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Shin TJ, Hasnain F, Shay EO, Ye MJ, Matt BH, Elghouche AN. Treatment of post-tonsillectomy hemorrhage with nebulized tranexamic acid: A retrospective study. Int J Pediatr Otorhinolaryngol 2023; 171:111644. [PMID: 37423163 DOI: 10.1016/j.ijporl.2023.111644] [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: 05/04/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE To evaluate the association of treatment with nebulized tranexamic acid (TXA) with rates of operative intervention in post-tonsillectomy hemorrhage (PTH). METHODS Single tertiary-referral center and satellite hospitals, retrospective cohort of adult and pediatric patients who were diagnosed with PTH in 2015-2022 and treated with nebulized TXA and standard care, compared with an age- and gender-matched control cohort treated with standard care. Patients were typically treated in the emergency department with a single dose of 500mg/5 mL TXA delivered via nebulizer. RESULTS 1110 total cases of PTH were observed, and 83 were treated with nebulized TXA. Compared to 249 age- and gender-matched PTH controls, TXA-treated patients had a rate of operating room (OR) intervention of 36.1% versus 60.2% (p < 0.0001) and a rate of repeat bleeding of 4.9% versus 14.2% (p < 0.02). The odds ratio for OR intervention with TXA treatment was 0.37 (95% CI 0.22, 0.63). There were no adverse effects identified with an average follow-up time of 586 days. CONCLUSION Treatment of PTH with nebulized TXA is associated with lower rates of operative intervention and lower rates of repeat bleeding events. Prospective studies are needed to further characterize efficacy and optimal treatment protocols. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Timothy J Shin
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA
| | - Fahad Hasnain
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Elizabeth O Shay
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael J Ye
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bruce H Matt
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alhasan N Elghouche
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA.
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Lourijsen E, Avdeeva K, Gan KL, Pundir V, Fokkens W. Tranexamic acid for the reduction of bleeding during functional endoscopic sinus surgery. Cochrane Database Syst Rev 2023; 2:CD012843. [PMID: 36808096 PMCID: PMC9943060 DOI: 10.1002/14651858.cd012843.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Chronic rhinosinusitis, with or without nasal polyps, can have a major impact on a person's quality of life. Treatment is usually conservative and may include nasal saline, intranasal corticosteroids, antibiotics or systemic corticosteroids. If these treatments fail endoscopic sinus surgery can be considered. During surgery, visibility of the surgical field is important for the identification of important anatomic landmarks and structures that contribute to safety. Impaired visualisation can lead to complications during surgery, inability to complete the operation or a longer duration of surgery. Different methods are used to decrease intraoperative bleeding, including induced hypotension, topical or systemic vasoconstrictors or total intravenous anaesthesia. Another option is tranexamic acid, an antifibrinolytic agent, which can be administered topically or intravenously. OBJECTIVES To assess the effects of peri-operative tranexamic acid versus no therapy or placebo on operative parameters in patients with chronic rhinosinusitis (with or without nasal polyps) who are undergoing functional endoscopic sinus surgery (FESS). SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 10 February 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing intravenous, oral or topical tranexamic acid with no therapy or placebo in the treatment of patients (adults and children) with chronic rhinosinusitis, with or without nasal polyps, undergoing FESS. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Primary outcome measures were surgical field bleeding score (e.g. Wormald or Boezaart grading system), intraoperative blood loss and significant adverse effects (seizures or thromboembolism within 12 weeks of surgery). Secondary outcomes were duration of surgery, incomplete surgery, surgical complications and postoperative bleeding (placing of packing or revision surgery) in the first two weeks after surgery. We performed subgroup analyses for methods of administration, different dosages, different forms of anaesthesia, use of thromboembolic prophylaxis and children versus adults. We evaluated each included study for risk of bias and used GRADE to assess the certainty of the evidence. MAIN RESULTS We included 14 studies in the review, with a total of 942 participants. Sample sizes in the included studies ranged from 10 to 170. All but two studies included adult patients (≥ 18 years). Two studies included children. Most studies had more male patients (range 46.6% to 80%). All studies were placebo-controlled and four studies had three treatment arms. Three studies investigated topical tranexamic acid; the other studies reported the use of intravenous tranexamic acid. For our primary outcome, surgical field bleeding score measured with the Boezaart or Wormald grading score, we pooled data from 13 studies. The pooled result demonstrated that tranexamic acid probably reduces the surgical field bleeding score, with a standardised mean difference (SMD) of -0.87 (95% confidence interval (CI) -1.23 to -0.51; 13 studies, 772 participants; moderate-certainty evidence). A SMD below -0.70 represents a large effect (in either direction). Tranexamic acid may result in a slight reduction in blood loss during surgery compared to placebo with a mean difference (MD) of -70.32 mL (95% CI -92.28 to -48.35 mL; 12 studies, 802 participants; low-certainty evidence). Tranexamic acid probably has little to no effect on the development of significant adverse events (seizures or thromboembolism) within 24 hours of surgery, with no events in either group and a risk difference (RD) of 0.00 (95% CI -0.02 to 0.02; 8 studies, 664 participants; moderate-certainty evidence). However, there were no studies reporting significant adverse event data with a longer duration of follow-up. Tranexamic acid probably results in little difference in the duration of surgery with a MD of -13.04 minutes (95% CI -19.27 to -6.81; 10 studies, 666 participants; moderate-certainty evidence). Tranexamic acid probably results in little to no difference in the incidence of incomplete surgery, with no events in either group and a RD of 0.00 (95% CI -0.09 to 0.09; 2 studies, 58 participants; moderate-certainty evidence) and likely results in little to no difference in surgical complications, again with no events in either group and a RD of 0.00 (95% CI -0.09 to 0.09; 2 studies, 58 participants; moderate-certainty evidence), although these numbers are too small to draw robust conclusions. Tranexamic acid may result in little to no difference in the likelihood of postoperative bleeding (placement of packing or revision surgery within three days of surgery) (RD -0.01, 95% CI -0.04 to 0.02; 6 studies, 404 participants; low-certainty evidence). There were no studies with longer follow-up. AUTHORS' CONCLUSIONS There is moderate-certainty evidence to support the beneficial value of topical or intravenous tranexamic acid during endoscopic sinus surgery with respect to surgical field bleeding score. Low- to moderate-certainty evidence suggests a slight decrease in total blood loss during surgery and duration of surgery. Whilst there is moderate-certainty evidence that tranexamic acid does not lead to more immediate significant adverse events compared to placebo, there is no evidence regarding the risk of serious adverse events more than 24 hours after surgery. There is low-certainty evidence that tranexamic acid may not change postoperative bleeding. There is not enough evidence available to draw robust conclusions about incomplete surgery or surgical complications.
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Affiliation(s)
- Evelijn Lourijsen
- Department of Otorhinolaryngology, Amsterdam UMC location AMC, Amsterdam, Netherlands
| | - Klementina Avdeeva
- Department of Otorhinolaryngology, Amsterdam UMC location AMC, Amsterdam, Netherlands
| | - Kit Liang Gan
- Department of Otorhinolaryngology, Mahkota Medical Centre, Melaka, Malaysia
| | - Vishal Pundir
- Department of Otorhinolaryngology, Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, UK
| | - Wytske Fokkens
- Department of Otorhinolaryngology, Amsterdam UMC location AMC, Amsterdam, Netherlands
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3
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Abtahi M, Kargoshai AA, Shetabi H, Manafi A, Manafi N, Badrouj A. The Effect of Tranexamic Acid Local Injection on Bleeding during and after Tonsillectomy: A Double-Blind Randomized Placebo-Controlled Trial. World J Plast Surg 2023; 12:31-36. [PMID: 38226192 PMCID: PMC10788099 DOI: 10.61186/wjps.12.3.31] [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] [Received: 06/30/2023] [Accepted: 10/11/2023] [Indexed: 01/17/2024] Open
Abstract
Background Tonsillectomy-related bleeding is one of the most prevalent and potentially fatal complications of this common surgical procedure. We aimed to assess the effect of tranexamic acid (TXA) local injection on bleeding during and after tonsillectomy. Methods This double-blind, randomized placebo-controlled trial included 20 candidates for tonsillectomy referred to Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran, in 2022. The subjects were randomized into two groups. Ten patients received TXA on their left side and the other ten on their right side 10 min before surgery. Placebo was administered to the contralateral side. The primary outcome was the volume of blood loss during tonsillectomy and up to 24 hours post-tonsillectomy. The secondary outcomes were surgeon satisfaction (rated 0-10), hemodynamic complications (patients' heart rate (HR) and mean arterial pressure (MAP) were recorded every 10 min), and rebleeding. The duration of surgery was also noted. Results The mean age of the patients was 21.35 ± 3.16 years, of whom 8 (30%) were male and 12 (60%) were female. there was no significant difference between groups in terms of HR and MAP at any time point. The median of surgery duration did not differ significantly between the two groups; however, the surgeon satisfaction with the procedure was significantly higher with TXA compared to placebo. None of the patients developed hemodynamic complications, and rebleeding did not occur in any of the subjects. Conclusions TXA local injection was not superior to placebo in terms of bleeding control during and after tonsillectomy, hemodynamic complications, rebleeding, and surgery duration.
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Affiliation(s)
- Mojtaba Abtahi
- Department of Otorhinolaryngology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir-Abbas Kargoshai
- Department of Otorhinolaryngology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamidreza Shetabi
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir Manafi
- Department of Anesthesia, Detroit Medical Center, NorthStar Anesthesia, Detroit, MI
| | - Navid Manafi
- Department of Anesthesia, Detroit Medical Center, NorthStar Anesthesia, Detroit, MI
| | - Ali Badrouj
- Department of Otorhinolaryngology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Abu-Zaid A, Baradwan S, Badghish E, AlSghan R, Ghazi A, Albouq B, Khadawardi K, AlNaim NF, AlNaim LF, Fodaneel M, AbuAlsaud FS, Jamjoom MZ, Almubarki AAMA, Alsehaimi SO, Alabdrabalamir S, Alomar O, Al-Badawi IA, Salem H. Prophylactic tranexamic acid to reduce blood loss and related morbidities during hysterectomy: a systematic review and meta-analysis of randomized controlled trials. Obstet Gynecol Sci 2022; 65:406-419. [PMID: 35896179 PMCID: PMC9483668 DOI: 10.5468/ogs.22115] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/08/2022] [Accepted: 07/04/2022] [Indexed: 11/19/2022] Open
Abstract
To perform a systematic review and meta-analysis of all randomized controlled trials (RCTs) that evaluated the efficacy and safety of prophylactic tranexamic acid (TXA) versus a control (placebo or no treatment) during hysterectomy for benign conditions. Six databases were screened from inception to January 23, 2022. Eligible studies were assessed for risk of bias. Outcomes were summarized as weighted mean differences and risk ratios with 95% confidence intervals in a random-effects model. Five studies, comprising six arms and 911 patients were included in the study. Two and three studies had an overall unclear and low risk of bias, respectively. Estimated intraoperative blood loss, requirement for postoperative blood transfusion, and requirement for intraoperative topical hemostatic agents were significantly reduced in a prophylactic TXA group when compared with a control group. Moreover, postoperative hemoglobin level was significantly higher in the prophylactic TXA group than in the control group. Conversely, the frequency of self-limiting nausea and vomiting was significantly higher in the prophylactic TXA group than in the control group. There were no significant differences between the groups in terms of surgery duration, hospital stay, and diarrhea rate. All the RCTs reported no incidence of major adverse events in either group, such as mortality, thromboembolic events, visual disturbances, or seizures. There was no publication bias for any outcome, and leave-one-out sensitivity analyses demonstrated stability of the findings. Among patients who underwent hysterectomy for benign conditions, prophylactic TXA appeared largely safe and correlated with substantial reductions in estimated intraoperative blood loss and related morbidities.
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Affiliation(s)
- Ahmed Abu-Zaid
- Department of Obstetrics and Gynecology, Alfaisal University, Riyadh,
Saudi Arabia
- Department of Pharmacology, College of Graduate Health Sciences, University of Tennessee Healt Science Center, Memphis, TN,
USA
| | - Saeed Baradwan
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah,
Kuwait
| | - Ehab Badghish
- Department of Obstetrics and Gynecology, Maternity and Children Hospital, Makkah,
Kuwait
| | - Rayan AlSghan
- Department of Obstetrics and Gynecology, Maternity and Children Hospital, AlKharj,
Kuwait
| | - Ahmed Ghazi
- Department of Obstetrics and Gynecology, College of Medicine, Jeddah University, Jeddah,
Kuwait
| | - Bayan Albouq
- Department of Obstetrics and Gynecology, Prince Mohammed Bin Abdulaziz National Guard Hospital, Madinah,
Kuwait
| | - Khalid Khadawardi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Umm Al-Qura University, Makkah,
Kuwait
| | - Nora F AlNaim
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh,
Kuwait
| | - Latifa F AlNaim
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh,
Kuwait
| | - Meshael Fodaneel
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh,
Kuwait
| | - Fatimah Shakir AbuAlsaud
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh,
Kuwait
| | - Mohammed Ziad Jamjoom
- Department of Obstetrics and Gynecology, King Fahad Armed Forces Hospital, Jeddah,
Kuwait
| | | | - Saud Owaimer Alsehaimi
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh,
Kuwait
| | - Safa Alabdrabalamir
- Department of Obstetrics and Gynecology, Riyadh Second Health Cluster, Riyadh,
Saudi Arabia
| | - Osama Alomar
- Department of Obstetrics and Gynecology, Alfaisal University, Riyadh,
Saudi Arabia
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh,
Kuwait
| | - Ismail A. Al-Badawi
- Department of Obstetrics and Gynecology, Alfaisal University, Riyadh,
Saudi Arabia
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh,
Kuwait
| | - Hany Salem
- Department of Obstetrics and Gynecology, Alfaisal University, Riyadh,
Saudi Arabia
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh,
Kuwait
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Eliashar R, Cohen SM, Hirshoren N. Tranexamic acid administration practice in otolaryngology head & neck surgery; international survey. Am J Otolaryngol 2022; 43:103590. [PMID: 35973268 DOI: 10.1016/j.amjoto.2022.103590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 08/07/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE Tranexamic acid (TXA) is a potent pro-coagulation drug. Pre-operative, preventive TXA administration and TXA use for active bleeding are established treatments in many medical situations; yet, less is known about its use in otolaryngology head and neck surgery practice. The primary study goals were: MATERIALS AND METHODS: This is an international survey exploring TXA administration strategy. The electronic, anonymous, questionnaire was emailed to all registered Israeli and American Otolaryngology Head and Neck Surgery (OHNS) physicians, investigating TXA administration: RESULTS: Overall, 317 otolaryngologists participated in the study. TXA was administered to 40.5 % of the pediatric population and 50 % of the adult patients when needed. Epistaxis was the most common indication for TXA administration (48-55 %). A small number of otolaryngologists, 4-13 %, recommended preventive TXA for various operations. More surgeons include TXA in their practice and adjusted the dose according to renal function in academic compared to non-academic medical centers and among otolaryngologists practicing in Israel compared to the United States. CONCLUSIONS TXA is provided by many otolaryngologists to treat active epistaxis but to a substantially lesser extent as a preventive measure. TXA is given to children and adults, some with substantial comorbidities. Treatment is more common among surgeons working in academic institutes and medical centers in Israel.
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Affiliation(s)
- Ron Eliashar
- Department of Otolaryngology/Head & Neck Surgery, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Seth M Cohen
- Department of Head and Neck Surgery & Communication Sciences, Duke University, NC, United States
| | - Nir Hirshoren
- Department of Otolaryngology/Head & Neck Surgery, Hadassah - Hebrew University Medical Center, Jerusalem, Israel.
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Efficacy of tranexamic acid (TXA) for post-tonsillectomy hemorrhage. Am J Otolaryngol 2022; 43:103582. [DOI: 10.1016/j.amjoto.2022.103582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/01/2022] [Indexed: 11/19/2022]
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Cao A, Silverman J, Zahtz G, Smith LP. Use of nebulized tranexamic acid in adult and pediatric post-tonsillectomy hemorrhage. OTOLARYNGOLOGY CASE REPORTS 2022. [DOI: 10.1016/j.xocr.2022.100409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Hong P, Liu R, Rai S, Liu J, Ding Y, Li J. Does Tranexamic Acid Reduce the Blood Loss in Various Surgeries? An Umbrella Review of State-of-the-Art Meta-Analysis. Front Pharmacol 2022; 13:887386. [PMID: 35662737 PMCID: PMC9160460 DOI: 10.3389/fphar.2022.887386] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Tranexamic acid (TXA) has been applied in various types of surgery for hemostasis purposes. The efficacy and safety of TXA are still controversial in different surgeries. Guidelines for clinical application of TXA are needed. Materials and method: We systematically searched multiple medical databases for meta-analyses examining the efficacy and safety of TXA. Types of surgery included joint replacement surgery, other orthopedic surgeries, cardiac surgery, cerebral surgery, etc. Outcomes were blood loss, blood transfusion, adverse events, re-operation rate, operative time and length of hospital stay, hemoglobin (Hb) level, and coagulation function. Assessing the methodological quality of systematic reviews 2 (AMSTAR 2) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) were used for quality assessment of the included meta-analyses. Overlapping reviews were evaluated by calculating the corrected covered area (CCA). Result: In all, we identified 47 meta-analyses, of which 44 of them were of "high" quality. A total of 319 outcomes were evaluated, in which 58 outcomes were assessed as "high" quality. TXA demonstrates significant hemostatic effects in various surgeries, with lower rates of blood transfusion and re-operation, shorter operative time and length of stay, and higher Hb levels. Besides, TXA does not increase the risk of death and vascular adverse events, but it is a risk factor for seizure (a neurological event) in cardiac surgery. Conclusion: Our study demonstrates that TXA has a general hemostatic effect with very few adverse events, which indicates TXA is the recommended medication to prevent excessive bleeding and reduce the blood transfusion rate. We also recommend different dosages of TXA for different types of adult surgery. However, we could not recommend a unified dosage for different surgeries due to the heterogeneity of the experimental design. Systematic Review Registration: clinicaltrials.gov/, identifier CRD42021240303.
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Affiliation(s)
- Pan Hong
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruikang Liu
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Department of Orthopaedics and Trauma Surgery, Blue Cross Hospital, Kathmandu, Nepal
| | - JiaJia Liu
- First Clinical School, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuhong Ding
- First Clinical School, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Basic Medical School, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jin Li
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Lee AC, Haché M. Pediatric Anesthesia Management for Post-Tonsillectomy Bleed: Current Status and Future Directions. Int J Gen Med 2022; 15:63-69. [PMID: 35027837 PMCID: PMC8749229 DOI: 10.2147/ijgm.s312866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 12/20/2021] [Indexed: 11/23/2022] Open
Abstract
After medical stabilization, several techniques are considered for anesthesia in the surgical intervention of post-tonsillectomy bleeding in children. Hypoxia during induction of general anesthesia occurs more frequently than aspiration for this population. While classical (apneic) rapid sequence induction and intubation with cricoid pressure still has a role, controlled rapid sequence induction and intubation that incorporates mask ventilation at low pressure (<12 cm H2O) before direct laryngoscopy under a deep plane of anesthesia is a viable alternative for cases of slow venous bleeding. Supplemental oxygen delivery during laryngoscopy to permit apneic oxygenation is a future trend in management. While the routine administration of tranexamic acid during tonsillectomy has not been shown to be of benefit, it may have a role in post-tonsillectomy hemorrhage with further study.
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Affiliation(s)
- Angela C Lee
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Manon Haché
- Division of Pediatric Anesthesia, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA
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Tranexamic acid in head and neck procedures: a systematic review and meta-analysis of randomized controlled trials. Eur Arch Otorhinolaryngol 2021; 279:2231-2238. [PMID: 34661715 DOI: 10.1007/s00405-021-07132-6] [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: 09/05/2021] [Accepted: 10/07/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We conducted a meta-analysis of all randomized controlled trials (RCTs) that examined the benefits of tranexamic acid (TXA) among cancer patients undergoing head and neck (H&N) procedures. METHODS We screened five databases from inception until 20 June 2021 and evaluated the risk of bias of the eligible studies. We pooled continuous outcomes using the weighted mean difference (WMD) with 95% confidence interval (CI). RESULTS Five studies, comprising seven RCTs, met the inclusion criteria. This meta-analysis included a total of 540 patients; 265 and 275 patients were assigned to the TXA and control group, respectively. Overall, the included RCTs revealed a low risk of bias. The volume of postoperative bleeding was significantly lower in favor of the TXA group compared with the control group (n = 7 RCTs, WMD = - 51.33 ml, 95% CI [- 101.47 to - 1.2], p = 0.04). However, no significant difference was found between both groups regarding the volume of intraoperative bleeding (n = 6 RCTs, WMD = - 3.48 ml, 95% CI [- 17.11 to 10.15], p = 0.62), postoperative hemoglobin (n = 3 RCTs, WMD = 0.42 mg/dl, 95% CI [- 0.27 to 1.11], p = 0.23), duration of drainage tube removal (n = 4 RCTs, MD = - 0.41 days, 95% CI [- 1.14 to 0.32], p = 0.27), and operation time (n = 6 RCTs, WMD = 1.59 min, 95% CI [- 10.09 to 13.27], p = 0.79). TXA was safe and did not culminate in thromboembolic events or major coagulation derangements. CONCLUSION TXA administration is safe and significantly reduces the volume of postoperative bleeding. However, no difference is identified between TXA and control groups regarding the volume of intraoperative bleeding, postoperative hemoglobin level, duration of drainage tube removal, and operation time.
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11
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Fuzi J, Budiono GR, Meller C, Jacobson I. Tranexamic acid in otorhinolaryngology - A contemporary review. World J Otorhinolaryngol Head Neck Surg 2021; 7:328-337. [PMID: 34632348 PMCID: PMC8486689 DOI: 10.1016/j.wjorl.2020.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/13/2020] [Accepted: 05/26/2020] [Indexed: 11/25/2022] Open
Abstract
Tranexamic acid (TXA) is an anti-fibrinolytic agent which has been proven beneficial in multiple surgical specialties where significant bleeding can occur. Whilst it has been widely available for over 40 years its use within Otorhinolaryngology is still limited. Operations in Otorhinolaryngology are particularly varied with some such as tonsillectomy having the potential for significant life threatening bleeding. Other operations are performed within small confined surgical fields and even small amounts of bleeding can significantly detriment surgical field and increase technical difficulty and operative time. This review evaluated the current literature on the benefits of tranexamic acid within the field of Otorhinolaryngology and Head and Neck Surgery. Overall TXA was demonstrated to be a safe drug with no major adverse effects including thromboembolic events reported in any study. It has been shown to be of particular benefit in rhinology by improving surgical field, reducing operative time and reducing postoperative swelling and ecchymosis. The benefit in tonsillectomy is less clear and further studies are required to evaluate its potential use in the reduction of post tonsillectomy haemorrhage rates.
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Affiliation(s)
- Jordan Fuzi
- Department of Otolaryngology, Head and Neck Surgery, Prince of Wales Hospital, New South Wales, Australia
| | | | - Catherine Meller
- Department of Otolaryngology, Head and Neck Surgery, Prince of Wales Hospital, New South Wales, Australia
| | - Ian Jacobson
- Department of Otolaryngology, Head and Neck Surgery, Prince of Wales Hospital, New South Wales, Australia
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Kuo CC, DeGiovanni JC, Carr MM. The efficacy of Tranexamic Acid Administration in Patients Undergoing Tonsillectomy: An Updated Meta-Analysis. Ann Otol Rhinol Laryngol 2021; 131:834-843. [PMID: 34515540 DOI: 10.1177/00034894211045264] [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: 11/17/2022]
Abstract
OBJECTIVE There is controversy regarding the efficacy and safety of tranexamic acid (TXA) in reducing tonsillectomy-related hemorrhage. We conducted a systematic review and meta-analysis to evaluate the prophylactic role of TXA in tonsillectomy. METHODS We searched 6 databases to identify studies that directly compare the effect of TXA versus controls in tonsillectomy patients. Standardized mean difference was applied to summate the findings across the studies. Dichotomous data were expressed as relative risk. RESULTS Ten studies representing a total of 111 898 patients were included. The pooled results showed a significant reduction of intraoperative blood loss by 39.02 ml (SMD = -1.05, 95% CI: -1.91 to -0.20, P = .016) and the rate of post-tonsillectomy hemorrhage (RR = 0.42, 95% CI: 0.28 to 0.65, P < .0001), with no significant difference in reduction of further intervention risk (RR = 0.78, 95% CI: 0.45 to 1.35, P = .373). CONCLUSIONS Overall, this study indicates that TXA may reduce blood loss and frequency of post-operative hemorrhage associated with tonsillectomy. Further large, high-quality clinical trials are still needed to explore TXA's effect on post-tonsillectomy hemorrhage and the safety of its use.
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Affiliation(s)
- Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Jason C DeGiovanni
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Michele M Carr
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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Monteilh C, Rabon L, Mayer-Hirshfeld I, McGreevy J. Nebulized Tranexamic Acid for Pediatric Post-tonsillectomy Hemorrhage: A Report of Two Cases. Clin Pract Cases Emerg Med 2021; 5:148-151. [PMID: 34436991 PMCID: PMC8143824 DOI: 10.5811/cpcem.2021.2.50799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/09/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) use in pediatrics to control hemorrhage has gained interest in recent years, but there is limited literature on nebulized TXA especially regarding dosing and adverse effects. Tranexamic acid has anti-fibrinolytic properties via competitive inhibition of plasminogen activation making it a logical approach to promote hemostasis in cases of post-tonsillectomy hemorrhage. CASE REPORT We describe two cases of post-tonsillectomy hemorrhage managed with nebulized TXA. In both cases, bleeding was stopped after TXA administration. CONCLUSION To our knowledge, this is the first case report to describe the use of nebulized TXA without an adjunct pharmacotherapy. Our two cases add additional reportable data on the safety of nebulized TXA and possible effectiveness on post-tonsillectomy hemorrhage.
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Affiliation(s)
- Cecilia Monteilh
- Phoenix Children's Hospital, Department of Emergency Medicine, Phoenix, Arizona
| | - Lydia Rabon
- Phoenix Children's Hospital, Department of Emergency Medicine, Phoenix, Arizona
| | - Ilana Mayer-Hirshfeld
- Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, Arizona
| | - Jon McGreevy
- Phoenix Children's Hospital, Department of Emergency Medicine, Phoenix, Arizona
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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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Dermendjieva M, Gopalsami A, Glennon N, Torbati S. Nebulized Tranexamic Acid in Secondary Post-Tonsillectomy Hemorrhage: Case Series and Review of the Literature. Clin Pract Cases Emerg Med 2021; 5:1-7. [PMID: 34437029 PMCID: PMC8373187 DOI: 10.5811/cpcem.2021.5.52549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Post-tonsillectomy hemorrhage is a serious postoperative complication, and its acute management can present a challenge for the emergency provider. Although various strategies have been proposed, guidance on the best approach for management of this condition in the emergency department (ED) setting remains limited. Anecdotal reports of the use of nebulized tranexamic acid (TXA) for management of tonsillar bleeding have emerged over the past two years. Two recently published case reports describe the successful use of nebulized TXA for stabilization of post-tonsillectomy hemorrhage in an adult and a pediatric patient. CASE SERIES Eight patients who presented to our ED with secondary post-tonsillectomy hemorrhage received nebulized TXA for hemostatic management. The most common TXA dose used was 500 milligrams, and all but one patient received a single dose of the medication in the ED. Hemostatic benefit was observed in six patients, with complete bleeding cessation observed in five cases. Interventions prior to nebulized TXA administration were attempted in three of the six patients and included ice water gargle, direct pressure with TXA-soaked gauze, and nebulized racemic epinephrine. All but one of the patients were taken to the operating room for definitive management after initial stabilization in the ED. CONCLUSION Nebulized TXA may offer a hemostatic benefit and aid in stabilization of tonsillectomy hemorrhage in the acute care setting, prior to definitive surgical intervention. Consideration of general principles of nebulization and aerosol particle size may be an important factor for drug delivery to the target tissue site.
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Affiliation(s)
- Mira Dermendjieva
- Cedars Sinai Medical Center, Department of Pharmacy Los Angeles, California
| | - Anand Gopalsami
- Cedars Sinai Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Nicole Glennon
- Cedars Sinai Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Sam Torbati
- Cedars Sinai Medical Center, Department of Emergency Medicine, Los Angeles, California
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Shafa A, Shetabi H, Adineh-Mehr L, Bahrami K. Selection of the optimal dosage of tranexamic acid to reduce blood loss during pediatric cleft palate surgery. Tzu Chi Med J 2020; 33:181-187. [PMID: 33912417 PMCID: PMC8059463 DOI: 10.4103/tcmj.tcmj_111_20] [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: 05/10/2020] [Revised: 06/22/2020] [Accepted: 07/07/2020] [Indexed: 11/04/2022] Open
Abstract
Objective The aim of the present study was to evaluate and select the optimal dosage of tranexamic acid (TXA) to reduce blood loss during cleft palate surgery in children. Materials and Methods This randomized double-blind clinical trial was performed on 80 children under 3 years of age that were candidates for cleft palate surgery. These children were divided into four groups as follows: the first, second, and third groups received 5, 7.5, and 10 mg/kg of TXA, respectively. Moreover, the fourth group was considered as the control group. Before induction of anesthesia and then every 15 min during the surgery, some parameters such as mean arterial pressure, heart rate, SpO2, and ETCO2 were recorded. Moreover, the amount of blood loss during the surgery, the level of surgeon's satisfaction, and incidence rate of complications were assessed and recorded. Results The amount of blood loss during the surgery in TXA groups receiving dosages of 5, 7.5, and 10 mg/kg with the means of 63.75 ± 10.62, 61.25 ± 15.03, and 61.00 ± 14.29, respectively, was significantly lower than that of the control group with the mean of 92.25 ± 19.83 (P < 0.001). Moreover, no significant difference was found between the three groups receiving TXA dosages in terms of the amount of blood loss, the level of surgeon's satisfaction (P > 0.05). Conclusion According to the results of the present study, all three dosages of TXA had a significant role in reducing blood loss in cleft palate surgery. Given the potential for increased risk of side effects from the drug, it seems safe to use the minimal dosage of this drug to control and reduce blood loss during cleft palate surgery in children <3 years of age.
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Affiliation(s)
- Amir Shafa
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamidreza Shetabi
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Lili Adineh-Mehr
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Keivan Bahrami
- Department of Anesthesiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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James TW, Thomson BJ, Naumann DN, Stevenson DS. Platelet function testing in patients with post-operative tonsillectomy bleeding may be a useful early identifier of inherited platelet function disorders. J Laryngol Otol 2020; 134:1-5. [PMID: 33016256 DOI: 10.1017/s0022215120002030] [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: 11/07/2022]
Abstract
BACKGROUND Post-tonsillectomy bleeding is the most frequent complication of tonsillectomy. Inherited platelet function disorders have an estimated prevalence of 1 per cent. Any association between post-tonsillectomy bleeds and undiagnosed inherited platelet function disorders has not been investigated before. OBJECTIVES To assess the prevalence of inherited platelet function disorders in a cohort of post-tonsillectomy bleed patients. METHODS An observational cohort study was conducted using hospital digital records. Platelet function analyser 100 ('PFA-100') closure time was tested on post-tonsillectomy bleed patients who presented to hospital. RESULTS Between 2013 and 2017, 9 of 91 post-tonsillectomy bleed patients who underwent platelet function analyser 100 testing (9.89 per cent) had positive results. Five patients (5.49 per cent) had undiagnosed inherited platelet function disorders. Four patients had false positive results secondary to a non-steroidal anti-inflammatory drug effect (specificity of 95.3 per cent) proven by repeat testing six weeks later, off medication. The false negative rate was 0 per cent. CONCLUSION The prevalence of inherited platelet function disorders in our post-tonsillectomy bleed cohort is five-fold higher than in the general population. Platelet function analyser 100 testing when patients present with a post-tonsillectomy bleed allows management of their inherited platelet function disorder.
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Affiliation(s)
- T W James
- Department of Otolaryngology, University Hospitals Birmingham NHS Foundation Trust, UK
| | - B J Thomson
- Department of Otolaryngology - Head and Neck Surgery, Christchurch Hospital, New Zealand
| | - D N Naumann
- Department of Otolaryngology, University Hospitals Birmingham NHS Foundation Trust, UK
| | - D S Stevenson
- Department of Otolaryngology - Head and Neck Surgery, Christchurch Hospital, New Zealand
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Poppe M, Grimaldo F. A Case Report of Nebulized Tranexamic Acid for Post-tonsillectomy Hemorrhage in an Adult. Clin Pract Cases Emerg Med 2020; 4:443-445. [PMID: 32926708 PMCID: PMC7434284 DOI: 10.5811/cpcem.2020.6.47676] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/10/2020] [Indexed: 01/10/2023] Open
Abstract
Introduction Post-tonsillectomy hemorrhage is a potentially life-threatening, postoperative complication that is commonly encountered in the emergency department (ED). Case Report Herein, we describe the case of a 22-year-old male who presented to the ED with an active post-tonsillectomy hemorrhage. He rapidly became hypotensive and experienced an episode of syncope. Immediate interventions included intravenous fluids, emergency release blood and nebulized tranexamic acid (TXA). After completion of the nebulized TXA, the patient’s bleeding was controlled. Conclusion To our knowledge, this is the first case in the emergency medicine literature that describes the use of nebulized TXA in an adult to achieve hemostasis in post-tonsillectomy hemorrhage.
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Affiliation(s)
- Michael Poppe
- Naval Medical Center San Diego, Department of Emergency Medicine, San Diego, California
| | - Felipe Grimaldo
- Naval Medical Center San Diego, Department of Emergency Medicine, San Diego, California
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Subcutaneous Injection of Tranexamic Acid to Reduce Bleeding During Dermatologic Surgery: A Double-Blind, Placebo-Controlled, Randomized Clinical Trial. Dermatol Surg 2019; 45:759-767. [PMID: 30640775 DOI: 10.1097/dss.0000000000001786] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Topical application, oral, and IV injection of tranexamic acid (TXA) have been used to reduce surgical bleeding. OBJECTIVE To evaluate the safety and efficacy of TXA injected subcutaneously to reduce bleeding during dermatologic surgery. METHODS In this double-blinded, placebo-controlled, randomized prospective study, 131 patients were randomized to subcutaneous injection of lidocaine 2% diluted 1:1 with either saline (placebo) or TXA 100 mg/1 mL before surgery. Before the second stage or closure, size measurements of bloodstain impregnation on Telfa and surgical wound size were recorded and analyzed using mixed-effects linear regression. Subjective evaluation of hemostasis was performed using 4-point scale grading and analyzed using Fischer's exact test. RESULTS One hundred twenty-seven patients completed the study. The bloodstain to surgical wound size ratio was smaller in the TXA group (1.77) compared with the placebo group (2.49) (p < .001). An improved effect of TXA on bleeding was observed in the subgroup of patients receiving anticoagulants (mean difference; 95% confidence interval; -0.83; -1.20 to -0.46 p < .001). The subjective hemostasis assessment was significantly better in the TXA group overall (p = .043) and anticoagulant subgroup (p = .001) compared with the placebo group. CONCLUSION Subcutaneous injection of TXA was safe, reduced bleeding during dermatologic surgery, and particularly effective for patients receiving anticoagulation treatment.
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20
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Liu L, Rodman C, Worobetz NE, Johnson J, Elmaraghy C, Chiang T. Topical biomaterials to prevent post-tonsillectomy hemorrhage. J Otolaryngol Head Neck Surg 2019; 48:45. [PMID: 31492172 PMCID: PMC6731608 DOI: 10.1186/s40463-019-0368-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 08/27/2019] [Indexed: 12/11/2022] Open
Abstract
Despite advances in surgical technique, postoperative hemorrhage remains a common cause of mortality and morbidity for patients following tonsillectomy. Application of biomaterials at the time of tonsillectomy can potentially accelerate mucosal wound healing and eliminate the risk of post-tonsillectomy hemorrhage (PTH). To understand the current state and identify possible routes for the development of the ideal biomaterials to prevent PTH, topical biomaterials for eliminating the risk of PTH were reviewed. Alternative topical biomaterials that hold the potential to reduce the risk of PTH were also summarized.
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Affiliation(s)
- Lumei Liu
- Center of Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Cole Rodman
- College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Noah E Worobetz
- Center of Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatric Otorhinolaryngology, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Charles Elmaraghy
- College of Medicine, The Ohio State University, Columbus, OH, USA.,Department of Pediatric Otorhinolaryngology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Tendy Chiang
- Center of Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA. .,College of Medicine, The Ohio State University, Columbus, OH, USA. .,Department of Pediatric Otorhinolaryngology, Nationwide Children's Hospital, Columbus, OH, USA.
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Soliman R, Alshehri A. Assessment of the effect of tranexamic acid on perioperative bleeding in pediatric patients undergoing tonsillectomy. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2015.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Rabie Soliman
- Department of Anesthesia, King Fahad Military Hospital, Khamis Mushait, Saudi Arabia
- Cairo University, Egypt
| | - Ali Alshehri
- Department of ENT, King Fahad Military Hospital, Khamis Mushait, Saudi Arabia
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Tranexamic acid and post-tonsillectomy hemorrhage: propensity score and instrumental variable analyses. Eur Arch Otorhinolaryngol 2018; 276:249-254. [DOI: 10.1007/s00405-018-5192-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 10/30/2018] [Indexed: 12/11/2022]
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Schwarz W, Ruttan T, Bundick K. Nebulized Tranexamic Acid Use for Pediatric Secondary Post-Tonsillectomy Hemorrhage. Ann Emerg Med 2018; 73:269-271. [PMID: 30292524 DOI: 10.1016/j.annemergmed.2018.08.429] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Indexed: 12/16/2022]
Abstract
Post-tonsillectomy hemorrhage is a frequent occurrence in the emergency department, and management of potentially life-threatening and ongoing bleeding by the emergency physician is challenging. Limited evidence-based guidelines exist, and practice patterns vary widely. We administered nebulized tranexamic acid to achieve hemostasis in a pediatric patient with associated bleeding cessation prior to definitive operative management.
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Affiliation(s)
- Whitney Schwarz
- Dell Children's Medical Center, University of Texas at Austin Dell Medical School, Austin, TX.
| | - Timothy Ruttan
- Dell Children's Medical Center, University of Texas at Austin Dell Medical School, Austin, TX
| | - Kelly Bundick
- Dell Children's Medical Center, University of Texas at Austin Dell Medical School, Austin, TX
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Paul C, Sanader S, Wetsch WA, Stangl R, Lechleuthner A. Lebensbedrohliche Blutung nach Tonsillektomie. Notf Rett Med 2018. [DOI: 10.1007/s10049-018-0421-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
Post-tonsillectomy hemorrhage represents a potentially life-threatening condition that occurs in up to 5% of pediatric patients. Minor bleeding often precedes severe hemorrhage. Patients with minor or self-resolving bleeding should be observed in the emergency department or admitted for monitoring. Patients with severe bleeding should be immediately assessed for airway and hemodynamic stability. Management of severe bleeding includes immediate surgical consultation or initiation of the transfer process to a center with surgical capabilities, direct pressure to the site of hemorrhage with or without the additional of a hemostatic agent, possible rapid sequence intubation, and management of hemodynamic instability with volume resuscitation.
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Affiliation(s)
- Jessica J Wall
- Department of Emergency Medicine, Penn Presbyterian Medical Center, 51 North 39th Street, Philadelphia, PA 19104, USA.
| | - Khoon-Yen Tay
- Division of Emergency Medicine, Children's Hospital of Philadelphia, 3501 Civic Center Boulevard, Philadelphia, PA 19104, USA
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[Prophylactic use of tranexamic acid in noncardiac surgery : Update 2017]. Med Klin Intensivmed Notfmed 2018; 114:642-649. [PMID: 29368267 DOI: 10.1007/s00063-018-0402-5] [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: 09/13/2017] [Revised: 11/08/2017] [Accepted: 12/09/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Minimising perioperative bleeding is a key goal of "patient blood management" programs. One component of respective strategies includes preventive inhibition of fibrinolysis using protease inhibitors, such as tranexamic acid (TXA). TXA inhibits plasminogen activation and plasmin-induced fibrin degradation. OBJECTIVES The present article provides an overview of the existing literature and TXA applications in the prophylaxis of perioperative bleeding. METHODS Literature search in PubMed/MEDLINE (U.S. National Library of Medicine®, Bethesda, MD, USA). RESULTS TXA reduces perioperative blood loss and transfusion requirements in several randomized controlled trials (RCTs) and meta-analyses in the field of hip and knee arthroplasty for both intravenous and topical use. Moreover, evidence favours use of TXA in complex spine surgery and reconstructive surgery (e. g. craniosynostosis in children). Single RCTs showed benefits of TXA in abdominal hysterectomy, open prostatectomy, liver surgery and actively bleeding trauma patients. For prophylaxis of peripartum haemorrhage (PPH) following vaginal delivery or Caesarean section, TXA cannot be routinely recommended, although evidence points to benefits in actively bleeding patients. A recommendation exists for the treatment of (active) PPH. For prophylactic perioperative administration, different dosage regimens exist for adults. Most often an initial i. v. bolus of 1 g or 10-15 mg/kg body weight with/without repetition after 6 h or continuous infusions over 8 h is administered. Increased rates of thromboembolic events were not noted. CONCLUSION Protease inhibitors such as TXA reduce perioperative blood loss and transfusion requirements in selected surgical fields.
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Pabinger I, Fries D, Schöchl H, Streif W, Toller W. Tranexamic acid for treatment and prophylaxis of bleeding and hyperfibrinolysis. Wien Klin Wochenschr 2017; 129:303-316. [PMID: 28432428 PMCID: PMC5429347 DOI: 10.1007/s00508-017-1194-y] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/14/2017] [Indexed: 02/08/2023]
Abstract
Uncontrolled massive bleeding with subsequent derangement of the coagulation system is a major challenge in the management of both surgical and seriously injured patients. Under physiological conditions activators and inhibitors of coagulation regulate the sensitive balance between clot formation and fibrinolysis. In some cases, excessive and diffuse bleeding is caused by systemic activation of fibrinolysis, i. e. hyperfibrinolysis (HF). Uncontrolled HF is associated with a high mortality. Polytrauma patients and those undergoing surgical procedures involving organs rich in plasminogen proactivators (e. g. liver, kidney, pancreas, uterus and prostate gland) are at a high risk for HF. Antifibrinolytics, such as tranexamic acid (TXA) are used for prophylaxis and treatment of bleeding caused by a local or generalized HF as well as other hemorrhagic conditions. TXA is a synthetic lysine analogue that has been available in Austria since 1966. TXA is of utmost importance in the prevention and treatment of traumatic and perioperative bleeding due to the resulting reduction in perioperative blood loss and blood transfusion requirements. The following article presents the different fields of application of TXA with particular respect to indications and dosages, based on a literature search and on current guidelines.
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Affiliation(s)
- Ingrid Pabinger
- Clinical Department of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria.
| | - Dietmar Fries
- Department of General and Surgical Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Accident Hospital Salzburg, Salzburg, Austria
- Academic Teaching Hospital, Paracelsus Private Medical University Salzburg, Salzburg, Austria
| | - Werner Streif
- Department of Children and Adolescents Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Wolfgang Toller
- Department of Anesthesiology and Intensive Care Medicine, Medical University Graz, Graz, Austria
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Abstract
Tonsillectomy is a commonly performed procedure with an accepted risk of posttonsillectomy hemorrhage (PTH) approaching 5%, but catastrophic effects of hemorrhage are exceedingly rare. A variety of surgical techniques and hemostatic agents have been used to reduce the rate of hemorrhage, although none eliminate the risk. Numerous patient, surgical, and postoperative care factors have been studied for an association with PTH. The most consistent risk factors for PTH seem to be patient age and coagulopathies. Surgeon skill and surgical technique are most consistently associated with primary PTH.
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Affiliation(s)
- Ryan M Mitchell
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, 1959 NE Pacific St, Box 256515, Seattle, WA 98195, USA
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, 1959 NE Pacific St, Box 256515, Seattle, WA 98195, USA; Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, 4800 Sand Point Way Northeast, OA.9.329, Seattle, WA 98105, USA.
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Kang KT, Chang IS, Tseng CC, Weng WC, Hsiao TY, Lee PL, Hsu WC. Impacts of disease severity on postoperative complications in children with sleep-disordered breathing. Laryngoscope 2017; 127:2646-2652. [DOI: 10.1002/lary.26539] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 12/04/2016] [Accepted: 01/23/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Kun-Tai Kang
- Department of Otolaryngology; National Taiwan University, College of Medicine and National Taiwan University Hospital; Taipei Taiwan
- Department of Otolaryngology; Taipei Hospital, Ministry of Health and Welfare; New Taipei City Taiwan
| | - I-Sheng Chang
- Department of Otolaryngology; National Taiwan University, College of Medicine and National Taiwan University Hospital; Taipei Taiwan
| | - Chia-Chen Tseng
- Department of Otolaryngology; National Taiwan University, College of Medicine and National Taiwan University Hospital; Taipei Taiwan
| | - Wen-Chin Weng
- Sleep Center; National Taiwan University Hospital; Taipei Taiwan
- Department of Pediatrics; National Taiwan University Hospital; Taipei Taiwan
| | - Tzu-Yu Hsiao
- Department of Otolaryngology; National Taiwan University, College of Medicine and National Taiwan University Hospital; Taipei Taiwan
| | - Pei-Lin Lee
- Sleep Center; National Taiwan University Hospital; Taipei Taiwan
- Department of Internal Medicine; National Taiwan University Hospital; Taipei Taiwan
| | - Wei-Chung Hsu
- Department of Otolaryngology; National Taiwan University, College of Medicine and National Taiwan University Hospital; Taipei Taiwan
- Sleep Center; National Taiwan University Hospital; Taipei Taiwan
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Vallamkondu V, Ah-See K, Rocke J, Bannister M. Tranexamic acid for the prevention and treatment of tonsillectomy-related haemorrhage in adults. Hippokratia 2016. [DOI: 10.1002/14651858.cd010740.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Vamsidhar Vallamkondu
- Aberdeen Royal Infirmary; Department of Otolaryngology, Head and Neck Surgery; Aberdeen UK
| | - Kim Ah-See
- Aberdeen Royal Infirmary; Department of Otolaryngology, Head and Neck Surgery; Aberdeen UK
| | - John Rocke
- Aberdeen Royal Infirmary; Department of Otolaryngology, Head and Neck Surgery; Aberdeen UK
| | - Miles Bannister
- Aberdeen Royal Infirmary; Department of Otolaryngology, Head and Neck Surgery; Aberdeen UK
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Averbukh VM, Dzhafarova MZ, Bebchuk GB, Avdeeva KS. [The possibility of using tranexamic acid for the treatment of bleeding in otorhinolaryngology]. Vestn Otorinolaringol 2015; 80:67-69. [PMID: 26145749 DOI: 10.17116/otorino201580267-69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This article is focused on the analysis of the literature publications pertaining to the problem of bleeding in otorhinolaryngology. It reports the epidemiological data on the structure of bleeding and the main methods used to arrest it. Special attention is given to the possibilities of application of tranexamic acid as an effective hemostatic agent not only for systemic but also for topical administration.
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Affiliation(s)
- V M Averbukh
- Research Centre of Otorhinolaryngology, Russian Federal Medico-Biological Agency, Moscow, Russia, 125310
| | - M Z Dzhafarova
- Research Centre of Otorhinolaryngology, Russian Federal Medico-Biological Agency, Moscow, Russia, 125310
| | - G B Bebchuk
- Research Centre of Otorhinolaryngology, Russian Federal Medico-Biological Agency, Moscow, Russia, 125310
| | - K S Avdeeva
- Research Centre of Otorhinolaryngology, Russian Federal Medico-Biological Agency, Moscow, Russia, 125310
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Durga P, Raavula P, Gurajala I, Gunnam P, Veerabathula P, Reddy M, Upputuri O, Ramachandran G. Evaluation of the Efficacy of Tranexamic Acid on the Surgical Field in Primary Cleft Palate Surgery on Children-A Prospective, Randomized Clinical Study. Cleft Palate Craniofac J 2014; 52:e183-7. [PMID: 25531733 DOI: 10.1597/14-263] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the effect of tranexamic acid on the quality of the surgical field. DESIGN Prospective, randomized, double-blind study. SETTING Institutional, tertiary referral hospital. PARTICIPANTS American Society of Anesthesiologists physical status class I patients, aged 8 to 60 months with Group II or III (Balakrishnan's classification) clefts scheduled for cleft palate repair. INTERVENTIONS Children were randomized into two groups. The control group received saline, and the tranexamic acid group received tranexamic acid 10 mg/kg as a bolus, 15 minutes before incision. MAIN OUTCOME MEASURES Grade of surgical field on a 10-point scale, surgeon satisfaction, and primary hemorrhage. RESULTS Significant improvements were noted in surgeon satisfaction and median grade of assessment of the surgical field (4 [interquartile range, 4 to 6] in the control group vs. 3 [interquartile range, 2 to 4] in the test group; P = .003) in the tranexamic acid group compared to the control group. CONCLUSION Preincision administration of 10 mg/kg of tranexamic acid significantly improved the surgical field during cleft palate repair.
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Stelter K. Tonsillitis and sore throat in children. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2014; 13:Doc07. [PMID: 25587367 PMCID: PMC4273168 DOI: 10.3205/cto000110] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery. The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.
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Affiliation(s)
- Klaus Stelter
- Dep. of Otorhinolaryngology, Head and Neck Surgery, Grosshadern Medical Centre, University of Munich, Munich, Germany
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Tengborn L, Blombäck M, Berntorp E. Tranexamic acid--an old drug still going strong and making a revival. Thromb Res 2014; 135:231-42. [PMID: 25559460 DOI: 10.1016/j.thromres.2014.11.012] [Citation(s) in RCA: 194] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 11/10/2014] [Accepted: 11/12/2014] [Indexed: 12/22/2022]
Abstract
Experience with tranexamic acid, an indirect fibrinolytic inhibitor, started as soon as it was released from Shosuke Okamoto's lab in the early 1960s. It was first prescribed to females with heavy menstrual blood loss and to patients with hereditary bleeding disorders. Soon the indications were widened to elective surgery because of its blood saving effects. Contraindications are few, most important is ongoing venous or arterial thrombosis and allergy to tranexamic acid, and the doses has to be reduced in renal insufficiency. In randomized controlled trials, however, patients with other risk factors are excluded as well (patients with history of cardiovascular disease, thromboembolism, bleeding diathesis, renal failure with creatinine >250μmol/L, pregnancy, and patients on treatment with anticoagulants). Recent meta-analyses of several randomized controlled trials in orthopedic arthroplasty have shown that tranexamic acid reduces peri- and postoperative blood loss, blood transfusion requirements and reoperations caused by bleedings. In general, the preoperative dose was 10-15mg/kg i.v. (or 1g), followed or not, by one or two doses, some as continuous infusion i.v. To validate relationship between dose and effect more data are needed. No evidence was found of increased thromboembolic accidents or other adverse events in the patients on tranexamic acid compared to the control groups. In major cardiac surgery tranexamic acid has been used in a large number of controlled trials with various dosing schemes in which the highest dosages seem to be associated with neurotoxicity; therefore a maximum total dose of 100mg/kg especially in patients over 50years of age is recommended by ISMICS (International Society for Minimally Invasive Cardiothoracic Surgery). Other indications for tranexamic acid are reviewed here as well. In recent years the extensive trial in severe trauma with massive bleedings using tranexamic acid was presented, CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage) comprising more than 20,000 patients. It showed that the survival was increased when tranexamic acid was given early after the accident compared to placebo; further studies are taking place is this field to get more information. Of utmost importance is the ongoing WOMAN (World Maternal Antifibrinolytic) a randomized, double-blind, placebo controlled trial among 15,000 with clinical diagnosis of postpartum haemorrhage bearing in mind that each year a large number of women in low and middle income countries, die from causes related to childbirth. In summary, we consider tranexamic acid is a drug of great value to reduce almost any kind of bleeding, it is cheap and convenient to use and has principally few contraindications. It may be added, that tranexamic acid is included in the WHOs list of essential medicines.
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Affiliation(s)
- Lilian Tengborn
- Lund University, Clinical Coagulation Research Unit, Skåne University Hospital, SE-205 02 Malmö, Sweden
| | - Margareta Blombäck
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Blood Coagulation, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Erik Berntorp
- Lund University, Clinical Coagulation Research Unit, Skåne University Hospital, SE-205 02 Malmö, Sweden.
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Tranexamic acid – a useful drug in ENT surgery? The Journal of Laryngology & Otology 2014; 128:574-9. [DOI: 10.1017/s0022215114001285] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Tranexamic acid is a synthetic antifibrinolytic drug. It has been widely available for over 40 years, but only recently has it started to be used routinely in many surgical disciplines. For ENT surgeons, epistaxis and post-tonsillectomy bleeding contribute a significant proportion of the morbidity and emergency workload in a general ENT department. Published evidence indicates a potentially helpful role for tranexamic acid in managing epistaxis.Results and conclusion:To date, the benefits of tranexamic acid as a prophylactic treatment to reduce the rate and severity of post-tonsillectomy bleeding are less certain. Two recently published pilot studies looking at primary haemorrhage in children and secondary haemorrhage in adults following tonsillectomy suggest that further large, randomised trials should explore the efficacy of tranexamic acid in routine ENT surgery. There are potential reductions in patient morbidity and cost savings if tranexamic acid is found to be efficacious in larger trials.
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Robb PJ, Thorning G. Perioperative tranexamic acid in day-case paediatric tonsillectomy. Ann R Coll Surg Engl 2014; 96:127-9. [PMID: 24780670 DOI: 10.1308/003588414x13814021676477] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Tranexamic acid has been used for many years to minimise blood loss during surgery and, more recently, to reduce morbidity after major trauma. While small studies have confirmed reduction in blood loss during tonsillectomy with its use, the rate of primary haemorrhage following tonsillectomy has not been reported. In the UK, less than 50% of children having a tonsillectomy are managed as day cases, partly because of concerns about bleeding during the initial 24 hours following surgery. METHODS A retrospective review of clinical records between January 2007 and January 2013 produced 476 children between the ages of 3 and 16 years who underwent Coblation™ tonsillectomy, with or without adenoidectomy and/or insertion of ventilation tubes. All children were ASA (American Society of Anesthesiologists) grade 1 or 2 and anaesthetised using a standard day surgery protocol. Following induction of anaesthesia, all received intravenous tranexamic acid at a dose of 10-15 mg/kg. RESULTS Two children (0.4%) had minor bleeding within two hours of surgery. Both returned to theatre for haemostasis and were discharged home later the same day with no further complications. The expected rate for primary haemorrhage in the UK using this technique for tonsillectomy is 1%. CONCLUSIONS Perioperative tranexamic acid in a single, parenteral dose might reduce the incidence of primary haemorrhage following paediatric tonsillectomy, facilitating discharge on the day of surgery. The results from this observational study indicate a potential benefit and need for a large, prospective, multicentre, randomised controlled trial.
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Affiliation(s)
- P J Robb
- Epsom and St Helier University Hospitals NHS Trust, UK
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Nguyen TBV, Chin RY, Paramaesvaran S, Eslick GD. Routine tonsillar bed oversew after diathermy tonsillectomy: does it reduce secondary tonsillar haemorrhage? Eur Arch Otorhinolaryngol 2014; 271:3005-10. [PMID: 24792067 DOI: 10.1007/s00405-014-3075-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 04/22/2014] [Indexed: 10/25/2022]
Abstract
Tonsillectomy is a common otolaryngological procedure and is associated with a small risk of postoperative pharyngeal haemorrhage. This study compares secondary post tonsillectomy haemorrhage rates between two operative techniques: diathermy tonsillectomy and diathermy tonsillectomy with tonsillar bed oversew. A total of 424 patients underwent tonsillectomies with or without other procedures such as adenoidectomy and grommet insertion by two ears, nose and throat surgeons at three hospitals from May 2012 to July 2013. A diathermy tonsillectomy was performed in 266 patients, while a diathermy tonsillectomy with tonsillar bed oversew was performed in 158 patients. All patients were followed up within 2-4 weeks of surgery. Primary haemorrhage did not occur in either surgical technique groups. Secondary haemorrhage occurred in 20 patients (7.52 %) in the diathermy tonsillectomy group and in 9 patients (5.70 %) in the diathermy with tonsillar bed oversew group. This result was not significantly different (OR = 0.74, 95 % CI 0.33-1.67, p = 0.47). Sex, age, indication for surgery and whether or not a tonsillectomy was performed alone or with other procedures were not significant factors for secondary haemorrhage. In summary, routine tonsillar bed oversew after diathermy tonsillectomy does not reduce the risk of secondary tonsillar haemorrhage.
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Affiliation(s)
- Thomas B V Nguyen
- Department of Otolaryngology, Head and Neck Surgery, Nepean Hospital, Derby St, Kingswood, Sydney, NSW, 2750, Australia,
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