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Gilman OP, Borgeat K, Wilson HE. The effect of prophylactic tranexamic acid on the incidence of postoperative hemorrhage in greyhounds. Vet J 2024:106226. [PMID: 39179146 DOI: 10.1016/j.tvjl.2024.106226] [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: 02/08/2024] [Revised: 08/19/2024] [Accepted: 08/20/2024] [Indexed: 08/26/2024]
Abstract
To investigate whether the incidence of postoperative hemorrhage in greyhounds was reduced when a standardized protocol for prophylactic tranexamic acid (TXA) administration to greyhounds undergoing surgery was followed, a retrospective clinical study at a private referral and first opinion hospital group was performed. Patient records of client-owned greyhounds undergoing elective surgery or dental procedures involving extractions were examined retrospectively, and 58 incidents of surgery considered eligible were documented, along with any subsequent reports of hemorrhage and whether the TXA protocol was followed. The use of TXA was not associated with a reduction in the incidence of postoperative hemorrhage in this population of greyhounds. In the group that did not receive TXA, post-operative hemorrhage was reported in 7/37 (18.9%) cases and in the prophylactic TXA group, post-operative hemorrhage was reported in 11/21 (52.4%) cases, a significantly higher number than in the group that did not receive TXA. Interestingly, in our population, prophylactic administration of TXA was not associated with a reduction in post-operative hemorrhage, but with a higher incidence of hemorrhage. We belief that descrepencies in our dataset may explain these findings, and a prospective randomized-controlled trial should be performed to further investigate the efficacy of TXA as an antifibrinolytic agent in greyhounds.
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Affiliation(s)
- O P Gilman
- Avalon Veterinary Services Ltd, United Kingdom.
| | - K Borgeat
- Eastcott Referrals, Edison Park, Hindle Way, Dorcan Way, Swindon, SN3 3FR, United Kingdom
| | - H E Wilson
- Small Animal Hospital, Langford Veterinary Services, Langford, Somerset, BS40 5DU, United Kingdom
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2
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Huang X, Du P, Jia H, Wang A, Hua Y, Liu X, Wu K, Li B, Zhao H. Methodologic Quality and Pharmacotherapy Recommendations for Patient Blood Management Guidelines for Cardiac Surgery on Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2024; 38:1569-1576. [PMID: 38594156 DOI: 10.1053/j.jvca.2024.03.011] [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: 12/20/2023] [Revised: 03/04/2024] [Accepted: 03/08/2024] [Indexed: 04/11/2024]
Abstract
Patient blood management (PBM) guidelines for patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) have increased during the past decade, and pharmacotherapy plays an important role in PBM. In the face of the undefined consistency in the methodologic quality and pharmacotherapy recommendations across multiple guidelines, this study exclusively evaluated methodologies of the related guideline development process, and compiled medication recommendations of PBM for cardiac surgery patients. PBM guidelines for cardiac surgery under CPB were searched through some mainstream literature and guideline databases from database establishment to May 15, 2023. Nine guidelines meeting inclusion criteria were included in this study. The quality of the guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. "Stakeholder involvement" received the lowest mean score of 49.38% in the AGREE II scoring among the guidelines. PBM for cardiac surgery patients spans the perioperative phase. Drug therapy strategies of PBM for cardiac surgery patients involve anemia therapy, perioperative administration of antithrombotic drugs, intraoperative anticoagulation, and the use of hemostatic drugs. Unlike for adults, there is less evidence about the management of antithrombotic drugs and hemostatic drugs for pediatric cardiac surgery patients. Recombinant activated factor VII (rFVIIa) and desmopressin (DDAVP) are not recommended after pediatric cardiac surgery, whereas prothrombin complex concentrate could be considered in clinical trials. As for the controversies regarding the administration of rFVIIa and DDAVP after adult cardiac surgery by different societies, clinicians should exercise their clinical judgment based on individual patient features.
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Affiliation(s)
- Xiaojing Huang
- Department of Pharmacy, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Pengqiang Du
- Department of Pharmacy, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Haipan Jia
- Department of Pharmacy, Henan Provincial People's Hospital, Zhengzhou, China
| | - Aifeng Wang
- Department of Pharmacy, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Ying Hua
- Children's Heart Center Intensive Care Unit, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Xuelan Liu
- Children's Heart Center Intensive Care Unit, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Kaiyuan Wu
- Children's Heart Center Intensive Care Unit, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Bin Li
- Children's Heart Center Intensive Care Unit, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Hongwei Zhao
- Department of Pharmacy, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China.
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Mess SA, Stephanos KN. Temperance With Tranexamic Acid: Increased Risk of Venous Thromboembolism in Abdominoplasty. Aesthet Surg J Open Forum 2024; 6:ojae044. [PMID: 38962469 PMCID: PMC11221427 DOI: 10.1093/asjof/ojae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Abstract
Tranexamic acid (TXA) is used widely in surgery to mitigate blood loss by inhibiting the fibrinolytic degradation of clots. The occurrence of venous thromboembolism (VTE) with TXA has not been reported in the plastic surgery literature. In the realm of plastic surgery, abdominoplasty has the highest rate of VTE. The purpose of this study is to report 5 cases of VTE with TXA. A single surgeon reviewed the records of 5 patients who incurred VTE with TXA. TXA was added to the tumescent fluid, 20 mg/kg total. Four of the 5 patients underwent abdominoplasty combined with liposuction and breast surgery, and the fifth, fat transfer to the breast. The abdominoplasty patients had received chemoprophylaxis. Upon presentation of symptoms, the patients were sent to the hospital for anticoagulation and hematology consultation. The 5 patients survived their VTE events; 2 only required oral anticoagulation, 2 required IV heparin then oral, and 1 required tissue plasminogen activator (tPA) then oral. VTE with abdominoplasty occurred in 0 of 399 cases prior to the use of TXA and in 4 of 98 cases after the use of TXA in the tumescent. Although the occurrence of VTE with abdominoplasty increased with the use of TXA for the senior author, this retrospective case study does not prove a causal relationship between TXA and VTE. Level of Evidence 4
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Affiliation(s)
- Sarah A Mess
- Corresponding Author: Dr Sarah A. Mess, 9821 Broken Land Pkwy #102, Columbia, MD 21046, USA. E-mail: ; Instagram: @sarahmessmd
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Cartagena-Reyes MA, Silva-Aponte JA, Nazario-Ferrer GI, Benes GA, Choudhary A, Raad M, Frank SM, Musharbash FN, Jain A. The cost-utility of intraoperative tranexamic acid in adult spinal deformity patients undergoing long posterior spinal fusion. Spine Deform 2024; 12:587-593. [PMID: 38427155 DOI: 10.1007/s43390-023-00818-3] [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: 07/22/2023] [Accepted: 12/29/2023] [Indexed: 03/02/2024]
Abstract
PURPOSE This study aims to evaluate the cost-utility of intraoperative tranexamic acid (TXA) in adult spinal deformity (ASD) patients undergoing long posterior (≥ 5 vertebral levels) spinal fusion. METHODS A decision-analysis model was built for a hypothetical 60-year-old adult patient with spinal deformity undergoing long posterior spinal fusion. A comprehensive review of the literature was performed to obtain event probabilities, costs and health utilities at each node. Health utilities were utilized to calculate Quality-Adjusted Life Years (QALYs). A base-case analysis was carried out to obtain the incremental cost and effectiveness of intraoperative TXA. Probabilistic sensitivity analysis was performed to evaluate uncertainty in our model and obtain mean incremental costs, effectiveness, and net monetary benefits. One-way sensitivity analyses were also performed to identify the variables with the most impact on our model. RESULTS Use of intraoperative TXA was the favored strategy in 88% of the iterations. The mean incremental utility ratio for using intraoperative TXA demonstrated higher benefit and lower cost while being lower than the willingness-to-pay threshold set at $50,000 per quality adjusted life years. Use of intraoperative TXA was associated with a mean incremental net monetary benefit (INMB) of $3743 (95% CI 3492-3995). One-way sensitivity analysis reported cost of blood transfusions due to post-operative anemia to be a major driver of cost-utility analysis. CONCLUSION Use of intraoperative TXAs is a cost-effective strategy to reduce overall perioperative costs related to post-operative blood transfusions. Administration of intraoperative TXA should be considered for long fusions in ASD population when not explicitly contra-indicated due to patient factors.
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Affiliation(s)
- Miguel A Cartagena-Reyes
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Juan A Silva-Aponte
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Gabriel I Nazario-Ferrer
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Gregory A Benes
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Ananya Choudhary
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University, 1800 Orleans St., Zayed 6208, Baltimore, MD, 21287, USA
| | - Farah N Musharbash
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA.
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Aghajanian S, Mohammadifard F, Kohandel Gargari O, Naeimi A, Bahadorimonfared A, Elsamadicy AA. Efficacy and utility of antifibrinolytics in pediatric spine surgery: a systematic review and network meta-analysis. Neurosurg Rev 2024; 47:177. [PMID: 38644447 DOI: 10.1007/s10143-024-02424-x] [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: 10/14/2023] [Revised: 01/09/2024] [Accepted: 04/16/2024] [Indexed: 04/23/2024]
Abstract
Antifibrinolytics have gained increasing attention in minimizing blood loss and mitigating the risks associated with massive transfusions, including infection and coagulopathy in pediatric patients undergoing spine surgery. Nevertheless, the selection of optimal agent is still a matter of debate. We aim to review the utility of these agents and compare the efficacy of antifibrinolytics in pediatric and adolescent spine surgeries. A comprehensive search was performed in Scopus, Web of Science, and MEDLINE databases for relevant works. Studies providing quantitative data on predefined outcomes were included. Primary outcome was perioperative bleeding between the groups. Secondary outcomes included transfusion volume, rate of complications, and operation time. Twenty-eight studies were included in the meta-analysis incorporating 2553 patients. The use of Tranexamic acid (RoM: 0.71, 95%CI: [0.62-0.81], p < 0.001, I2 = 88%), Aprotinin (RoM: 0.54, 95%CI: [0.46-0.64], p < 0.001, I2 = 0%), and Epsilon-aminocaproic acid (RoM: 0.71, 95%CI: [0.62-0.81], p < 0.001, I2 = 60%) led to a 29%, 46%, and 29% reduction in perioperative blood loss, respectively. Network meta-analysis revealed higher probability of efficacy with Tranexamic acid compared to Epsilon-aminocaproic acid (P score: 0.924 vs. 0.571). The rate of complications was not statistically different between each two antifibrinolytic agent or antifibrinolytics compared to placebo or standard of care. Our network meta-analysis suggests a superior efficacy of all antifibrinolytics compared to standard of care/placebo in reducing blood loss and transfusion rate. Further adequately-powered randomized clinical trials are recommended to reach definite conclusion on comparative performance of these agents and to also provide robust objective assessments and standardized outcome data and safety profile on antifibrinolytics in pediatric and adolescent pediatric surgeries.
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Affiliation(s)
- Sepehr Aghajanian
- School of Medicine, Alborz University of Medical Sciences, Karaj, Iran.
- Neuroscience Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | | | - Omid Kohandel Gargari
- Student Research Committee, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
- Headache Research Center, Neurology Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Arvin Naeimi
- Student Research Committee, School of Medicine, Guilan University of Medical Sciences, Rasht, Gilan, Iran
| | - Ayad Bahadorimonfared
- Department of Health & Community Medicine, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
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Montano-Pedroso JC, Perini FV, Donizetti E, Oliveira LC, Rodrigues RDR, Rizzo SRCP, Rabello G, Langhi DM. Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Antifibrinolytics. Hematol Transfus Cell Ther 2024; 46 Suppl 1:S40-S47. [PMID: 38555249 PMCID: PMC11069061 DOI: 10.1016/j.htct.2024.02.011] [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: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 04/02/2024] Open
Abstract
The use of strategies to reduce blood loss and transfusions is essential in the treatment of surgical patients, including in complex cardiac surgeries and those that use cardiopulmonary bypass. Antifibrinolytics, such as epsilon-aminocaproic acid (EACA) and tranexamic acid (TXA), are widely used in these procedures, as well as in other types of surgeries. These medicines are included in the World Health Organization (WHO) list of 'essential medicines'. Scientific evidence demonstrates the effectiveness of EACA in reducing bleeding and the need for transfusions in heart surgery. EACA is highly recommended for use in heart surgery by the American Society of Anesthesiology Task Force on Perioperative Blood Management. Regarding the safety of EACA, there is no robust evidence of any significant thrombotic potential. TXA has also been shown to be effective in reducing the use of blood transfusions in cardiac and non-cardiac surgeries and is considered safer than other antifibrinolytic agents. There is no evidence of any increased risk of thromboembolic events with TXA, but doses greater than 2 g per day have been associated with an increased risk of seizures. It is also important to adjust the dose in patients with renal impairment. In conclusion, antifibrinolytics, such as EACA and TXA, are effective in reducing blood loss and transfusion use in cardiac and non-cardiac surgeries, without causing serious adverse effects.
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Affiliation(s)
- Juan Carlos Montano-Pedroso
- Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil; Instituto de Assistência Médica do Servidor Público Estadual (Iamspe), São Paulo, SP, Brazil
| | - Fernanda Vieira Perini
- Grupo GSH - Gestor de Serviços de Hemoterapia, São Paulo, SP, Brazil; Associação Beneficente Síria HCOR, São Paulo, SP, Brazil
| | | | - Luciana Correa Oliveira
- Hemocentro de Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil
| | - Roseny Dos Reis Rodrigues
- Hospital Israelita Albert Einstein são Paulo, São Paulo, SP, Brazil; Faculdade de Medicina da Universidade de São Paulo (FM USP), São Paulo, SP, Brazil
| | | | - Guilherme Rabello
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Incor - HCFMUSP), São Paulo, SP, Brazil.
| | - Dante Mario Langhi
- Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM UNIFESP), São Paulo, SP, Brazil
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Bagaria V, Badragiri L, Hiremath CS. Effect of blood conservation protocol on the utilisation of blood and outcome of patients undergoing open heart surgery. Perfusion 2024:2676591241239838. [PMID: 38491948 DOI: 10.1177/02676591241239838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2024]
Abstract
INTRODUCTION Cardiac surgery is fraught with increased consumption of blood and blood products. Various strategies for blood conservation have been described. Our aim was to study the impact of a structured blood conservation protocol (BCP) on the utilization of blood and patient outcome. METHODS Retrospective analysis of prospectively collected data comparing adult patients undergoing open heart surgery with BCP with those undergoing surgery without BCP. The primary objective was to compare the amount of blood utilized and the hematocrit at discharge. The secondary objective was to compare the parameters of patient outcomes. The level of significance was set at 0.05. RESULTS The proportion of patients requiring transfusion (19.1% [9/47] vs 58.9% [33/56]; p < 0.001) and the quantity of blood transfused (12 units vs 45 units; p 0.003) in the BCP group was significantly lower. Interestingly, the hematocrit level at discharge was comparable between the groups (30.9 (4.8) versus 31.8 (2.4), p-0.671). The average cost incurred for transfusing blood in the BCP group was ₹ 370.2 as compared to ₹1165.1 in the other (p < 0.001). BCP reduced the odds of overall blood transfusion by 79.8% (OR 0.202 (0.084-0.485); p < 0.001) and intraoperative blood transfusion by 95.3% (OR 0.047 (0.010-0.213); p < 0.001). The morbidity and mortality were comparable between the groups. CONCLUSION Implementing a structured blood conservation protocol in patients undergoing open heart surgery significantly reduces the need for blood transfusion. It also has a promising impact on patient recovery after surgery and significant positive cost implications.
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Affiliation(s)
- Vivek Bagaria
- Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
- Department of Congenital Cardiac Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Lahari Badragiri
- Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - C S Hiremath
- Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
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Kristjansen KA, Engel Krag A, Schmidt H, Hölmich LR, Bønnelykke-Behrndtz ML. Perioperative treatment with tranexamic acid in melanoma (PRIME): protocol for a Danish multicentre randomised controlled trial investigating the prognostic and treatment-related impact of the plasminogen-plasmin pathway. BMJ Open 2024; 14:e077012. [PMID: 38309757 PMCID: PMC10840044 DOI: 10.1136/bmjopen-2023-077012] [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: 06/23/2023] [Accepted: 01/18/2024] [Indexed: 02/05/2024] Open
Abstract
INTRODUCTION Inflammation is a hallmark of cancer and is involved in tumour growth and dissemination. However, the hallmarks of cancer are also the hallmarks of wound healing, and modulating the wound inflammatory response and immune contexture in relation to cancer surgery may represent effective targets of therapies.Repurposing anti-inflammatory drugs in a cancer setting has gained increasing interest in recent years. Interestingly, the known and thoroughly tested antifibrinolytic drug tranexamic acid reduces the risk of bleeding, but it is also suggested to play important roles in anti-inflammatory pathways, improving wound healing and affecting anti-carcinogenic mechanisms.As a novel approach, we will conduct a randomised controlled trial using perioperative treatment with tranexamic acid, aiming to prevent early relapses by >10% for patients with melanoma. METHODS AND ANALYSIS Design: investigator-initiated parallel, two-arm, randomised, blinded, Danish multicentre superiority trial. PATIENTS ≥T2 b melanoma and eligible for sentinel lymph node biopsy (n=1204).Project drug: tranexamic acid or placebo. TREATMENT before surgery (intravenous 15 mg/kg) and daily (peroral 1000 mg x 3) through postoperative day 4. PRIMARY OUTCOME relapse within 2 years after surgery.Primary analysis: risk difference between the treatment arms (χ2 test). SECONDARY OUTCOMES postoperative complications, adverse events and survival.Inclusion period: summer 2023 to summer 2026. ETHICS AND DISSEMINATION The trial will be initiated during the summer of 2023 and is approved by the National Committee on Health Research Ethics, the Danish Medicine Agency, and registered under the Data Protection Act. The study will be conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. Patients included in the study will adhere to normal Danish treatment protocols and standards of care, and we expect only mild and temporary side effects. Positive and negative results will be published in peer-reviewed journals, with authorships adhering to the Vancouver rules. TRIAL REGISTRATION NUMBER NCT05899465; ClinicalTrials.gov Identifier.
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Affiliation(s)
- Karoline Assifuah Kristjansen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Andreas Engel Krag
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Schmidt
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Lisbet Rosenkrantz Hölmich
- Department of Plastic Surgery, Herlev Hospital, Herlev, Denmark
- Department of Clinical Medicine, Copenhagen University Hospital, Kobenhavn, Denmark
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Gammon R, Becker J, Cameron T, Eichbaum Q, Jindal A, Lamba DS, Nalezinski S, Rios J, Shaikh S, Shepherd J, Tanhehco YC. How do I manage a blood product shortage? Transfusion 2023; 63:2205-2213. [PMID: 37840217 DOI: 10.1111/trf.17572] [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: 06/30/2023] [Revised: 09/14/2023] [Accepted: 09/21/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND The demand for blood products sometimes exceeds the available inventory. Blood product inventories are dependent upon the availability of donors, supplies and reagents, and collection staff. During prolonged extreme shortages, blood centers and transfusion services must alter practices to meet the needs of patients. STUDY DESIGN AND METHODS The Association for the Advancement of Blood and Biotherapies Donor and Blood Component Management Subsection compiled some strategies from its blood center and hospital transfusion service members that could be implemented during blood product shortages. RESULTS Some strategies that blood centers could use to increase their available inventories include increasing donor recruitment efforts, using alternate types of collection kits, manufacturing low-yield apheresis-derived platelets and/or whole blood-derived platelets, using cold-stored platelets, transferring inventory internally among centers of the same enterprise, using frozen inventory, decreasing standing order quantities, prioritizing allocation to certain patient populations, filling partial orders, and educating customers and blood center staff. Transfusion service strategies that could be implemented to maximize the use of the limited available inventory include increasing patient blood management efforts, using split units, finding alternate blood suppliers, trading blood products with other hospital transfusion services, developing a patient priority list, assembling a hospital committee to decide on triaging priorities, using expired products in extreme situations, and accepting nonconforming products after performing safety checks. DISCUSSION Blood centers and transfusion services must choose the appropriate strategies to implement based on their needs.
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Affiliation(s)
- Richard Gammon
- OneBlood, Scientific, Medical, Technical Direction, Orlando, Florida, USA
| | - Joanne Becker
- Department of Pathology and Laboratory Medicine; Blood Bank and Therapeutic Apheresis Unit, Roswell Park Comprehensive Cancer Center, and Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Tracy Cameron
- Ontario Regional Blood Coordinating Network, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Quentin Eichbaum
- Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, USA
| | - Aikaj Jindal
- Department of Transfusion Medicine, Mohandai Oswal Hospital, Ludhiana, India
| | - Divjot Singh Lamba
- Department of Transfusion Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shaughn Nalezinski
- Department of Laboratory Medicine Transfusion Services, Concord Hospital, Concord, New Hampshire, USA
| | - Jorge Rios
- American Red Cross Blood Services, Dedham, Massachusetts, USA
| | - Salima Shaikh
- Vitalant, Northeast Division, Montvale, New Jersey, USA
| | - Janine Shepherd
- Transfusion Services Laboratory, Denver Health Hospital, Denver, Colorado, USA
| | - Yvette C Tanhehco
- Department of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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10
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van Kouswijk HW, Tolk JJ, van Bommel CPE, Reijman M, Kempink DRJ, de Witte PB. Effect of tranexamic acid on intraoperative blood loss in pediatric osteotomies around the hip: Study protocol for a double-blind randomized placebo-controlled trial. J Child Orthop 2023; 17:404-410. [PMID: 37799317 PMCID: PMC10549700 DOI: 10.1177/18632521231199518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/19/2023] [Indexed: 10/07/2023] Open
Abstract
Background Proximal femoral and/or pelvic osteotomies (PFPOs) can be indicated for a multitude of hip pathologies in (often asymptomatic) children, to prevent future hip problems. These procedures can result in significant blood loss. Tranexamic acid (TXA) is an antifibrinolytic agent routinely administered in adult trauma and joint reconstruction surgery to reduce blood loss. TXA is also registered for use in children and reported safe and beneficial for pediatric trauma, cardiac, and spinal surgery. However, for pediatric orthopedics, particularly for PFPOs, the available evidence is limited. Therefore, the current trial will investigate the potential reducing effect of preoperative TXA on intraoperative blood loss in pediatric PFPOs. Methods In this single-center, double-blind, randomized placebo-controlled trial, we aim to include 180 participants aged from 1 to 18 years undergoing PFPOs for any indication at our institution. Participants will be randomized to receive either TXA or placebo (saline) during anesthetic induction. The primary outcome is intraoperative estimated blood loss (mL/kg), which is determined gravimetrically. Secondary outcomes include the percentage of patients with excessive blood loss (>20 mL/kg), procedure time and hospital stay, and postoperative hemoglobin level changes. Discussion This will be the first prospective study investigating the effect of preoperative TXA on intraoperative blood loss in pediatric PFPOs. Its results will help to determine whether it would be advisable to adopt preoperative TXA as a standard medication to minimize blood loss and prevent complications in this vulnerable population. Trial registration EudraCT: 2022-002384-30. Prospectively registered on September 26, 2022.
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Affiliation(s)
- Hilde W van Kouswijk
- Department of Orthopaedics and Sports Medicine, Erasmus MC—Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Orthopaedic Surgery, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Jaap J Tolk
- Department of Orthopaedics and Sports Medicine, Erasmus MC—Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Christian PE van Bommel
- Department of Hospital Pharmacy, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Max Reijman
- Department of Orthopaedics and Sports Medicine, Erasmus MC—Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Dagmar RJ Kempink
- Department of Orthopaedics and Sports Medicine, Erasmus MC—Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Pieter B de Witte
- Department of Orthopaedics and Sports Medicine, Erasmus MC—Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
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Ma SY, An Y, Sun JX, Xu MY, Liu CQ, Xu JZ, Zhong XY, Zeng N, He HD, Xia QD, Wang SG. The effect of different timing of blood transfusion on oncological outcomes of patients undergoing radical cystectomy for bladder cancer: a systematic review and meta-analysis. Front Oncol 2023; 13:1223592. [PMID: 37719020 PMCID: PMC10499617 DOI: 10.3389/fonc.2023.1223592] [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: 05/16/2023] [Accepted: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
Highlights This meta-analysis and systematic review aim to analyze the association between BT and oncological outcomes of patients undergoing RC for bladder cancer, and tries to find out whether the timing of blood transfusion could also have an effect on this relationship. A total of 20 retrospective studies from online databases and other sources are identified and enrolled in this study. The results show that BT administration during RC operation or perioperative period is significantly associated with worse oncological outcomes including ACM, CSM and DR. Background Bladder cancer is one of the most common urological malignancies. Radical cystectomy (RC) remains the main treatment for localized muscle-invasive bladder cancer (MIBC) or high-grade non-muscle-invasive bladder cancer (NMIBC). In the process of RC, the administration of blood transfusion (BT) is sometimes needed, however, it may cause transfusion-related complications or lead to worse oncological outcomes. This meta-analysis and systematic review aims to give a comprehensive insight into the association between BT and oncological outcomes of patients undergoing RC, and tries to find out whether the timing of blood transfusion could also have an impact on this association. Methods This systematic review and meta-analysis were carried out according to the PRISMA 2020 reporting guideline. We have searched four bibliographic databases including PubMed (Medline), EMBASE, Cochrane Library, and Web of Science with no language limitation. Studies investigating the association between BT and oncological outcomes of patients undergoing RC are identified and included in this research from inception through March 20, 2023. This research calculates the pooled hazard ratios (pHR) and 95% confidence intervals (95% CI) of all-cause mortality (ACM), cancer-specific mortality (CSM) and disease recurrence (DR) using Random Effects models or Fixed Effects models. Subgroup analyses stratified by parameters such as timing of transfusion are also conducted. This meta-analysis was registered with PROSPERO, CRD42022381656. Results A total of 20 retrospective studies from online databases and other sources are identified and enrolled in this study. Results show that blood transfusion significantly increased the risks for ACM (HR = 1.33, 95% CI: 1.23-1.44), CSM (HR = 1.25, 95% CI: 1.15 - 1.35) and DR (HR = 1.26, 95% CI: 1.15 - 1.38). However, when stratified by the timing of BT, we find that only intraoperative and perioperative transfusion significantly increased in risks for worse prognosis, while postoperative transfusion raised none of the risks of ACM (HR = 1.26, 95% CI: 0.92-1.73), CSM (HR = 1.08, 95% CI: 0.93-1.26) nor DR (HR = 1.08, 95% CI: 0.90-1.29) significantly. Conclusion BT administration during RC operation or perioperative period is significantly associated with worse oncological outcomes including ACM, CSM and DR. Clinicians should consider carefully when deciding to administrate BT to patients undergoing RC and carry out according to current guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Qi-Dong Xia
- *Correspondence: Qi-Dong Xia, ; Shao-Gang Wang,
| | - Shao-Gang Wang
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Shaker EH, Soliman AM, Hussein AF, Fayek ES, Elrawas MM. Evaluating the Efficacy and Safety of a Single-Dose Tranexamic Acid in Reducing Blood Loss During Cytoreductive Surgery Followed by Hyperthermic Intraperitoneal Chemotherapy: A Randomized Comparative Pilot Study. Anesth Pain Med 2023; 13:e136578. [PMID: 38024001 PMCID: PMC10664172 DOI: 10.5812/aapm-136578] [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: 04/04/2023] [Revised: 05/31/2023] [Accepted: 06/08/2023] [Indexed: 12/01/2023] Open
Abstract
Background Hyperthermic intraperitoneal chemotherapy (HIPEC), following cytoreductive surgery (CRS), is a lengthy procedure, usually associated with considerable bleeding due to the extensive nature of surgery. Various techniques have been used to decrease blood transfusion requirements. Objectives This study aimed to evaluate the possible advantage of a single dose of tranexamic acid (TA) in such surgeries. Methods In this randomized comparative pilot study, 60 patients scheduled to undergo CRS followed by HIPEC were randomly assigned to 2 equal groups: group 1 (TA group) that received 10 mg/kg of TA in 100 mL of 0.9% NaCl over 20 minutes after the induction of anesthesia and before surgical incision, and group 2 (control group) that received a placebo of 100 mL of 0.9% NaCl during the same time interval. The primary endpoint was the blood loss volume. The secondary endpoints were the number of patients requiring transfusion and the occurrence of any postoperative thrombotic events 30 days after surgery. Serum creatinine levels were measured before the operation and on postoperative days 1, 3, and 5. Intraoperative and first 24 hours urine outputs were also recorded. The levels of hemoglobin (Hb) were measured before the operation, immediately after the operation, and 5 days postoperatively. Results Compared to the control group, the TA group exhibited lower intraoperative blood loss, as well as lower blood loss on postoperative day 1 and in total blood loss (P = 0.006, 0.035, and 0.001, respectively). However, the blood loss on the remaining postoperative days was comparable between both groups. Intraoperative blood transfusion requirements were lower in the TA group (P = 0.032) than in the control group. The total number of units of blood and plasma transfused was also lower in the TA group both intra and postoperatively (0.007, 0.40, and 0.032, 0.008, respectively) than in the control group. Hemoglobin levels, serum creatinine levels, and urine outputs during the first 24 hours postoperatively were comparable between the 2 groups. The thromboembolic events within 30 days were also comparable between the 2 groups. Conclusions Administering a single dose of TA between the induction of anesthesia and the surgical incision may reduce blood loss and transfusion rates in CRS followed by HIPEC without causing significant adverse effects. It is a promising approach in surgeries where massive blood loss is expected shortly after anesthesia induction. This can minimize the drawbacks of repeated blood transfusions during and after the operation without causing significant adverse effects. Besides reducing the need for repeated blood transfusions, it would also reduce the costs of blood/blood products and the risks of transfusion.
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Affiliation(s)
- Ehab Hanafy Shaker
- Department of Anesthesia, Intensive Care and Pain Management, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ahmed Mohamed Soliman
- Department of Anesthesia, Intensive Care and Pain Management, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ahmed Fahmy Hussein
- Department of Anesthesia, Intensive Care and Pain Management, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ehab Samy Fayek
- Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mai Mohamed Elrawas
- Department of Anesthesia, Intensive Care and Pain Management, National Cancer Institute, Cairo University, Cairo, Egypt
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13
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Gibbs VN, Geneen LJ, Champaneria R, Raval P, Dorée C, Brunskill SJ, Novak A, Palmer AJ, Estcourt LJ. Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic and long bone fractures. Cochrane Database Syst Rev 2023; 6:CD013499. [PMID: 37272509 PMCID: PMC10241722 DOI: 10.1002/14651858.cd013499.pub2] [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: 06/06/2023]
Abstract
BACKGROUND Pelvic, hip, and long bone fractures can result in significant bleeding at the time of injury, with further blood loss if they are treated with surgical fixation. People undergoing surgery are therefore at risk of requiring a blood transfusion and may be at risk of peri-operative anaemia. Pharmacological interventions for blood conservation may reduce the risk of requiring an allogeneic blood transfusion and associated complications. OBJECTIVES To assess the effectiveness of different pharmacological interventions for reducing blood loss in definitive surgical fixation of the hip, pelvic, and long bones. SEARCH METHODS We used a predefined search strategy to search CENTRAL, MEDLINE, PubMed, Embase, CINAHL, Transfusion Evidence Library, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) from inception to 7 April 2022, without restrictions on language, year, or publication status. We handsearched reference lists of included trials to identify further relevant trials. We contacted authors of ongoing trials to acquire any unpublished data. SELECTION CRITERIA We included randomised controlled trials (RCTs) of people who underwent trauma (non-elective) surgery for definitive fixation of hip, pelvic, and long bone (pelvis, tibia, femur, humerus, radius, ulna and clavicle) fractures only. There were no restrictions on gender, ethnicity, or age. We excluded planned (elective) procedures (e.g. scheduled total hip arthroplasty), and studies published since 2010 that had not been prospectively registered. Eligible interventions included: antifibrinolytics (tranexamic acid, aprotinin, epsilon-aminocaproic acid), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using GRADE. We did not perform a network meta-analysis due to lack of data. MAIN RESULTS We included 13 RCTs (929 participants), published between 2005 and 2021. Three trials did not report any of our predefined outcomes and so were not included in quantitative analyses (all were tranexamic acid versus placebo). We identified three comparisons of interest: intravenous tranexamic acid versus placebo; topical tranexamic acid versus placebo; and recombinant factor VIIa versus placebo. We rated the certainty of evidence as very low to low across all outcomes. Comparison 1. Intravenous tranexamic acid versus placebo Intravenous tranexamic acid compared to placebo may reduce the risk of requiring an allogeneic blood transfusion up to 30 days (RR 0.48, 95% CI 0.34 to 0.69; 6 RCTs, 457 participants; low-certainty evidence) and may result in little to no difference in all-cause mortality (Peto odds ratio (Peto OR) 0.38, 95% CI 0.05 to 2.77; 2 RCTs, 147 participants; low-certainty evidence). It may result in little to no difference in risk of participants experiencing myocardial infarction (risk difference (RD) 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 199 participants; low-certainty evidence), and cerebrovascular accident/stroke (RD 0.00, 95% CI -0.02 to 0.02; 3 RCTs, 324 participants; low-certainty evidence). We are uncertain if there is a difference between groups for risk of deep vein thrombosis (Peto OR 2.15, 95% CI 0.22 to 21.35; 4 RCTs, 329 participants, very low-certainty evidence), pulmonary embolism (Peto OR 1.08, 95% CI 0.07 to 17.66; 4 RCTs, 329 participants; very low-certainty evidence), and suspected serious drug reactions (RD 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 185 participants; very low-certainty evidence). No data were available for number of red blood cell units transfused, reoperation, or acute transfusion reaction. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures), and upgraded the evidence for transfusion requirement for a large effect. Comparison 2. Topical tranexamic acid versus placebo We are uncertain if there is a difference between topical tranexamic acid and placebo for risk of requiring an allogeneic blood transfusion (RR 0.31, 95% CI 0.08 to 1.22; 2 RCTs, 101 participants), all-cause mortality (RD 0.00, 95% CI -0.10 to 0.10; 1 RCT, 36 participants), risk of participants experiencing myocardial infarction (Peto OR 0.15, 95% CI 0.00 to 7.62; 1 RCT, 36 participants), cerebrovascular accident/stroke (RD 0.00, 95% CI -0.06 to 0.06; 1 RCT, 65 participants); and deep vein thrombosis (Peto OR 1.11, 95% CI 0.07 to 17.77; 2 RCTs, 101 participants). All outcomes reported were very low-certainty evidence. No data were available for number of red blood cell units transfused, reoperation, incidence of pulmonary embolism, acute transfusion reaction, or suspected serious drug reactions. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), inconsistency (moderate heterogeneity), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures, and high risk of attrition and reporting biases in one trial). Comparison 3. Recombinant factor VIIa versus placebo Only one RCT of 48 participants reported data for recombinant factor VIIa versus placebo, so we have not presented the results here. AUTHORS' CONCLUSIONS We cannot draw conclusions from the current evidence due to lack of data. Most published studies included in our analyses assessed the use of tranexamic acid (compared to placebo, or using different routes of administration). We identified 27 prospectively registered ongoing RCTs (total target recruitment of 4177 participants by end of 2023). The ongoing trials create six new comparisons: tranexamic acid (tablet + injection) versus placebo; intravenous tranexamic acid versus oral tranexamic acid; topical tranexamic acid versus oral tranexamic acid; different intravenous tranexamic acid dosing regimes; topical tranexamic acid versus topical fibrin glue; and fibrinogen (injection) versus placebo.
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Affiliation(s)
- Victoria N Gibbs
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Louise J Geneen
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Rita Champaneria
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Parag Raval
- Trauma and Orthopaedic Specialist Registrar, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Alex Novak
- Emergency Medicine Research Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antony Jr Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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14
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Ishii K, Yokoyama Y, Yonekawa Y, Hayashi D, Kinoshita F, Kuwatsuka Y, Okuno M, Natsume S, Minami T, Sugawara G, Seita K, Sato F, Aoba T, Shimizu Y, Kurumiya Y, Maeda A, Yamaguchi R, Hiramatsu K, Ebata T. Tranexamic acid and blood loss in pancreaticoduodenectomy: TAC-PD randomized clinical trial. Br J Surg 2023; 110:159-165. [PMID: 36379883 DOI: 10.1093/bjs/znac382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/04/2022] [Accepted: 10/21/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) may reduce intraoperative blood loss, but it has not been investigated in pancreaticoduodenectomy (PD). METHODS A pragmatic, multicentre, randomized, blinded, placebo-controlled trial was conducted. Adult patients undergoing planned PD for biliary, duodenal, or pancreatic diseases were randomly assigned to TXA or placebo groups. Patients in the TXA group were administered 1 g TXA before incision, followed by a maintenance infusion of 125 mg/h TXA. Patients in the placebo group were administered the same volume of saline as those in the placebo group. The primary outcome was blood loss during PD. The secondary outcomes included perioperative blood transfusions, operating time, morbidity, and mortality. RESULTS Between September 2019 and May 2021, 218 patients were randomly assigned and underwent surgery (108 in the TXA group and 110 in the placebo group). Mean intraoperative blood loss was 659 ml in the TXA group and 701 ml in the placebo group (mean difference -42 ml, 95 per cent c.i. -191 to 106). Of the 218 patients, 202 received the intervention and underwent PD, and the mean blood loss during PD was 667 ml in the TXA group and 744 ml in the placebo group (mean difference -77 ml, 95 per cent c.i. -226 to 72). The secondary outcomes were comparable between the two groups. CONCLUSION Perioperative TXA use did not reduce blood loss during PD. REGISTRATION NUMBER jRCTs041190062 (https://jrct.niph.go.jp).
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Affiliation(s)
- Kenta Ishii
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.,Department of General Surgery, Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.,Division of Perioperative Medicine, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yoshihiko Yonekawa
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Daisuke Hayashi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Fumie Kinoshita
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Yachiyo Kuwatsuka
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Masataka Okuno
- Department of Gastroenterological Surgery, Aichi Cancer Centre Hospital, Nagoya, Aichi, Japan
| | - Seiji Natsume
- Department of Gastroenterological Surgery, Aichi Cancer Centre Hospital, Nagoya, Aichi, Japan
| | - Takayuki Minami
- Department of Surgery, Toyota Kosei Hospital, Toyota, Aichi, Japan
| | - Gen Sugawara
- Department of Surgery, Toyota Kosei Hospital, Toyota, Aichi, Japan
| | - Kazuaki Seita
- Department of Surgery, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Fumiya Sato
- Department of Surgery, Kasugai Municipal Hospital, Kasugai, Aichi, Japan
| | - Taro Aoba
- Department of General Surgery, Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Centre Hospital, Nagoya, Aichi, Japan
| | | | - Atsuyuki Maeda
- Department of Surgery, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Ryuzo Yamaguchi
- Department of Surgery, Kasugai Municipal Hospital, Kasugai, Aichi, Japan
| | - Kazuhiro Hiramatsu
- Department of General Surgery, Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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15
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Wang E, Wang Y, Li Y, Hu S, Yuan S. Tranexamic acid is associated with improved hemostasis in elderly patients undergoing coronary-artery surgeries in a retrospective cohort study. Front Surg 2023; 10:1117974. [PMID: 36896258 PMCID: PMC9989169 DOI: 10.3389/fsurg.2023.1117974] [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: 12/07/2022] [Accepted: 02/03/2023] [Indexed: 02/23/2023] Open
Abstract
Background More elderly patients undergo coronary artery bypass surgery (CABG) than younger patients. Whether tranexamic acid (TA) is still effective and safe in elderly patients undergoing CABG surgeries is still unclear. Methods In this study, a cohort of 7,224 patients ≥70 years undergoing CABG surgery were included. Patients were categorized into the no TA group, TA group, high-dose group, and low-dose group according whether TA was administered and the dose administered. The primary endpoint was blood loss and blood transfusion after CABG. The secondary endpoints were thromboembolic events and in-hospital death. Results The blood loss at 24 and 48 h and the total blood loss after surgery in patients in the TA group were 90, 90, and 190 ml less than those in the no-TA group, respectively (p < 0.0001). The total blood transfusion was reduced 0.38-fold with TA administration compared to that without TA (OR = 0.62, 95% CI 0.56-0.68, p < 0.0001). Blood component transfusion was also reduced. High-dose TA administration reduced the blood loss by 20 ml 24 h after surgery (p = 0.032) but had no relationship with the blood transfusion. TA increased the risk of perioperative myocardial infarction (PMI) by 1.62-fold [p = 0.003, OR = 1.62, 95% CI (1.18-2.22)] but reduced the hospital stay time in patients who were administered TA compared to that of patients who did not receive TA (p = 0.026). Conclusion We revealed that elderly patients undergoing CABG surgeries had better hemostasis after TA administration but increased the risk of PMI. High-dose TA was effective and safe compared with low-dose TA administration in elderly patients undergoing CABG surgery.
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Affiliation(s)
- Enshi Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yang Wang
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Yuan Li
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Olivares G, Sharman M, Miller R, Kisielewicz C, Seth M. Use of tranexamic acid in dogs with primary immune thrombocytopenia: A feasibility study. Front Vet Sci 2023; 10:946127. [PMID: 37035812 PMCID: PMC10073717 DOI: 10.3389/fvets.2023.946127] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 02/09/2023] [Indexed: 04/11/2023] Open
Abstract
Objective The aim of this feasibility study is to evaluate the use of tranexamic acid and its safe use alongside standard therapy in dogs with primary immune thrombocytopenia (ITP). Design This is a cohort feasibility study involving 10 dogs diagnosed with primary ITP that received standard therapy for ITP including corticosteroids, a single dose of vincristine, and omeprazole. Dogs were randomly divided into either the control group (n = 6) or the group receiving tranexamic acid (TXA group, n = 4). Key findings The mean time from the start of treatment until remission was 5 days in the TXA group and 6 days in the control group (P = 0.69). Two dogs, one in each group, did not achieve remission. Clinical bleeding scores were not significantly different between both groups (p = 0.43), and the median blood volume administered was 37.5 ml/kg for the TXA group and 9.72 ml/kg for the control group (p = 0.084). Three out of the four dogs receiving TXA of 20 mg/kg IV started vomiting within 15 min of administration and were given a reduced dose of 15 or 10 mg/kg IV. Conclusion Tranexamic acid did not confer a clinical benefit in this small cohort study and was associated with a high incidence of vomiting. This study provides useful information for the design of future trials in dogs with ITP receiving tranexamic acid including outcome measures and safety.
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Affiliation(s)
- Gerard Olivares
- Department of Small Animal Internal Medicine, Animal Health Trust, Newmarket, Suffolk, United Kingdom
- Department of Small Animal Internal Medicine, Eastcott Veterinary Referrals, Part or Linnaeus Veterinary Limited, Swindon, United Kingdom
- *Correspondence: Gerard Olivares
| | - Mellora Sharman
- Department of Small Animal Internal Medicine, Animal Health Trust, Newmarket, Suffolk, United Kingdom
| | - Rachel Miller
- Department of Small Animal Internal Medicine, Dick White Referrals, Cambridgeshire, United Kingdom
| | - Caroline Kisielewicz
- Department of Small Animal Internal Medicine, Pride Veterinary Centre, Derby, United Kingdom
| | - Mayank Seth
- Department of Small Animal Internal Medicine, Animal Health Trust, Newmarket, Suffolk, United Kingdom
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17
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Manevskiу AA, Sviridov SV, Melekhov AV, Barmotin GV, Demin AK, Nikitin IG. Enhanced Recovery in Total Knee and Hip Arthroplasty: the Need for National Recommendations. MESSENGER OF ANESTHESIOLOGY AND RESUSCITATION 2022. [DOI: 10.21292/2078-5658-2022-19-6-86-96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- A. A. Manevskiу
- National Medical Research Center, Medical and Rehabilitation Center; Pirogov Russian National Research Medical University
| | | | - A. V. Melekhov
- National Medical Research Center, Medical and Rehabilitation Center; Pirogov Russian National Research Medical University
| | - G. V. Barmotin
- National Medical Research Center, Medical and Rehabilitation Center
| | - A. K. Demin
- National Medical Research Center, Medical and Rehabilitation Center; Institute for Leadership and Health Management, I. M. Sechenov First Moscow State Medical University (Sechenov University)
| | - I. G. Nikitin
- National Medical Research Center, Medical and Rehabilitation Center; Pirogov Russian National Research Medical University
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Huang H, Xin M, Wu X, Liu J, Zhang W, Yang K, Zhang J. The efficacy of tranexamic acid treatment with different time and doses for traumatic brain injury: a systematic review and meta-analysis. Thromb J 2022; 20:79. [PMID: 36529753 PMCID: PMC9762012 DOI: 10.1186/s12959-022-00440-9] [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: 02/19/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Tranexamic acid (TXA) plays a significant role in the treatment of traumatic diseases. However, its effectiveness in patients with traumatic brain injury (TBI) seems to be contradictory, according to the recent publication of several meta-analyses. We aimed to determine the efficacy of TXA treatment at different times and doses for TBI treatment. METHODS PubMed, MEDLINE, EMBASE, Cochrane Library, and Google Scholar were searched for randomized controlled trials that compared TXA and a placebo in adults and adolescents (≥ 15 years of age) with TBI up to January 31, 2022. Two authors independently abstracted the data and assessed the quality of evidence. RESULTS Of the identified 673 studies, 13 involving 18,675 patients met our inclusion criteria. TXA had no effect on mortality (risk ratio (RR) 0.99; 95% confidence interval (CI) 0.92-1.06), adverse events (RR 0.93, 95% Cl 0.76-1.14), severe TBI (Glasgow Coma Scale score from 3 to 8) (RR 0.99, 95% Cl 0.94-1.05), unfavorable Glasgow Outcome Scale (GOS < 4) (RR 0.96, 95% Cl 0.82-1.11), neurosurgical intervention (RR 1.11, 95% Cl 0.89-1.38), or rebleeding (RR 0.97, 95% Cl 0.82-1.16). TXA might reduce the mean hemorrhage volume on subsequent imaging (standardized mean difference, -0.35; 95% CI [-0.62, -0.08]). CONCLUSION TXA at different times and doses was associated with reduced mean bleeding but not with mortality, adverse events, neurosurgical intervention, and rebleeding. More research data is needed on different detection indexes and levels of TXA in patients with TBI, as compared to those not receiving TXA; although the prognostic outcome for all harm outcomes was not affected, the potential for harm was not ruled out. TRIAL REGISTRATION The review protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42022300484).
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Affiliation(s)
- Honghao Huang
- grid.413855.e0000 0004 1764 5163Department of Cardiovascular Surgery, General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610036 China ,grid.263901.f0000 0004 1791 7667College of Medicine, Southwest Jiaotong University, Chengdu, 610036 China
| | - Mei Xin
- grid.413855.e0000 0004 1764 5163Department of Cardiovascular Surgery, General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610036 China
| | - Xiqiang Wu
- grid.413855.e0000 0004 1764 5163Department of Cardiovascular Surgery, General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610036 China
| | - Jian Liu
- grid.413855.e0000 0004 1764 5163Department of Cardiovascular Surgery, General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610036 China
| | - Wenxin Zhang
- grid.413855.e0000 0004 1764 5163Department of Cardiovascular Surgery, General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610036 China ,grid.263901.f0000 0004 1791 7667College of Medicine, Southwest Jiaotong University, Chengdu, 610036 China
| | - Ke Yang
- grid.413855.e0000 0004 1764 5163Department of Cardiovascular Surgery, General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610036 China ,grid.263901.f0000 0004 1791 7667College of Medicine, Southwest Jiaotong University, Chengdu, 610036 China
| | - Jinbao Zhang
- grid.413855.e0000 0004 1764 5163Department of Cardiovascular Surgery, General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610036 China
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Calpin GG, McAnena PF, Davey MG, Calpin P, Kerin MJ, McInerney N, Walsh SR, Lowery AJ. The role of tranexamic acid in reducing post-operative bleeding and seroma formation in breast surgery: A meta-analysis. Surgeon 2022. [PMID: 36572609 DOI: 10.1016/j.surge.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Tranexamic acid (TXA) reduces blood loss and blood transfusion requirements in surgery. Seroma and haematoma formation occur as complications of breast surgery. We aimed to perform a meta-analysis evaluating TXA in reducing post-operative haematoma and seroma formation for breast surgery. METHODS A systematic review was performed in accordance with PRISMA guidelines. Results were expressed as dichotomous variables pooled as odds ratios (OR) with corresponding 95% confidence intervals (CIs) using the Mantel-Haenszel method. RESULTS Seven studies including 1446 patients were included. There were 1830 breast surgery procedures performed with TXA administered in 797 cases (43.6%). There was a significant reduction in haematoma rates in the TXA group (TXA: 3.184% (22/691) vs Control: 6.787% (64/943), OR: 0.41, 95% CI: 0.20-0.86, P = 0.020). Based on surgical procedure, haematoma rates were similar for TXA and control groups in cancer surgery (P = 0.230). Haematoma rates reduced following TXA use in cosmetic procedures (TXA: 3.807% (15/394) vs. Control: 9.091% (34/374), OR: 0.41, 95% CI: 0.22-0.75, P = 0.004). Haematoma rates were also reduced in procedures where axillary lymph node dissection (ALND) was not performed; in the TXA group, 3.379% (22/651) developed a haematoma versus 6.623% (60/906) in the control group (OR: 0.45, 95% CI 0.27-0.77, P = 0.003). TXA administration did not impact seroma formation or infection rates. CONCLUSION Perioperative administration of TXA may impact the incidence of haematoma in breast surgery, particularly in cosmetic procedures and procedures without ALND. Well-designed randomised studies are required to determine its true efficacy. TXA has no effect on seroma formation or infection in breast surgery.
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Joo YB, Kim YM, An BK, Lee CW, Kwon ST, Song JH. Topical Tranexamic Acid Can Be Used Safely Even in High Risk Patients: Deep Vein Thrombosis Examination Using Routine Ultrasonography of 510 Patients. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121750. [PMID: 36556952 PMCID: PMC9784633 DOI: 10.3390/medicina58121750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/24/2022] [Accepted: 11/26/2022] [Indexed: 12/02/2022]
Abstract
Background and Objectives: Previous studies regarding tranexamic acid (TXA) in total knee arthroplasty (TKA) investigated only symptomatic deep vein thrombosis (DVT), or did not include high risk patients. The incidence of DVT including both symptomatic and asymptomatic complications after applying topical TXA has not been evaluated using ultrasonography. Materials and Methods: The medical records of 510 patients who underwent primary unilateral TKA between July 2014 and December 2017 were retrospectively reviewed. Because TXA was routinely applied through the topical route, those who had a history of venous thromboembolism, myocardial infarction, or cerebral vascular occlusive disease, were not excluded. Regardless of symptom manifestation, DVT was examined at 1 week postoperatively for all patients using ultrasonography, and the postoperative transfusion rate was investigated. The study population was divided according to the use of topical TXA. After the two groups were matched based on the propensity scores, the incidence of DVT and the transfusion rate were compared between the groups. Results: Of the 510 patients, comprising 298 patients in the TXA group and 212 patients in the control group, DVT was noted in 22 (4.3%) patients. Two patients had DVT proximal to the popliteal vein. After propensity score matching (PSM), 168 patients were allocated to each group. In all, 11 patients in the TXA group and seven patients in the control group were diagnosed with DVT, which did not show a significant difference (p = 0.721). However, the two groups differ significantly in the transfusion rate (p < 0.001, 50.0% in the TXA group, 91.7% in the control group). Conclusions: The incidence of DVT, whether symptomatic or asymptomatic, was not affected by the use of topical TXA. The postoperative transfusion rate was reduced in the TXA group. Topical TXA could be applied safely even in patients who had been known to be at high risk.
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Affiliation(s)
- Yong Bum Joo
- Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea
| | - Young Mo Kim
- Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea
| | - Byung Kuk An
- Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea
| | - Cheol Won Lee
- Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea
| | - Soon Tae Kwon
- Department of Radiology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea
| | - Ju-Ho Song
- Department of Orthopedic Surgery, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong 30099, Republic of Korea
- Correspondence: ; Tel.:+82-44-995-4798
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Antifibrinolytics in Cardiac Surgery: What Is the Best Practice in 2022? CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00538-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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22
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Hunter CW, Deer TR, Jones MR, Chang Chien GC, D'Souza RS, Davis T, Eldon ER, Esposito MF, Goree JH, Hewan-Lowe L, Maloney JA, Mazzola AJ, Michels JS, Layno-Moses A, Patel S, Tari J, Weisbein JS, Goulding KA, Chhabra A, Hassebrock J, Wie C, Beall D, Sayed D, Strand N. Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience. J Pain Res 2022; 15:2683-2745. [PMID: 36132996 PMCID: PMC9484571 DOI: 10.2147/jpr.s370469] [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: 04/13/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022] Open
Abstract
Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from – unfortunately, there is no consensus on which treatments are “better” and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.
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Affiliation(s)
- Corey W Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA.,Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | | | | | - Ryan S D'Souza
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | | | - Erica R Eldon
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lissa Hewan-Lowe
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jillian A Maloney
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Anthony J Mazzola
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Jeanmarie Tari
- Ainsworth Institute of Pain Management, New York, NY, USA
| | | | | | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - Chris Wie
- Interventional Spine and Pain, Dallas, TX, USA
| | - Douglas Beall
- Comprehensive Specialty Care, Oklahoma City, OK, USA
| | - Dawood Sayed
- Department of Anesthesiology, Division of Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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Huang J, Guo H, Huang W, Tan X, Huang H, Zeng C. Topical Application of Tranexamic Acid Can Reduce Postoperative Blood Loss in Calcaneal Fractures: A Randomized Controlled Trial. J Foot Ankle Surg 2022; 61:1056-1059. [PMID: 35193803 DOI: 10.1053/j.jfas.2022.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 07/06/2021] [Accepted: 01/10/2022] [Indexed: 02/03/2023]
Abstract
The traditional lateral "L" approach is common for managing calcaneal fractures with a drawback of significant blood loss. Yet there are no prospective studies on the hemostatic effect of the topical use of tranexamic acid (TXA) in calcaneal fracture surgeries. The purpose of this study was to evaluate the role of topical administration of TXA in reducing postoperative blood loss in calcaneal fractures. Forty participants were randomly distributed into the TXA group (n = 20) and the control group (n = 20). All participants underwent the same surgery via the lateral "L" approach. At the end of the operation, the surgical wound was irrigated with 80 mL 0.5 g/L TXA in the TXA group and 80 mL 0.9% sodium chloride in the control group, followed by the routine use of a drainage tube when closing the incision. Then, 20 mL 0.5 g/L TXA (TXA group) or 20 mL 0.9% sodium chloride solution (control group) was injected retrogradely into the wound through the drainage tube, which was clipped for 30 minutes thereafter. There were no significant differences in the baseline data between the 2 groups (p > .05). There was significantly less blood loss in the first 24 hours and total blood loss postoperation in the TXA group (p < .01). The surgical wounds healed well after surgery in both groups with no complication. We concluded that topical application of TXA in calcaneal fracture surgeries is a safe and useful method that can reduce postoperative blood loss.
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Affiliation(s)
- Jianguo Huang
- Resident, Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China; Postgraduate student, Southern Medical University, Guangzhou, Guangdong, China
| | - Hao Guo
- Attending, Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Weiqi Huang
- Attending, Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Xinyu Tan
- Attending, Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Huajun Huang
- Attending, Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Canjun Zeng
- Director, Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China.
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Alfitian J, Scheyerer MJ, Rohde A, Schick V, Kammerer T, Schier R. Omission of tranexamic acid does not increase the amount of perioperative blood transfusions in patients undergoing one-level spinal fusion surgery: a retrospective propensity score-matched noninferiority study. Arch Orthop Trauma Surg 2022; 143:2943-2950. [PMID: 35708870 DOI: 10.1007/s00402-022-04494-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 05/18/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Application of tranexamic acid (TXA) in spine surgery is very frequent even without signs of hyperfibrinolysis, although its beneficial blood-saving effects are offset by harmful adverse events such as thromboembolic incidents. Thus, we investigated whether in relatively less invasive spinal procedures such as one-level posterior spinal fusion, omission of TXA affects the requirement for blood transfusions. METHODS We conducted a retrospective propensity score-matched noninferiority study with 212 patients who underwent one-level posterior spine fusion and who were stratified according to whether they received TXA intraoperatively at our tertiary care center. The primary endpoint was the volume of transfused packed red cells. Testing for noninferiority or equivalence was performed by two one-sided testing procedure (TOST) with a priori defined noninferiority margins ([Formula: see text]). RESULTS After propensity score matching a total of five patients (11.6%) treated with TXA were transfused compared with five patients (11.6%) who did not receive TXA. The majority of patients (51.2%) had a risk-increasing condition. The risk difference (no TXA-TXA) of intraoperative transfusion was - 4.7% (CI 90% - 13.62 to 4.32%), and omitting TXA was noninferior ([Formula: see text] = [Formula: see text] 10%). The mean intergroup difference in transfused volume (no TXA-TXA) was - 23.26 ml intraoperatively (CI 90% - 69.34 to 22.83 ml) and - 46.51 ml overall (CI 90% - 181.12 to 88.1 ml), respectively, suggesting equivalence of TXA omission ([Formula: see text] = [Formula: see text] 300 ml). The hemoglobin decline between both groups was also equivalent (with [Formula: see text] = [Formula: see text] 1 g/dl) both on the first postoperative day ([Formula: see text] Hb = 0.02 g/dl, CI 90% - 0.53 to 0.56 g/dl) and at discharge ([Formula: see text] Hb = - 0.29 g/dl, CI 90% - 0.89 to 0.31 g/dl). CONCLUSION We demonstrated that requirement of transfusion is rare among one-level fusion surgery and the omission of TXA is noninferior with regard to blood transfusion in high-risk patients undergoing this procedure. Therefore, the prophylactic use of TXA cannot be recommended here, suggesting to focus on alternative blood conservation strategies, if necessary.
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Affiliation(s)
- Jonas Alfitian
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Max Joseph Scheyerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedics and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Axel Rohde
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedics and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Volker Schick
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany
| | - Tobias Kammerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany
| | - Robert Schier
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany
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Kelava M, Mehta A, Sale S, Gillinov M, Johnston D, Thuita L, Kumar N, Blackstone EH. Effectiveness and safety of E-aminocaproic acid in overall and less invasive cardiac surgeries. J Cardiothorac Vasc Anesth 2022; 36:3780-3790. [DOI: 10.1053/j.jvca.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/18/2022] [Accepted: 06/05/2022] [Indexed: 11/11/2022]
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Klein A, Agarwal S, Cholley B, Fassl J, Griffin M, Kaakinen T, Paulus P, Rex S, Siegemund M, van Saet A. A review of European guidelines for patient blood management with a particular emphasis on antifibrinolytic drug administration for cardiac surgery. J Clin Anesth 2022; 78:110654. [DOI: 10.1016/j.jclinane.2022.110654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/05/2022] [Accepted: 01/08/2022] [Indexed: 10/19/2022]
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Konarski W, Poboży T, Hordowicz M. Tranexamic acid in total knee replacement and total hip replacement - a single-center retrospective, observational study. Orthop Rev (Pavia) 2022; 14:33875. [PMID: 35775036 PMCID: PMC9239398 DOI: 10.52965/001c.33875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 10/25/2021] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Numerous strategies are used to decrease the risk of the need for [allogeneic blood transfusion (ABT)], including [tranexamic acid (TXA)]. OBJECTIVE In a single-center retrospective observational study, we have assessed the impact of TXA on the need and average volume of blood used during transfusion. METHODS We have reviewed medical records of a total of 491 patients undergoing arthroplasty in our hospital from Dec 2016 to Dec 2019. RESULTS 226 patients were administered TXA IV, and 265 did not receive an additional intervention. In the TXA group, 7/226 patients required ABT vs. 41/265 in the non-TXA group (p<0,001). The Non-TXA group required a significantly higher blood transfusion volume than the TXA group (mean 82,42 mL vs. 12,74 mL; p<0,001). CONCLUSION We conclude that two doses of 1g TXA administered [intravenously (IV)] before incision and during skin suturing reduce the need for blood transfusion in patients undergoing JRS.
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Affiliation(s)
| | - Tomasz Poboży
- Department of Orthopaedic Surgery, Ciechanów Hospital, Ciechanów
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Shokri H, Ali I. Intravenous iron supplementation treats anemia and reduces blood transfusion requirements in patients undergoing coronary artery bypass grafting-A prospective randomized trial. Ann Card Anaesth 2022; 25:141-147. [PMID: 35417958 PMCID: PMC9244267 DOI: 10.4103/aca.aca_209_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 01/09/2021] [Accepted: 02/06/2021] [Indexed: 12/03/2022] Open
Abstract
Study Objective Preoperative anemia results in two- to sixfold increased incidence of perioperative blood transfusion requirements and reduced postoperative hemoglobin (Hb) level. This prospective study was designed to investigate the effect of preoperative intravenous infusion of iron on Hb levels, blood transfusion requirements, and incidence of postoperative adverse events in patients undergoing coronary artery bypass grafting. Design Prospective randomized trial. Setting Academic university hospital. Patients Eighty patients (52-67 years old) underwent coronary artery bypass grafting and received either iron therapy or saline infusion preoperatively. Interventions Patients were randomly allocated to iron or placebo groups. In the iron group, patients received a single intravenous dose of ferric carboxymaltose (1000 mg in 100 mL saline) infused slowly over 15 min 7 days before surgery. In placebo group, patients received a single intravenous dose of saline (100 mL saline) infused slowly over 15 min 7 days before surgery. Measurements Patients were followed up with regards to incidence of anemia, Hb level on admission, preoperatively, postoperatively, 1 week and 4 weeks after discharge, aortic cross-clamp time, the number of packed red blood cells (pRBCs) units, the percentage of reticulocytes pre-postoperatively and 1 week later, hospital stay and intensive care unit (ICU) stay length, and the incidence of postoperative complications. Main Results Iron therapy was associated with lower incidence of anemia 4 weeks after discharge (P < 0.001). Hb level was significantly higher in the iron group compared to the placebo group preoperatively and postoperatively, and 4 weeks after discharge (P < 0.001). Iron therapy resulted in shorter hospital and ICU stay (P < 0.001) and shorter aortic cross-clamp time, reduced pRBCs requirements postoperatively. Percentage of reticulocytes was significantly higher in placebo group than in iron group postoperatively and 1 week after discharge and the incidence of postoperative complications was similar to the placebo group. Conclusions Preoperative IV iron infusion is a safe and feasible way to manage preoperative anemia. Preoperative administration of IV iron is associated with a higher postoperative Hb level, shorter hospital and ICU stay, and reduced perioperative red blood cell transfusion requirements with insignificant difference in incidence of postoperative complications.
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Affiliation(s)
- Hoda Shokri
- Department of Anesthesiology, Ain Shams University, Cairo, Egypt
| | - Ihab Ali
- Department of Cardiothoracic Surgery, Ain Shams University, Cairo, Egypt
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Wong D, Lam TK. The role of tranexamic acid in breast and body contouring surgery: a review of the literature. AUSTRALASIAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.34239/ajops.v5n1.277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Postoperative seroma and haematoma are two of the most common complications follow-ing large surface area surgeries. A review of the literature was performed to evaluate evidence for the use of tranexamic acid in reducing postoperative seroma and haematoma formation in breast surgery and body contouring surgery.
Methods A literature search was performed using MEDLINE, the Cochrane Database of Systematic Review, the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Ef-fect (DARE) and PubMed in English from 1 Jan 1990–30 Mar 2020. The search terms ‘TXA’, ‘breast reduction’, ‘mammaplasty’, ‘breast implants’, ‘breast implantation’, ‘breast reconstruction’, ‘mastectomy’, ‘tissue ex-pansion’, ‘body contouring’, ‘breast’ and ‘abdominoplasty’ were used alone and in combination.
Results: A total of six articles were found including three randomised controlled trials, two cohort studies and one retrospective study. Two ongoing trials were found on The Cochrane Central Register of Con-trolled Trials (CENTRAL). No systematic reviews were found.
Conclusion: Literature surrounding the use of TXA in breast and body contouring surgery is sparse com-pared to what is available in other surgical sub-specialties. The literature available shows promising results with the use of TXA in controlling haematoma, drain output and seroma formation in breast surgery and body contouring surgery with minimal morbidity in these patient groups.
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30
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O'Connor MK, Emanuelli E, Garg RK. Le Fort I maxillary osteotomy in a Jehovah's Witness patient: strategies for minimizing blood loss and maximizing safety. Maxillofac Plast Reconstr Surg 2022; 44:10. [PMID: 35235074 PMCID: PMC8891397 DOI: 10.1186/s40902-022-00338-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Watch Tower Society, the main governing organization of the Jehovah's Witness (JW) faith, introduced the doctrine to refuse blood in 1945 and has been enforcing it since 1961. A member can be expelled for accepting prohibited blood components. Many reconstructive surgeries place patients at an increased risk for blood loss. There have been attempts at reducing the rate of transfusions in craniofacial surgery, even in patients not opposed to it. PRESENTATION A 15-year-old female patient, who refused blood transfusion due to her faith, presented with a class III malocclusion, transverse maxillary constriction, and a lateral open bite. Surgery was deferred until the patient reached 18 years of age and had undergone preoperative orthodontics. A two-piece Le Fort I osteotomy was performed. Erythropoietin, oral iron, and tranexamic acid were used to minimize intraoperative blood loss. CONCLUSION Here we discuss preoperative and intraoperative management strategies to ensure a transfusion-free environment for patients with religious objections to blood transfusions undergoing operations with increased bleeding risk.
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Affiliation(s)
| | - Elisa Emanuelli
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Ravi K Garg
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, KS, USA.
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31
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Karanicolas PJ, Lin Y, McCluskey S, Roke R, Tarshis J, Thorpe KE, Ball CG, Chaudhury P, Cleary SP, Dixon E, Eeson G, Moulton CA, Nanji S, Porter G, Ruo L, Skaro AI, Tsang M, Wei AC, Guyatt G. Tranexamic acid versus placebo to reduce perioperative blood transfusion in patients undergoing liver resection: protocol for the haemorrhage during liver resection tranexamic acid (HeLiX) randomised controlled trial. BMJ Open 2022; 12:e058850. [PMID: 35210348 PMCID: PMC8883280 DOI: 10.1136/bmjopen-2021-058850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/14/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Despite use of operative and non-operative interventions to reduce blood loss during liver resection, 20%-40% of patients receive a perioperative blood transfusion. Extensive intraoperative blood loss is a major risk factor for postoperative morbidity and mortality and receipt of blood transfusion is associated with serious risks including an association with long-term cancer recurrence and overall survival. In addition, blood products are scarce and associated with appreciable expense; decreasing blood transfusion requirements would therefore have health system benefits. Tranexamic acid (TXA), an antifibrinolytic, has been shown to reduce the probability of receiving a blood transfusion by one-third for patients undergoing cardiac or orthopaedic surgery. However, its applicability in liver resection has not been widely researched. METHODS AND ANALYSIS This protocol describes a prospective, blinded, randomised controlled trial being conducted at 10 sites in Canada and 1 in the USA. 1230 eligible and consenting participants will be randomised to one of two parallel groups: experimental (2 g of intravenous TXA) or placebo (saline) administered intraoperatively. The primary endpoint is receipt of blood transfusion within 7 days of surgery. Secondary outcomes include blood loss, postoperative complications, quality of life and 5-year disease-free and overall survival. ETHICS AND DISSEMINATION This trial has been approved by the research ethics boards at participating centres and Health Canada (parent control number 177992) and is currently enrolling participants. All participants will provide written informed consent. Results will be distributed widely through local and international meetings, presentation, publication and ClinicalTrials.gov. TRIAL REGISTRATION NUMBER NCT02261415.
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Affiliation(s)
- Paul Jack Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Stuart McCluskey
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Roke
- Department of Evaluative Clinical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin E Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Chad G Ball
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Prosanto Chaudhury
- Department of Surgery, McGill University Health Centre, Montreal, Québec, Canada
| | - Sean P Cleary
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elijah Dixon
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Gareth Eeson
- Department of Surgery, Kelowna General Hospital, Kelowna, British Columbia, Canada
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Carol-Anne Moulton
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, University Health Network, Toronto, Ontario, Canada
| | - Sulaiman Nanji
- Department of Surgery, Kingston General Hospital, Kingston, Ontario, Canada
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Geoff Porter
- Department of Surgery, Nova Scotia Health, Halifax, Nova Scotia, Canada
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Leyo Ruo
- Department of Surgery, Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada
- Deparment of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Anton I Skaro
- Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
- Department of Surgery, University of Western Ontario Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Melanie Tsang
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, St. Joseph's Health Centre - Unity Health Toronto, Toronto, Ontario, Canada
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Wang E, Yuan X, Wang Y, Chen W, Zhou X, Hu S, Yuan S. Tranexamic Acid Administered During Off-Pump Coronary Artery Bypass Graft Surgeries Achieves Good Safety Effects and Hemostasis. Front Cardiovasc Med 2022; 9:775760. [PMID: 35187119 PMCID: PMC8854353 DOI: 10.3389/fcvm.2022.775760] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/06/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Tranexamic acid (TXA) administered during off-pump coronary artery bypass (OPCAB) surgeries has achieved good blood control in small cohorts. We aimed to investigate the safety issues and hemostasis associated with TXA administration during OPCAB in a large retrospective cohort study. METHODS This study included 19,687 patients with OPCAB from 2009 to 2019. A total of 1,307 patients were excluded because they were younger than 18 years or certain values were missing. Among the remaining 18,380 patients, 10,969 were in the TXA group and 7,411 patients were in the no-TXA group. There were 4,889 patients whose TXA dose was ≥50 mg/kg, and the remaining 6,080 patients had a TXA dose of <50 mg/kg. Propensity score matching (PSM) was performed between the TXA and no-TXA groups and between the high-dose and low-dose groups, and statistical analysis was performed. RESULTS Tranexamic acid administration did not increase the risk of hospital death or thromboembolic events. Patients who administered TXA had less blood loss at 24 h (478.32 ± 276.41 vs. 641.28 ± 295.09, p < 0.001) and 48 h (730.59 ± 358.55 vs. 915.24 ± 390.13, p < 0.001) and total blood loss (989.00 ± 680.43 vs. 1,220.01 ± 720.68, p < 0.001) after OPCAB than the patients with non-TXA. Therefore, the risk of total blood exposure [odds ratio (OR) = 0.50, 95% CI 0.47-0.54, p < 0.001] or blood component exposure (p < 0.001) was decreased significantly in the patients who administered TXA. The TXA dosage did not impact the patient survival, thromboembolic events, or blood management. CONCLUSIONS The application of TXA was safe and provided blood control in patients with OPCAB, and the dosage did not affect these parameters.
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Affiliation(s)
- Enshi Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xin Yuan
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Wang
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Weinan Chen
- Information Center, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xingtong Zhou
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Thota B, Marinica A, Oh MW, Cripps MW, Moon TS. The Use of Tranexamic Acid in Trauma. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00509-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wang E, Yuan X, Wang Y, Chen W, Zhou X, Hu S, Yuan S. Tranexamic Acid Administered During Off-Pump Coronary Artery Bypass Graft Surgeries Achieves Good Safety Effects and Hemostasis. Front Cardiovasc Med 2022. [PMID: 35187119 DOI: 0.3389/fcvm.2022.775760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) administered during off-pump coronary artery bypass (OPCAB) surgeries has achieved good blood control in small cohorts. We aimed to investigate the safety issues and hemostasis associated with TXA administration during OPCAB in a large retrospective cohort study. METHODS This study included 19,687 patients with OPCAB from 2009 to 2019. A total of 1,307 patients were excluded because they were younger than 18 years or certain values were missing. Among the remaining 18,380 patients, 10,969 were in the TXA group and 7,411 patients were in the no-TXA group. There were 4,889 patients whose TXA dose was ≥50 mg/kg, and the remaining 6,080 patients had a TXA dose of <50 mg/kg. Propensity score matching (PSM) was performed between the TXA and no-TXA groups and between the high-dose and low-dose groups, and statistical analysis was performed. RESULTS Tranexamic acid administration did not increase the risk of hospital death or thromboembolic events. Patients who administered TXA had less blood loss at 24 h (478.32 ± 276.41 vs. 641.28 ± 295.09, p < 0.001) and 48 h (730.59 ± 358.55 vs. 915.24 ± 390.13, p < 0.001) and total blood loss (989.00 ± 680.43 vs. 1,220.01 ± 720.68, p < 0.001) after OPCAB than the patients with non-TXA. Therefore, the risk of total blood exposure [odds ratio (OR) = 0.50, 95% CI 0.47-0.54, p < 0.001] or blood component exposure (p < 0.001) was decreased significantly in the patients who administered TXA. The TXA dosage did not impact the patient survival, thromboembolic events, or blood management. CONCLUSIONS The application of TXA was safe and provided blood control in patients with OPCAB, and the dosage did not affect these parameters.
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Affiliation(s)
- Enshi Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xin Yuan
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Wang
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Weinan Chen
- Information Center, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xingtong Zhou
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Yousuf MS, Samad K, Ahmed SS, Siddiqui KM, Ullah H. Cardiac Surgery and Blood-Saving Techniques: An Update. Cureus 2022; 14:e21222. [PMID: 35186524 PMCID: PMC8844256 DOI: 10.7759/cureus.21222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/12/2022] Open
Abstract
Cardiac surgery is typically attributed with a significant risk of intraoperative blood loss and allogeneic blood transfusions. Intraoperative blood loss, allogenic blood transfusions, high dose anticoagulation requirement, and interactions with cardiopulmonary bypass (CPB) have all been linked to cardiac surgeries. To reduce unnecessary transfusions and their negative effects, it is recommended to follow evidence-based multidisciplinary strategies, which are collectively termed patient blood management (PBM). This review highlights the most recent blood conservation strategies in adult cardiac surgery, which can be employed pre-operatively, intra-operatively, and postoperatively, to enhance red cell mass and attenuate the utilization of packed red blood cells (PRBCs) and other blood products.
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Affiliation(s)
| | - Khalid Samad
- Anaesthesia and Critical Care, The Aga Khan University Hospital, Karachi, PAK
- Anaesthesia and Critical Care, Aga Khan Health Service, Pakistan (AKHS,P), Karachi, PAK
| | | | | | - Hameed Ullah
- Anaesthesiology, The Aga Khan University Hospital, Karachi, PAK
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OLIVEIRA JOSÉALBERTOALVES, BRITO GABRIELLACRISTINACOELHODE, BEZERRA FRANCISCAMAGNAPRADO, CARVALHO NETO CARLOSALFREDODE, ALENCAR NETO JONATASBRITODE, IBIAPINA ROBERTOCÉSARPONTES. THE USE OF ANTIFIBRINOLYTICS IN HIP TRAUMA SURGERY IN A PUBLIC HEALTH SYSTEM: A PROSPECTIVE STUDY. ACTA ORTOPEDICA BRASILEIRA 2021; 29:304-307. [PMID: 34849094 PMCID: PMC8601384 DOI: 10.1590/1413-785220212906244502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/09/2020] [Indexed: 11/22/2022]
Abstract
Objective: To evaluate the use of tranexamic acid (TXA) and ε-aminocaproic acid (EACA) in reducing blood loss in hip and proximal femur trauma surgery. Methods: Prospective study with 49 patients surgically treated in a trauma hospital between Nov/2015 and Feb/2017. The patients were divided in two groups: TXA (n = 24) and EACA (n = 25). The comparison was made according to gender, age at the time of surgery, ASA, fracture and surgery type, estimated blood loss during surgical approach, hemoglobin and hematocrit levels pre and post-operative, and pharmacological cost. The data was processed using SPSS 22.0 with significance level of p < 0,05. Results: No significant difference was found in the variables age, gender, ASA and estimated blood loss during surgical approach. No patient needed blood transfusion. When evaluated post-operatively, the hemoglobin and hematocrit values decrease had no significant difference between the antifibrinolytics (p > 0.05). When analyzing total cost for both pharmacological agents, higher cost was observed in EACA than in TXA (US$ 16.09 - US$ 2.73), resulting in a US$ 13.36 addition per patient. Conclusion: Antifibrinolytic use was efficient on lowering the total blood loss, without the need of blood transfusion. Level of evidence II, Prospective Comparative Study.
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Roberts I, Shakur-Still H, Afolabi A, Akere A, Arribas M, Austin E, Bal K, Bazeer N, Beaumont D, Brenner A, Carrington L, Chaudhri R, Coats T, Gilmore I, Halligan K, Hussain I, Jairath V, Javaid K, Kayani A, Lisman T, Mansukhani R, Miners A, Mutti M, Nadeem MA, Pollok R, Prowse D, Simmons J, Stanworth S, Veitch A, Williams J. A high-dose 24-hour tranexamic acid infusion for the treatment of significant gastrointestinal bleeding: HALT-IT RCT. Health Technol Assess 2021; 25:1-86. [PMID: 34663491 DOI: 10.3310/hta25580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Tranexamic acid reduces blood loss in surgery and the risk of death in trauma patients. Meta-analyses of small trials suggest that tranexamic acid decreases the number of deaths from gastrointestinal bleeding, but these meta-analyses are prone to selection bias. OBJECTIVE The trial provides reliable evidence of the effect of tranexamic acid on mortality, rebleeding and complications in significant acute gastrointestinal bleeding. DESIGN A multicentre, randomised, placebo-controlled trial and economic analysis. Patients were assigned by selecting one treatment pack from a box of eight, which were identical apart from the pack number. Patients, caregivers and outcome assessors were masked to allocation. The main analyses were by intention to treat. SETTING The setting was 164 hospitals in 15 countries, co-ordinated from the London School of Hygiene & Tropical Medicine. PARTICIPANTS Adults with significant upper or lower gastrointestinal bleeding (n = 12,009) were eligible if the responsible clinician was substantially uncertain about whether or not to use tranexamic acid. The clinical diagnosis of significant bleeding implied a risk of bleeding to death, including hypotension, tachycardia or signs of shock, or urgent transfusion, endoscopy or surgery. INTERVENTION Tranexamic acid (a 1-g loading dose over 10 minutes, then a 3-g maintenance dose over 24 hours) or matching placebo. MAIN OUTCOME MEASURES The primary outcome was death due to bleeding within 5 days of randomisation. Secondary outcomes were all-cause and cause-specific mortality; rebleeding; need for endoscopy, surgery or radiological intervention; blood product transfusion; complications; disability; and days spent in intensive care or a high-dependency unit. RESULTS A total of 12,009 patients were allocated to receive tranexamic acid (n = 5994, 49.9%) or the matching placebo (n = 6015, 50.1%), of whom 11,952 (99.5%) received the first dose. Death due to bleeding within 5 days of randomisation occurred in 222 (3.7%) patients in the tranexamic acid group and in 226 (3.8%) patients in the placebo group (risk ratio 0.99, 95% confidence interval 0.82 to 1.18). Thromboembolic events occurred in 86 (1.4%) patients in the tranexamic acid group and 72 (1.2%) patients in the placebo group (risk ratio 1.20, 95% confidence interval 0.88 to 1.64). The risk of arterial thromboembolic events (myocardial infarction or stroke) was similar in both groups (0.7% in the tranexamic acid group vs. 0.8% in the placebo group; risk ratio 0.92, 95% confidence interval 0.60 to 1.39), but the risk of venous thromboembolic events (deep-vein thrombosis or pulmonary embolism) was higher in tranexamic acid-treated patients than in placebo-treated patients (0.8% vs. 0.4%; risk ratio 1.85, 95% confidence interval 1.15 to 2.98). Seizures occurred in 38 patients who received tranexamic acid and in 22 patients who received placebo (0.6% vs. 0.4%, respectively; risk ratio 1.73, 95% confidence interval 1.03 to 2.93). In the base-case economic analysis, tranexamic acid was not cost-effective and resulted in slightly poorer health outcomes than no tranexamic acid. CONCLUSIONS Tranexamic acid did not reduce death from gastrointestinal bleeding and, although inexpensive, it is not cost-effective in adults with acute gastrointestinal bleeding. FUTURE WORK These results caution against a uniform approach to the management of patients with major haemorrhage and highlight the need for randomised trials targeted at specific pathophysiological processes. LIMITATIONS Although this is one of the largest randomised trials in gastrointestinal bleeding, we cannot rule out a modest increase or decrease in death due to bleeding with tranexamic acid. TRIAL REGISTRATION Current Controlled Trials ISRCTN11225767, ClinicalTrials.gov NCT01658124 and EudraCT 2012-003192-19. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 58. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Adefemi Afolabi
- Department of Surgery, University College Hospital Ibadan, Ibadan, Nigeria
| | - Adegboyega Akere
- Department of Medicine, University College Hospital Ibadan, Ibadan, Nigeria
| | - Monica Arribas
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Emma Austin
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Kiran Bal
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Nuha Bazeer
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.,Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Danielle Beaumont
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Amy Brenner
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Laura Carrington
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Rizwana Chaudhri
- Department of Obstetrics and Gynaecology, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Timothy Coats
- Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Ian Gilmore
- Liverpool Centre for Alcohol Research, University of Liverpool, Liverpool, UK
| | | | - Irshad Hussain
- Department of Medicine, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Vipul Jairath
- Division of Gastroenterology, Western University and London Health Sciences Centre, London, ON, Canada
| | - Kiran Javaid
- Rawalpindi Medical University - Pakistan National Coordinating Centre (RMU-PNCC), Rawalpindi, Pakistan
| | - Aasia Kayani
- Rawalpindi Medical University - Pakistan National Coordinating Centre (RMU-PNCC), Rawalpindi, Pakistan
| | - Ton Lisman
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Raoul Mansukhani
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Muttiullah Mutti
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Muhammad Arif Nadeem
- Medical Unit III, Services Institute of Medical Sciences, Services Hospital Gastrointestinal, Lahore, Pakistan
| | - Richard Pollok
- Gastroenterology and Hepatology Department, St George's Hospital, London, UK
| | - Danielle Prowse
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Jonathan Simmons
- Gastroenterology Department, Royal Berkshire Hospital, Reading, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant (NHSBT), John Radcliffe Hospital, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Andrew Veitch
- Gastroenterology Department, New Cross Hospital, Wolverhampton, UK
| | - Jack Williams
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Abbasciano RG, Lai FY, Roman MA, Rizzello A, Pathak S, Ramzi J, Lucarelli C, Layton GR, Kumar T, Wozniak MJ, Eagle-Hemming B, Akowuah E, Rogers CA, Angelini GD, Murphy GJ. Activation of the innate immune response and organ injury after cardiac surgery: a systematic review and meta-analysis of randomised trials and analysis of individual patient data from randomised and non-randomised studies. Br J Anaesth 2021; 127:365-375. [PMID: 34229833 DOI: 10.1016/j.bja.2021.04.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND It is unclear whether the innate immune response represents a therapeutic target for organ protection strategies in cardiac surgery. METHODS A systematic review of trials of interventions targeting the inflammatory response to cardiac surgery reporting treatment effects on both innate immune system cytokines and organ injury was performed. The protocol was registered at the International Prospective Register of Systematic Reviews: CRD42020187239. Searches of the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase were performed. Random-effects meta-analyses were used for the primary analysis. A separate analysis of individual patient data from six studies (n=785) explored sources of heterogeneity for treatment effects on cytokine levels. RESULTS Searches to May 2020 identified 251 trials evaluating 24 interventions with 20 582 participants for inclusion. Most trials had important limitations. Methodological limitations of the included trials and heterogeneity of the treatment effects on cytokine levels between trials limited interpretation. The primary analysis demonstrated inconsistency in the direction of the treatment effects on innate immunity and organ failure or death between interventions. Analyses restricted to important subgroups or trials with fewer limitations showed similar results. Meta-regression, pooling available data from all trials, demonstrated no association between the direction of the treatment effects on inflammatory cytokines and organ injury or death. The analysis of individual patient data demonstrated heterogeneity in the association between the cytokine response and organ injury after cardiac surgery for people >75 yr old and those with some chronic diseases. CONCLUSIONS The certainty of the evidence for a causal relationship between innate immune system activation and organ injury after cardiac surgery is low.
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Affiliation(s)
| | - Florence Y Lai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Marius A Roman
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Angelica Rizzello
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Suraj Pathak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Joussi Ramzi
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Carla Lucarelli
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | | | - Tracy Kumar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Marcin J Wozniak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Enoch Akowuah
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | | | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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39
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K S A, Kumar P, Subair M, Sharma RK. Effect of single dose intravenous tranexamic acid on blood loss in tangential excision of burn wounds - A double blind randomised controlled trial. Burns 2021; 48:1311-1318. [PMID: 34952736 DOI: 10.1016/j.burns.2021.08.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 08/21/2021] [Accepted: 08/26/2021] [Indexed: 11/02/2022]
Abstract
INTRODUCTION This study was carried out to evaluate role of intravenous tranexamic acid (TXA) in reducing blood loss during tangential excision of burns. METHODS This was a single center, prospective double-blinded parallel arm superiority randomized placebo-controlled trial. Patients (15-55 years) with deep dermal thermal burns <30% undergoing tangential excision were randomly assigned (1:1) to TXA and placebo groups. Patients in TXA and placebo groups received injection TXA 15 mg/kg and 10 ml saline respectively, 10 min preoperatively. Primary outcome was volume of blood loss per square centimeter area of burn excised. Secondary outcomes were total volume of blood loss, postoperative hemoglobin, intraoperative fluid requirement, blood transfusion, graft take and length of hospitalization (LOH). RESULTS Thirty patients were included. Both groups were comparable in terms of Body Mass Index (BMI) preoperative hemoglobin, area of burn excised, duration of surgery and the intraoperative temperature. The average blood loss per square centimeter burn area excised was found to be significantly lower in TXA when compared to placebo group (mean difference: 0.28 ± 0.025 ml/cm2; p = 0.000). The total volume of blood loss was lower in TXA group (258.7 ± 124.10 ml vs 388.1 ± 173.9 ml; p = 0.07). None of the patients required transfusion. The requirement of intra-operative fluids was similar between the two groups (crystalloids: p = 0.236; colloids: p = 0.238). Postoperative hemoglobin, length of hospitalization and graft-take were comparable between the two groups. CONCLUSION TXA reduced blood loss per unit burn area of tangential excision in <30%TBSA burn, however, we found no significant effect on postoperative Hb and transfusion.
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Affiliation(s)
- Ajai K S
- Department of Plastic & Reconstructive Surgery, PGIMER, Chandigarh, India.
| | - Parmod Kumar
- Department of Plastic & Reconstructive Surgery, PGIMER, Chandigarh, India.
| | - Mohsina Subair
- Department of Plastic & Reconstructive Surgery, PGIMER, Chandigarh, India.
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Jozefowicz E, Sabourdin N, Lambelin V, Lejeune V, Delassus R, Tavernier B. The effect of tranexamic acid on blood loss in orthognathic surgery: a randomized, placebo-controlled, equivalence study. Int J Oral Maxillofac Surg 2021; 51:637-642. [PMID: 34465477 DOI: 10.1016/j.ijom.2021.08.018] [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: 02/08/2021] [Revised: 06/01/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
Orthognathic surgery can cause substantial bleeding. Recent meta-analyses concluded that there is a statistically significant reduction in perioperative blood loss with the preventive use of tranexamic acid (TA). However, the mean reported difference in bleeding was moderate, and the clinical relevance of this blood-sparing effect remains debated. We therefore conducted a prospective, double-blind, randomized, placebo-controlled equivalence study of the effect of TA in patients undergoing Lefort I or bimaxillary osteotomies. Our main outcome measure was total blood loss on postoperative day 1. The equivalence margin was ± 250 ml for the difference in blood loss and its 95% confidence interval. One hundred and forty-seven patients were randomized, of which 122 underwent bimaxillary osteotomies. Blood loss in the treatment group was 682 ± 323 vs. 875 ± 492 ml. The mean difference in bleeding was -132 [-243; -21] ml as per-protocol, but -193 [-329; -57] ml in intention-to-treat: the limits of this confidence interval exceeded the margin of equivalence. Similar results were obtained when analysing only patients undergoing bimaxillary osteotomy. Haemoglobin decreased by 1.8 ± 1.2 g/dl with TA, vs. 2.6 ± 1.1 g/dl with placebo (p<0.001). Our study did not demonstrate equivalence between TA and placebo on perioperative blood loss in orthognathic surgery. TA may reduce blood loss but without evidence of clinical consequences.
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Affiliation(s)
- E Jozefowicz
- CHU Lille, Pôle d'Anesthésie-Réanimation, F-59000 Lille, France.
| | - N Sabourdin
- Department of Anesthesiology, Armand Trousseau University Hospital, DMU DREAM, APHP, GRC 29, Sorbonne Université, Paris, France
| | - V Lambelin
- CHU Lille, Pôle d'Anesthésie-Réanimation, F-59000 Lille, France
| | - V Lejeune
- CHU Lille, Pôle d'Anesthésie-Réanimation, F-59000 Lille, France
| | - R Delassus
- CHU Lille, Pôle d'Anesthésie-Réanimation, F-59000 Lille, France
| | - B Tavernier
- CHU Lille, Pôle d'Anesthésie-Réanimation, F-59000 Lille, France; Université Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des Technologies de santé et des Pratiques médicales, F-59000 Lille, France
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Burbul M, Tomaszewski D, Rogalska A, Gawroński K, Literacki S, Waśko M. Thrombotic activation before and after total hip arthroplasty. A prospective cohort study. BMC Musculoskelet Disord 2021; 22:691. [PMID: 34389001 PMCID: PMC8364023 DOI: 10.1186/s12891-021-04566-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 06/09/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) causes acute blood loss. It may lead to a deficiency in coagulation factors, which, in turn, may lead to increased bleeding during the postoperative period. METHODS Thirty patients (18 women) with a mean age of 67 years (range: 63-72 years) participated in this prospective diagnostic study. THA was performed without tranexamic acid administration in the perioperative period. Activities of clotting factors II, VIII, X, and fibrinogen concentration were evaluated before surgery, 6 hours after the procedure, 2, 4, and 6 days after the operation. All laboratory tests were performed using ACL TOP 500 CTS analyzer. RESULTS No thromboembolic complications were noted during hospitalization. Mean fibrinogen concentration was 366 mg/dL before surgery, which decreased to 311 mg/dL 6 hours after the operation and peaked at 827 mg/dL on the 4th day after the procedure. Activities of factors II and X decreased on the second and fourth days after surgery. Although the activity of factor VIII decreased after the procedure, it remained within the normal range. Increased baseline fibrinogen concentrations were observed in 6 out of 30 (20%) patients. Mean blood loss was 1332 mL (range, 183-2479 mL) and did not correlate with changes in clotting factor activities. CONCLUSIONS In patients undergoing THA, fibrinogen acts as an acute-phase protein. Activities of clotting factors II and X normalize within 6 days, and although the activity of factor VIII decreases, it remains within the normal range. TRIAL REGISTRATION The study was pre-registered May 1st, 2020 on ClinicalTrials.gov.
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Affiliation(s)
- Marta Burbul
- Department of Traumatology and Orthopaedics, Military Institute of Medicine, Warsaw, Poland
| | - Dariusz Tomaszewski
- Department of Anesthesiology and Intensive Therapy, Military Institute of Medicine, Warsaw, Poland
| | - Anna Rogalska
- Department of Health Economics and Health Management, School of Health Sciences in Bytom, Medical University of Silesia in Katowice, Bytom, Poland
| | | | - Sławomir Literacki
- Department of Laboratory Diagnostics, Military Institute of Medicine, Warsaw, Poland
| | - Marcin Waśko
- Department of Radiology and Imaging, The Medical Center of Postgraduate Education, Warsaw, Poland
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Ockerman A, Vanassche T, Garip M, Vandenbriele C, Engelen MM, Martens J, Politis C, Jacobs R, Verhamme P. Tranexamic acid for the prevention and treatment of bleeding in surgery, trauma and bleeding disorders: a narrative review. Thromb J 2021; 19:54. [PMID: 34380507 PMCID: PMC8356407 DOI: 10.1186/s12959-021-00303-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We review the evidence for tranexamic acid (TXA) for the treatment and prevention of bleeding caused by surgery, trauma and bleeding disorders. We highlight therapeutic areas where evidence is lacking and discuss safety issues, particularly the concern regarding thrombotic complications. METHODS An electronic search was performed in PubMed and the Cochrane Library to identify clinical trials, safety reports and review articles. FINDINGS TXA reduces bleeding in patients with menorrhagia, and in patients undergoing caesarian section, myomectomy, hysterectomy, orthopedic surgery, cardiac surgery, orthognathic surgery, rhinoplasty, and prostate surgery. For dental extractions in patients with bleeding disorders or taking antithrombotic drugs, as well as in cases of idiopathic epistaxis, tonsillectomy, liver transplantation and resection, nephrolithotomy, skin cancer surgery, burn wounds and skin grafting, there is moderate evidence that TXA is effective for reducing bleeding. TXA was not effective in reducing bleeding in traumatic brain injury and upper and lower gastrointestinal bleeding. TXA reduces mortality in patients suffering from trauma and postpartum hemorrhage. For many of these indications, there is no consensus about the optimal TXA dose. With certain dosages and with certain indications TXA can cause harm, such as an increased risk of seizures after high TXA doses with brain injury and cardiac surgery, and an increased mortality after delayed administration of TXA for trauma events or postpartum hemorrhage. Whereas most trials did not signal an increased risk for thrombotic events, some trials reported an increased rate of thrombotic complications with the use of TXA for gastro-intestinal bleeding and trauma. CONCLUSIONS TXA has well-documented beneficial effects in many clinical indications. Identifying these indications and the optimal dose and timing to minimize risk of seizures or thromboembolic events is work in progress.
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Affiliation(s)
- Anna Ockerman
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium.
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Melisa Garip
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Jeroen Martens
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peter Verhamme
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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Hussey P, Onodera Y, Reddy S, Samuelson B, Subramani S, Siddapura Ranganath Y, Jaradat T, Hanada S. Need for preoperative anemia management clinics in Japan: initiatives at a university hospital in the USA. J Anesth 2021; 35:710-722. [PMID: 34338863 DOI: 10.1007/s00540-021-02979-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/21/2021] [Indexed: 12/26/2022]
Abstract
Untreated preoperative anemia increases the risk of morbidity and mortality and there is increasing evidence that early intervention for preoperative anemia improves outcomes after major surgery. Accordingly, anemia management clinics have been established in various institutions in the USA. As an example, the University of Iowa Hospitals and Clinics outpatient clinic treats pre-surgical anemic patients, who undergo major surgery with anticipated blood loss of more than 500 mL, by providing effective standardized care in a timely manner. This standardized care is an integral part of patient blood management to reduce perioperative blood transfusion and improve patient outcomes. The importance of preoperative anemia management has not yet been sufficiently recognized in Japan. Timely intervention for preoperative anemia should be incorporated into routine pre-surgical patient care in Japan.
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Affiliation(s)
- Patrick Hussey
- Department of Anesthesia, School of Medicine, University of Alabama at Birmingham, 619 19th Street S, Birmingham, AL, 35226, USA
| | - Yoshiko Onodera
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA.,Surgical Operation Department, Asahikawa Medical University Hospital, Midorigaoka-higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Sundara Reddy
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Blain Samuelson
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Sudhakar Subramani
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Yatish Siddapura Ranganath
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Tariq Jaradat
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Satoshi Hanada
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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D’Souza RS, Duncan CM, Whiting DR, Brown MJ, Warner MA, Smith HM, Kremers HM, Stewart TM. Tranexamic acid is associated with decreased transfusion, hospital length of stay, and hospital cost in simultaneous bilateral total knee arthroplasty. Bosn J Basic Med Sci 2021; 21:471-476. [PMID: 33119480 PMCID: PMC8292867 DOI: 10.17305/bjbms.2020.5060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023] Open
Abstract
Tranexamic acid (TXA) reduces blood loss and transfusion rates in unilateral total knee arthroplasty (TKA), but there is limited data regarding its efficacy in bilateral TKA. This study reports the impact TXA has on clinical outcomes and hospital cost of care in simultaneous, primary bilateral TKA. The 449 patients were retrospectively reviewed. Primary outcomes included the rates of allogeneic and autologous blood transfusion. Secondary outcomes included hospital length of stay (HLOS), post-hospital discharge disposition, 30-day thromboembolic events (TEE), and mean hospital cost of care. Total direct medical costs were obtained from an institutional research database and adjusted to nationally representative unit costs in 2013 inflation-adjusted dollars. Our study revealed that in patients undergoing simultaneous bilateral TKA, TXA use was associated with reduced allogeneic (OR 0.181, 95% CI 0.090-0.366, p < 0.001) and combined allogeneic and autologous transfusion rates (OR 0.451, 95% CI 0.235-0.865, p = 0.017). TXA was associated with a HLOS reduction of 0.9 days (β-coefficient -0.582, 95% CI -1.008--0.156, p = 0.008), an increased likelihood of hospital discharge over skilled nursing facility (SNF) (OR 2.25, 95% CI 1.117-4.531, p = 0.023) and reduced total hospital cost of care by 6.45% (p < 0.001), room and board costs by 11.76% (p < 0.001), and transfusion costs by 81.65% (p < 0.001). In conclusion, TXA use in bilateral TKA is associated with lower blood transfusion rates, reduced hospital length of stay, reduced cost of hospital care and skilled nursing facility avoidance.
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Affiliation(s)
- Ryan S. D’Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Christopher M. Duncan
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Daniel R. Whiting
- Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Michael J. Brown
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Matthew A. Warner
- Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Hugh M. Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Hilal Maradit Kremers
- Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Thomas M. Stewart
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
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45
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Monteiro OM, Perrone RT, Almeida FN, Moura CPDE, Oliveira SGDE, Almeida GDBDE. COMPARISON OF HEMOSTASIS WITH TRANEXAMIC ACID IN TOTAL KNEE ARTHROPLASTY. ACTA ORTOPEDICA BRASILEIRA 2021; 29:184-188. [PMID: 34566475 PMCID: PMC8443016 DOI: 10.1590/1413-785220212904235714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 08/27/2020] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To compare the use of intravenous and topical tranexamic acid (TXA) in unilateral primary total knee arthroplasty (TKA) in relation to blood loss and complications inherent to the medication. METHOD Three groups with 14 patients each were constituted, and all of them were operated using the same surgical technique. In Group 1, usual measures for bleeding control were performed. Group 2 patients received TXA topically on the joint surface. In Group 3, intravenous TXA was used. Hemoglobin (HB), hematocrit (HTC), platelets (PLAT), prothrombin time, activated partial thromboplastin time and volume of blood drained observed 24 hours after arthroplasty were compared to the values of tests found before surgery. RESULTS There was a decrease in the concentration of HB, HTC and PLAT in all groups in relation to the preoperative, however without significant difference. Group 3 had a lower mean volume of drained blood than the other groups, with statistical significance. No adverse effects or thromboembolic events were observed in the groups that received TXA. CONCLUSION This study showed superiority in the use of intravenous TXA in decreasing the volume of bleeding, without increasing the risk of thromboembolic events. Level of Evidence I, High quality randomized trial with statistically significant difference or no statistically significant difference but narrow confidence intervals.
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46
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Bleeding Disorders in Primary Fibrinolysis. Int J Mol Sci 2021; 22:ijms22137027. [PMID: 34209949 PMCID: PMC8268566 DOI: 10.3390/ijms22137027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/07/2021] [Accepted: 06/18/2021] [Indexed: 11/24/2022] Open
Abstract
Fibrinolysis is a complex enzymatic process aimed at dissolving blood clots to prevent vascular occlusions. The fibrinolytic system is composed of a number of cofactors that, by regulating fibrin degradation, maintain the hemostatic balance. A dysregulation of fibrinolysis is associated with various pathological processes that result, depending on the type of abnormality, in prothrombotic or hemorrhagic states. This narrative review is focused on the congenital and acquired disorders of primary fibrinolysis in both adults and children characterized by a hyperfibrinolytic state with a bleeding phenotype.
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47
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Samir M, Saafan AM, Afifi RM, Tawfick A. Can high-dose tranexamic acid have a role during transurethral resection of the prostate in large prostates? A randomised controlled trial. Arab J Urol 2021; 20:24-29. [PMID: 35223106 PMCID: PMC8881071 DOI: 10.1080/2090598x.2021.1932125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/16/2021] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES To assess the efficacy and safety of high-dose tranexamic acid (TXA) during bipolar transurethral resection of the prostate (B-TURP) in patients with large prostates compared to placebo. PATIENTS AND METHODS From February 2018 to May 2020, 204 patients with enlarged prostates of 80-130 g and in need of surgical intervention were randomised into two groups. Patients in Group A underwent B-TURP and received TXA as an intravenous loading dose of 50 mg/kg over 20 min before induction of anaesthesia followed by a maintenance infusion of 5 mg/kg/h until resection was completed. The patients in Group B (placebo) received a saline infusion of a similar volume. RESULTS There was highly significant drop in haemoglobin in the placebo group at 4- and 24-h postoperatively compared with the TXA group (P < 0.001). However, there was no significant difference in the blood transfusion rate between the two groups with five patients (5.5%) in the placebo group and four (4.2%) in the TXA group requiring a transfusion (P = 0.74). The procedural time was significantly less in the TXA group vs the control group, at a mean (SD) of 79.93 (22.18) vs 90.91 (21.4) min (P = 0.001). Also, the intraoperative irrigation fluid volume and postoperative irrigation duration were significantly less in the TXA group vs the control group, at a mean (SD) of 19.21 (3.13) vs 23.05 (3.8) L and 14.75 (5.15) vs 18.33 (5.96) h, respectively (P = 0.001). Catheterisation and hospital stay durations were comparable between both groups (P = 0.384 and P = 0.388, respectively). No complications were recorded with use of high-dose TXA. CONCLUSION High-dose TXA was effective in controlling blood loss during B-TURP in patients with large prostates, with no adverse drug reactions.
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Affiliation(s)
- Mohamed Samir
- Department of Urology, Ain Shams University, Cairo, Egypt
| | | | - Rania M. Afifi
- Department of Urology, Ain Shams University, Cairo, Egypt
| | - Ahmed Tawfick
- Department of Urology, Ain Shams University, Cairo, Egypt
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48
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Tranexamic acid in plastic surgery: routes of administration and dosage considerations. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01794-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Leow L, Ng J, Luo HD, Choong AMTL, Mithiran H, Kofidis T, Tam JKC. Antifibrinolytics reduces blood loss in thoracic surgery: a systematic review and meta-analysis. ANZ J Surg 2021; 91:1251-1259. [PMID: 33928739 DOI: 10.1111/ans.16909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 03/21/2021] [Accepted: 04/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The purpose of this systematic review is to evaluate the efficacy of antifibrinolytics in non-cardiac thoracic surgery. METHODS We searched for all randomized controlled trials on this topic. A set of strict inclusion and exclusion criteria was developed. Six studies were meta-analysed together then in subgroups of topical tranexamic acid and intravenous aprotinin. We compared postoperative chest drain output, transfusions requirements and duration of hospital stay where available to determine the efficacy of topical tranexamic acid or intravenous aprotinin in reducing blood loss. RESULTS The use of antifibrinolytics reduces 24-h chest drain output (-290.21 mL [-524.75, -55.66], P = 0.02, I2 = 98%), red blood cell transfusion requirements (-1.27 units [-2.24, -0.30], P = 0.01, I2 = 100%) and shortened duration of hospital stay (-1.81 days [-3.25, -0.36], P = 0.01, I2 = 96%). The subgroup analysis also supported this trend. CONCLUSION We conclude that the use of antifibrinolytics appears to reduce postoperative blood loss by reducing chest drain output, transfusion requirements and length of stay after thoracic surgery.
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Affiliation(s)
- Lowell Leow
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre Singapore, National University Hospital Singapore, Singapore
| | - Josiah Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hai Dong Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre Singapore, National University Hospital Singapore, Singapore
| | - Andrew M T L Choong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre Singapore, National University Hospital Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore
| | - Harish Mithiran
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre Singapore, National University Hospital Singapore, Singapore
| | - Theo Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre Singapore, National University Hospital Singapore, Singapore
| | - John Kit Chung Tam
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre Singapore, National University Hospital Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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50
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Koh A, Adiamah A, Gomez D, Sanyal S. Safety and efficacy of tranexamic acid in minimizing perioperative bleeding in extrahepatic abdominal surgery: meta-analysis. BJS Open 2021; 5:6220258. [PMID: 33839754 PMCID: PMC8038263 DOI: 10.1093/bjsopen/zrab004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/06/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Perioperative bleeding is associated with increased morbidity and mortality in patients undergoing elective abdominal surgery. The antifibrinolytic agent tranexamic acid (TXA) has been shown to reduce perioperative bleeding and mortality risk in patients with traumatic injuries, but there is a lack of evidence for its use in elective abdominal and pelvic surgery. This meta-analysis of RCTs evaluated the effectiveness and safety of TXA in elective extrahepatic abdominopelvic surgery. METHODS PubMed, Embase, and ClinicalTrial.gov databases were searched to identify relevant RCTs from January 1947 to May 2020. The primary outcome, intraoperative blood loss, and secondary outcomes, need for perioperative blood transfusion, units of blood transfused, thromboembolic events, and mortality, were extracted from included studies. Quantitative pooling of data was based on a random-effects model. RESULTS Some 19 studies reporting on 2205 patients who underwent abdominal, pelvic, gynaecological or urological surgery were included. TXA reduced intraoperative blood loss (mean difference -188.35 (95 per cent c.i. -254.98 to -121.72) ml) and the need for perioperative blood transfusion (odds ratio (OR) 0.43, 95 per cent c.i. 0.28 to 0.65). TXA had no impact on the incidence of thromboembolic events (OR 0.49, 0.18 to 1.35). No adverse drug reactions or in-hospital deaths were reported. CONCLUSION TXA reduces intraoperative blood loss during elective extrahepatic abdominal and pelvic surgery without an increase in complications.
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Affiliation(s)
- A Koh
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - A Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - D Gomez
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - S Sanyal
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
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