotinin in this patient group remain uncertain.There is some evidence from pooling data from one study (n = 240) and a subset of data from CRASH-2 (n = 270) in patients with TBI which suggest that TXA may reduce mortality although the estimates are imprecise, the quality of evidence is low, and uncertainty remains. Stronger evidence exists for the possibility of TXA reducing intracranial bleeding in this population.

AUTHORS' CONCLUSIONS

TXA safely reduces mortality in trauma patients with bleeding without increasing the risk of adverse events.  TXA should be given as early as possible and within three hours of injury, as further analysis of the CRASH-2 trial showed that treatment later than this is unlikely to be effective and may be harmful. Although there is some promising evidence for the effect of TXA in patients with TBI, substantial uncertainty remains.Two ongoing trials being conducted in patients with isolated TBI should resolve these remaining uncertainties.

Topical tranexamic Acid does not affect electrophysiologic or neurovascular sciatic nerve markers in an animal model

BACKGROUND

Tranexamic acid is a safe and effective antifibrinolytic agent used systemically and topically to reduce blood loss and transfusion rate in patients having TKA or THA. As the hip does not have a defined capsule, topical application of tranexamic acid may entirely envelop the sciatic nerve during THA. Accidental application of tranexamic acid onto the spinal cord in spinal anesthesia has been shown to produce seizures; therefore, we sought to investigate if topical application of tranexamic acid on the sciatic nerve has a deleterious effect.

QUESTIONS/PURPOSES

We explored whether there were any short- or long-term alterations in (1) electrophysiologic measures, (2) macrophage recruitment, or (3) blood-nerve barrier permeability. Our hypothesis was that local application of tranexamic acid would have a transient effect or no effect on histologic features and function of the sciatic nerve.

METHODS

We used a rat protocol to model sciatic nerve exposure in THA to determine the effects of tranexamic acid on neural histologic features and function. We evaluated 35 rats by the dorsal gluteal splitting approach to expose the sciatic nerve for topical use of control and tranexamic acid. We evaluated EMG changes (distal latency, amplitude, nerve conduction velocity), histologic signs of nerve injury via macrophage recruitment, and changes in blood-nerve barrier permeability at early (4 days) and late (1 month) times after surgery, after application of subtherapeutic (1 mg/kg body weight [1.6 mg]), therapeutic (10 mg/kg [16 mg]), and supratherapeutic (100 mg/kg [160 mg]) concentrations of tranexamic acid. Differences in blood-nerve barrier permeability, macrophage recruitment, and EMG between normal and tranexamic acid-treated nerves were calculated using one-way ANOVA, with Newman-Keuls post hoc analyses, at each time. A post hoc power calculation showed that with the numbers available, we had 16% power to detect a 50% difference in EMG changes between the control, 1 mg/kg group, 10 mg/kg group, and 100 mg/kg group.

RESULTS

At the early and late times, with the numbers available, there were no differences in EMG except for distal latency at 4 days, macrophage recruitment, or changes in blood-nerve barrier between control rats and those with tranexamic acid-treated nerves. The distal latency in the 1 mg tranexamic acid-treated animals at 4 days was 1.06 ± 0.15 ms (p = 0.0036 versus all other groups, 95% CI, 0.89-1.25), whereas the distal latencies in the control, the 10 mg/kg, and 100 mg/kg tranexamic acid-treated animals were 0.83 ± 0.11, 0.89 ± 0.05, and 0.87 ± 0.13, respectively. Distal latencies were not increased in any of the groups at 1 month with the numbers available (0.81 ± 0.10, 0.89 ± 0.03, 0.81 ± 0.06, and 0.83 ± 0.08 ms, respectively, for controls; 1 mg/kg, 10 mg/kg, and 100 mg/kg for the tranexamic acid-treated groups).

CONCLUSION

In our in vivo rat model study, tranexamic acid did not appear to have any clinically relevant effect on the sciatic nerve resulting from topical administration up to 1 month. However, because our statistical power was low, these data should be considered hypothesis-generating pilot data for larger, more-definitive studies.

CLINICAL RELEVANCE

Topical tranexamic acid is effective in decreasing patient blood loss during THA, and results from our in vivo rat model study suggest there may be no electrophysiologic and histologic effects on the sciatic nerve, with the numbers available, up to 1 month.

Safety and efficacy of caproamin fides and tranexamic Acid versus placebo in patients undergoing coronary artery revascularization

Introduction: Excessive fibrinolysis contributes to post-cardiopulmonary bypass bleeding. Tranexamic Acid (TXA) and Caproamin Fides are synthetic lysine analogues that inhibit plasminogen-fibrin binding. The present study aimed to compare TXA and Caproamin Fides versus placebo in patients undergoing elective coronary artery revascularization.

Methods: We analyzed perioperative data of 300 adult patients undergoing coronary artery revascularization. Patients were randomly allocated to receive TXA (n=100), Caproamin Fides (n=100) or placebo (n=100) during perioperative time. Mediastinal bleeding during the first 24 hours post-operation, transfusion requirement and post-surgical complications were assessed.

Results: Most descriptive and intra-operative parameters were well comparable between the 3 study groups. Except for mean number of packed red blood cell (PRBC) units transfused during ICU stay (P=0.01), patients in the Caproamin Fides and TXA groups did not show any statistically significant differences regarding transfusion of blood products during peri-operative period. There was no evidence of a significant difference in mediastinal blood loss during the first 24 hours post-operation between the patients receiving TXA or placebo, while patients in the Caproamin Fides group had significantly lower mediastinal bleeding than the other 2 groups (Caproamin Fides vs. placebo, P=0.002, <0.001 and <0.001 at 6, 12 and 24 hours post-operation; Caproamin Fides vs. TXA, P=0.009, 0.003, <0.001 at 6, 12 and 24 hours post-operation). The incidence of postoperative complications were comparable between Caproamin Fides and TXA groups (P>0.05).

Conclusion: In conclusion, Caproamin Fides seems to be superior to TXA regarding the blood saving effects in patients undergoing coronary artery revascularization.

A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement

Intravenous tranexamic acid (TXA) has been shown to be effective in reducing blood loss and the need for transfusion after joint replacement. Recently, there has been interest in applying it topically before the closure of surgical wounds. This has the advantages of ease of application, maximum concentration at the site of bleeding, minimising its systemic absorption and, consequently, concerns about possible side-effects. We conducted a systematic review and meta-analysis which included 14 randomised controlled trials (11 in knee replacement, two in hip replacement and one in both) which investigated the effect of topical TXA on blood loss and rates of transfusion. Topical TXA significantly reduced the rate of blood transfusion (total knee replacement: risk ratio (RR) 4.51; 95% confidence interval (CI): 3.02 to 6.72; p < 0.001 (nine trials, I(2) = 0%); total hip replacement: RR 2.56; 95% CI: 1.32 to 4.97, p = 0.004 (one trial)). The rate of thromboembolic events with topical TXA were similar to those found with a placebo. Indirect comparison of placebo-controlled trials of topical and intravenous TXA indicates that topical administration is superior to the intravenous route. In conclusion, topical TXA is an effective and safe method of reducing the need for blood transfusion after total knee and hip replacement. Further research is required to find its optimum dose for topical use.

The acute management of haemorrhage, surgery and overdose in patients receiving dabigatran

Dabigatran is an oral direct thrombin inhibitor (DTI) licensed for stroke prevention in atrial fibrillation and likely to be soon approved in Europe for treatment of venous thrombosis. Predictable pharmacokinetics and a reduced risk of intracranial haemorrhage do not negate the potential risk of haemorrhage. Unlike warfarin, there is no reversal agent and measurement of the anticoagulant effect is not 'routine'. The prothrombin time/international normalised ratio response to dabigatran is inconsistent and should not be measured when assessing a patient who is bleeding or needs emergency surgery. The activated partial thromboplastin time (APTT) provides a qualitative measurement of the anticoagulant effect of dabigatran. Knowledge of the time of last dose is important for interpretation of the APTT. Commercially available DTI assays provide a quantitative measurement of active dabigatran concentration in the plasma. If a patient receiving dabigatran presents with bleeding: omit/delay next dose of dabigatran; measure APTT and thrombin time (consider DTI assay if available); administer activated charcoal, with sorbitol, if within 2 h of dabigatran ingestion; give tranexamic acid (1 g intravenously if significant bleeding); maintain renal perfusion and urine output to aid dabigatran excretion. Dabigatran exhibits low protein binding and may be removed by dialysis. Supportive care should form the mainstay of treatment. If bleeding is life/limb threatening, consider an additional haemostatic agent. There is currently no evidence to support the choice of one haemostatic agent (FEIBA, recombinant factor VIIa, prothrombin complex concentrates) over another. Choice will depend on access to and experience with available haemostatic agent(s).

The effect of tranexamic acid on transfusion rate in primary total hip arthroplasty

Total hip arthroplasty (THA) may produce blood loss requiring allogenic blood transfusion. Recently several authors have reported success decreasing their transfusion rate with tranexamic acid (TXA). We retrospectively reviewed our last 1595 primary THA in 1494 patients looking at whether the patients received TXA via IV infusion, topical application, or neither, and the need for a blood transfusion. Infusion of TXA acid produced a statistically significant difference in transfusion rate (p<0.001) while topical TXA failed to reach statistical significance (P=0.15). The transfusion rate without TXA was 19.86%, 4.39% with TXA infusion (odds ratio=5.36), and 12.86% (odds ratio=1.67) with topical TXA.

Decoy plasminogen receptor containing a selective Kunitz-inhibitory domain

Kunitz domain 1 (KD1) of tissue factor pathway inhibitor-2 in which P2' residue Leu17 (bovine pancreatic trypsin inhibitor numbering) is mutated to Arg selectively inhibits the active site of plasmin with ∼5-fold improved affinity. Thrombin cleavage (24 h extended incubation at a 1:50 enzyme-to-substrate ratio) of the KD1 mutant (Leu17Arg) yielded a smaller molecule containing the intact Kunitz domain with no detectable change in the active-site inhibitory function. The N-terminal sequencing and MALDI-TOF/ESI data revealed that the starting molecule has a C-terminal valine (KD1L17R-VT), whereas the smaller molecule has a C-terminal lysine (KD1L17R-KT). Because KD1L17R-KT has C-terminal lysine, we examined whether it could serve as a decoy receptor for plasminogen/plasmin. Such a molecule might inhibit plasminogen activation as well as the active site of generated plasmin. In surface plasmon resonance experiments, tissue plasminogen activator (tPA) and Glu-plasminogen bound to KD1L17R-KT (Kd ∼ 0.2 to 0.3 μM) but not to KD1L17R-VT. Furthermore, KD1L17R-KT inhibited tPA-induced plasma clot fibrinolysis more efficiently than KD1L17R-VT. Additionally, compared to ε-aminocaproic acid KD1L17R-KT was more effective in reducing blood loss in a mouse liver-laceration injury model, where the fibrinolytic system is activated. In further experiments, the micro(μ)-plasmin-KD1L17R-KT complex inhibited urokinase-induced plasminogen activation on phorbol-12-myristate-13-acetate-stimulated U937 monocyte-like cells, whereas the μ-plasmin-KD1L17R-VT complex failed to inhibit this process. In conclusion, KD1L17R-KT inhibits the active site of plasmin as well as acts as a decoy receptor for the kringle domain(s) of plasminogen/plasmin; hence, it limits both plasmin generation and activity. With its dual function, KD1L17R-KT could serve as a preferred agent for controlling plasminogen activation in pathological processes.