A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial

Instant clot forming and antibacterial wound dressings: Achieving hemostasis in trauma injuries with S-nitroso-N-acetylpenicillamine-tranexamic acid-propolis formulation

Wound infection and excessive blood loss are the two major challenges associated with trauma injuries that account for 10% of annual deaths in the United States. Nitric oxide (NO) is a gasotransmitter cell signaling molecule that plays a crucial role in the natural wound healing process due to its antibacterial, anti-inflammatory, cell proliferation, and tissue remodeling abilities. Tranexamic acid (TXA), a prothrombotic agent, has been used topically and systemically to control blood loss in reported cases of epistaxis and combat-related trauma injuries. Its properties could be incorporated in wound dressings to induce immediate clot formation, which is a key factor in controlling excessive blood loss. This study introduces a novel, instant clot-forming NO-releasing dressing, and fabricated using a strategic bi-layer configuration. The layer adjacent to the wound was designed with TXA suspended on a resinous bed of propolis, which is a natural bioadhesive possessing antibacterial and anti-inflammatory properties. The base layer, located furthest away from the wound, has an NO donor, S-nitroso-N-acetylpenicillamine (SNAP), embedded in a polymeric bed of Carbosil®, a copolymer of polycarbonate urethane and silicone. Propolis was integrated with a uniform layer of TXA in variable concentrations: 2.5, 5.0, and 7.5 vol % of propolis. This design of the TXA-SNAP-propolis (T-SP) wound dressing allows TXA to form a more stable clot by preventing the lysis of fibrin. The lactate dehydrogenase-based platelet adhesion assay showed an increase in fibrin activation with 7.5% T-SP as compared with control within the first 15 min of its application. A scanning electron microscope (SEM) confirmed the presence of a dense fibrin network stabilizing the clot for fabricated dressing. The antibacterial activity of NO and propolis resulted in a 98.9 ± 1% and 99.4 ± 1% reduction in the colony-forming unit of Staphylococcus aureus and multidrug-resistant Acinetobacter baumannii, respectively, which puts forward the fabricated dressing as an emergency first aid for traumatic injuries, preventing excessive blood loss and soil-borne infections.

The efficacy and application of tranexamic acid in emergency medicine: Emergency Medicine Association of Türkiye clinical policy- 2024

The clinical policy of the Emergency Medicine Association of Türkiye (EMAT) provides guidance on the use of tranexamic acid (TXA) in emergency settings. TXA, an antifibrinolytic drug, is used to control bleeding by inhibiting plasminogen. Its applications have expanded from hemophilia and severe menstrual bleeding to include various forms of trauma and surgery-related bleeding. Despite its potential benefits, the use of TXA in emergency settings must be carefully evaluated due to its associated risks, including venous thromboembolism. This policy aimed to offer evidence-based recommendations on the indications and contraindications of TXA in different clinical scenarios encountered in the emergency departments. The guidelines were developed using the "Grading of Recommendations, Assessment, Development, and Evaluations" approach, incorporating systematic literature reviews, and expert consensus from the EMAT Research Committee. This document focuses on critical clinical questions regarding the efficacy and safety of TXA in situations such as gastrointestinal bleeding, multitrauma, traumatic brain injury, nontraumatic intracranial hemorrhage, hemoptysis, and epistaxis. By addressing these issues, the policy seeks to assist emergency physicians in making informed decisions about the use of TXA, ultimately aiming to improve the patient outcomes.

Appropriate dose of tranexamic acid in the topical treatment of anterior epistaxis, 500 mg vs 1000 mg: A double-blind randomized controlled trial

AIMS

Patients with epistaxis typically visit the emergency department for initial treatment. According to recent studies, tranexamic acid (TXA) is effective in the treatment of epistaxis. This study compared the therapeutic superiority of saline to that of 500 and 1000 mg doses of topical TXA for the treatment of anterior epistaxis. Materials and methods: This phase 4 clinical trial was a randomized, controlled, and double-blind trial. A total of 152 patients were divided into three groups. Group 1 was treated with 1000 mg TXA, Group 2 with 500 mg TXA, and Group 3 with saline. Results: Based on multinomial logistic regression analysis, the bleeding frequency at the 5th minute was 2.9 times and rebleeding status was 4.3 times less in Group 1 (1000 mg TXA) than in Group 3 (saline). There were no differences between the three groups in terms of side effects or salvage therapy. Conclusion: In addition to its superiority in treatment, 1000 mg of TXA is recommended because of the decreased rate of recurrent bleeding and low incidence of side effects.

Treatment of Post-Tonsillectomy Hemorrhage With Nebulized Tranexamic Acid: Initial Investigation of a Novel Therapeutic Modality

OBJECTIVES

The use of nebulized tranexamic acid (TXA) in massive pulmonary hemorrhage is well-described. Published utilization in post-tonsillectomy bleeding (PTB) is limited to a single case. This study examines whether TXA resulted in change of operative intervention necessity and narcotic utilization.

METHODS

This was a retrospective cohort study at a single, urban academic medical center in the United States. Chart review was conducted of all patients who presented to the hospital for post-tonsillectomy bleed (PTB) between 3/1/2018 and 7/1/2020. Demographic data, intervention modality, need for control under general anesthesia, and opioid use were collected and analyzed.

RESULTS

Twenty-one patients underwent a total of 23 visits for PTB over the study period. Control of hemorrhage without need for operating room intervention for PTB was 100% (6/6) for patients receiving TXA nebulizer and 53% (9/17) for those receiving other treatment modalities. Opioid usage in hospital and on discharge was also lower in patients receiving TXA nebulizers. All results were statistically significant.

CONCLUSIONS

Our study supports nebulized TXA as an effective, non-invasive mode of hemostasis in patients presenting to the emergency department for post-tonsillectomy hemorrhage. Nebulized TXA may prevent the need for general anesthesia and operative intervention. Otolaryngologists should consider addition of this novel treatment appropriation of TXA to their management options for postoperative tonsillar hemorrhage.

Comparative Study of Topical Application of Injection Tranexamic Acid and Anterior Nasal Packing in the Management of Epistaxis

Epistaxis, defined as bleeding from the nose, is one of the common ENT cases coming to emergency department. Epistaxis is experienced by at least 60% of the population once in their life time and about 6% of them will require medical attention. The different treatment modalities include: local pressure, application of topical vasoconstrictor substances, or nasal packing depending on personal physician preference. Tranexamic acid (TXA), a synthetic analogue of the amino acid lysine, belongs to a class of drugs known as antifibrinolytics. It acts by reversibly binding four to five lysine receptor sites on plasminogen and can be used in emergency department for reducing the bleeding time in epistaxis. To evaluate the efficacy of topical application of injection TXA compared to cases managed with anterior nasal packing for the treatment of patients with epistaxis. 100 patients presenting with epistaxis in emergency department, above the age of 18 years were randomly divided into two groups with 50 patients each. Group 1 were managed with anterior nasal packing with gel foam and Group 2 with topical application of injection TXA. Causes,duration to control epistaxis, and occurrence of rebleeding were recorded. Our study showed homogenous distribution of age and sex among the patients. Bleeding stopped within 10 min in 38 patients in group 2 compared to 17 patients in group 1. For 31 patients in group 1, bleeding stopped between 10 and 15 min compared to 12 in group 2. In group 1, 8 patients had rebleeding compared to 2 patients in group 2. Our study showed that topical application of TXA reduces the bleeding time and number of rebleeds compared to anterior nasal packing with gelfoam. Since it is easily available in an emergency setup and cheaper compared to gelfoam, it can be used as an elective method in managing epistaxis in emergency department.

Tranexamic acid versus adrenaline-soaked pledgets for the reduction of intraoperative bleeding in functional endoscopic sinus surgery

OBJECTIVE

Aim: To examine the impact of locally applied tranexamic acid and adrenaline, separately and in combination, on intraoperative blood loss and surgical field quality during functional endoscopic sinus surgery.

PATIENTS AND METHODS

Materials and Methods: The study involved 40 patients with chronic rhinosinusitis. They were divided into two groups. Group I received adrenaline alone in one side and a mixture of adrenaline and tranexamic acid in the other side. Group II received adrenaline alone in one side and tranexamic acid in the otherside. Parameters like surgery time, blood loss, and surgical field quality were studied.

RESULTS

Results: In Group I, the combination of adrenaline and tranexamic acid significantly reduced blood loss and enhanced surgical field quality compared to adrenaline alone. In Group II, adrenaline outperformed tranexamic acid in shortening surgery duration and improving surgical field quality. However, there was no significant difference in blood loss reduction between adrenaline and tranexamic acid.

CONCLUSION

Conclusions: The study concluded that tranexamic acid is less effective than adrenaline when introduced as topical intranasal pledgets in both decreasing the time needed for the surgery and improving the subjective satisfaction of the surgeon while there is no significant difference regarding decreasing intraoperative blood loss. The mixture of adrenaline and tranexamic acid pledgets are more effective than adrenaline-only pledgets in terms of decreasing the intraoperative blood loss and improving the surgeon's satisfaction with no significant difference regarding the time needed for the surgery.

Comparative effectiveness of various noninvasive local treatments in patients with epistaxis: A systematic review and network meta-analysis

BACKGROUND

The best initial strategy for managing epistaxis is unclear. We performed a systematic review and network meta-analysis (NMA) to compare the effectiveness of various noninvasive treatments for patients with epistaxis.

METHODS

We searched PubMed, Embase, and the Cochrane Library from inception to September 2022 without language restrictions. Randomized controlled trials (RCTs) assessing immediate hemostasis, 2-day and 7-day rebleeding outcomes, as well as the use of noninvasive interventions for the treatment of epistaxis were selected. Frequentist NMA was performed.

RESULTS

The systematic review included 20 RCTs (2994 participants) involving 12 different interventions. The NMA demonstrated that topical treatment with tranexamic acid (TXA) significantly reduced the odds of 2-day rebleeding compared with the control conservative treatment (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.21-0.61) and traditional anterior nasal packing (OR 0.45, 95% CI 0.26-0.76). The sensitivity analysis yielded robust results, and the overall evidence was high. Topical TXA significantly reduced the odds of 7-day rebleeding compared with traditional nasal packing (OR 0.33, 95% CI 0.15-0.70), with moderate evidence owing to the heterogeneous results. Despite the significant effects of topical TXA on achieving immediate hemostasis and Rapid Rhino nasal packing on preventing 2-day rebleeding compared to the control and traditional nasal packing, the evidence is low to very low due to heterogeneity, inconsistency, and within-study bias.

CONCLUSIONS

In the treatment of epistaxis, topical TXA may be superior to conservative treatment or traditional nasal packing, particularly in preventing 2-day rebleeding.

Epistaxis Treatment Options: Literature Review

Epistaxis means bleeding from nostrils, nasal cavity or nasopharynx. To summarize the available epistaxis treatment options. Methods: 61 articles published in the last 20 years were included. Duplicate records, irrelevant and inaccessible ones were excluded.  Epistaxis can be treated with first aid measures such as external pressure and ice packing and applying topical agents, e.g. oxymetazoline that stops 65-75% of nosebleeds in A&E. Also, with electrocautery which is more effective and has fewer recurrences (14.5% vs. 35.1%) than chemical cauterization and applying tranexamic acid that promotes hemostasis in 78% of patients, versus 35% and 31% respectively in patients treated with oxymetazoline and nasal packing. Furthermore, nasal packing can be applied with non-absorbable materials, e.g. petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel), Foley catheter, balloons (Rapid-Rhino), absorbable materials, e.g. nasal tampon (Nasopore), and with newer hemostatic materials which are more effective and with fewer complications, e.g. hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan) and fibrin glue. Moreover, epistaxis can be achieved with endoscopic ligation of arteries, mainly SPA, which is more effective than conventional nasal packing (97% vs. 62%), and with endoscopic cauterization which is more effective than ligation. Finally, for intractable cases embolization can be applied using gelatin sponge, foam, PVA and coils with 80% success rate and comparable efficacy and complications to surgical methods. Epistaxis can be dealt with various methods depending on patient's history and available resources. Newer hemostatic agents in combination with endoscopic methods have advantages over traditional methods.

Awareness of Epistaxis and Its First Aid Management Among Teachers Working in Schools of Al-Baha Region, Saudi Arabia

Background Epistaxis (nosebleed) is a frequent emergency presentation in the emergency department (ED). Generally, any harm to the nasal mucosa lining can lead the nose to bleed. The etiologies of epistaxis are widely classified as environmental, local, systemic, and medication-related causes. The initial management for epistaxis is first aid. First aid by applying pressure on the nostrils is essential to stop the bleeding and minimize discomfort. This study intends to evaluate teachers' awareness regarding epistaxis first aid management inside schools in Al-Baha region, Saudi Arabia. Methodology A cross-sectional study was conducted among a target of 439 teachers regarding epistaxis first aid management inside schools in Al-Baha region, Saudi Arabia. Data were collected using a structured questionnaire and analyzed using descriptive statistics and a chi-square test. Results Of the teachers, 50.7% had received training regarding epistaxis, while 49.3% had never been trained. Also, 73.3% considered that applying nasal compression may help stop bleeding, while the rest were completely unaware. On further investigation, tilting the head forward would be done by 56.27% of the teachers, while 40.73% said that the head should be tilted back. Of the teachers, 53.3% would go to the emergency if bleeding continued for more than 10 minutes. No association between age, gender, and working area, and training received regarding the management of epistaxis was found (p>0.05), but teachers from a scientific background, as compared to those from a literature background, were able to answer better regarding the management of epistaxis (p<0.05). Conclusion The study highlights knowledge gaps regarding epistaxis first aid management inside schools in Al-Baha region, Saudi Arabia. The research highlights the need for focused training programs and awareness efforts to enhance teachers' knowledge and first aid practices. Addressing misknowledge and mispractices, enhancing the practices and attitudes of healthcare providers toward appropriate feeding practices, and promoting a supportive and safe environment could all contribute to the improvement of quality of life and health among the population of Saudi Arabia.

Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study

INTRODUCTION

Local applications of tranexamic acid (TXA) have been effective in treating various hemorrhagic conditions. In patients with gross hematuria, the main treatment in the emergency department (ED) is continuous bladder irrigation (CBI). However, CBI has no pharmacological effects except blood clot removal from dilution. The aim of this study was to evaluate the impact of the intravesical TXA injection before CBI.

METHODS

This study was a before-and-after, retrospective, and single-center study. The target population was hematuria patients who received CBI via a 3-way Foley catheter. As the intervention procedure, 1000 mg of TXA was injected through the Foley catheter and after 15 min, the Foley catheter was declamped and CBI started. Since the intervention started in March 2022, the patients from March 2022 to August 2022 were assigned to the after group and the patients from March 2021 to August 2021 were assigned to the before group. The primary outcomes were the length of stay in the ED and duration of Foley catheter placement. The secondary outcomes were the admissions and the revisits for CBI within 48 h after discharge.

RESULTS

The numbers of patients in the before group and after group were 73 and 86, respectively. The median length of stay in the ED was shorter in the intervention group than in the group not treated with TXA (274 min vs. 411 mins, P < 0.001). The median duration of Foley catheter placement was also shorter in the intervention group than not treated with TXA (145 min vs. 308 mins, P < 0.001). The revisits after ED discharge were lower in the after group than in the before group (2.3% vs. 12.3%, P = 0.031). There was a trend for lower admissions in the TXA treatment group than before group (29.1% vs. 45.2%, P = 0.052).

CONCLUSION

After the TXA intervention, reduction in the length of stay in the ED, the duration of Foley catheter placement, and the revisits after ED discharge was observed.

Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial

STUDY OBJECTIVE

To determine the effectiveness of intranasal topical application of tranexamic acid in reducing the need for anterior nasal packing and determine the number of episodes of rebleeding in adult patients presenting with spontaneous atraumatic anterior epistaxis.

METHODS

This study was a double-blind randomized trial conducted from September to November 2021 in the ears, nose, and throat (ENT) emergency department (ED), Khalili Hospital, Shiraz, Iran. Cotton pledgets soaked in either phenylephrine and lidocaine (control group) or tranexamic acid with phenylephrine and lidocaine (intervention group) were inserted into the patients' nostrils for 15 minutes. The primary outcome was the need for anterior nasal packing. The secondary outcomes were staying in the ED for more than 2 hours, needing electrical cauterization, and rebleeding within 24 hours and 1 to 7 days of the first referral to the ED. The trial was registered with the Iranian Registry of Clinical Trials (IRCT20210403050815N1).

RESULTS

A total of 240 patients (120 in each group) were enrolled in this study. Tranexamic acid was associated with a lower rate of need for anterior nasal packing (50.0% versus 64.2%; odds ratio [OR], 0.56; 95% confidence interval [CI], 0.33 to 0.94). There were no significant differences between the 2 groups in terms of the need for electrical cauterization and the rate of rebleeding within 1 to 7 days. Tranexamic acid was associated with a lower rate of stay in the ED for more than 2 hours (9.2% versus 20.8%; OR, 0.38; 95% CI, 0.18 to 0.82) and rebleeding in 24 hours (15.0% versus 30%; OR, 0.41; 95% CI, 0.22 to 0.78) compared with the rates in the control group.

CONCLUSION

Intranasal topical application of tranexamic acid is associated with a lower rate of need for anterior nasal packing and a shortened stay in the ED; it may be considered a part of the treatment for atraumatic anterior epistaxis.

Evaluation of applying topical tranexamic acid to control septorhinoplasy - induced hemorrhage

OBJECTIVES

Hemorrhagic events related to surgical field is a common disturbing complication which could worsen the outcomes of operation. This study aimed to evaluate how applying of topical tranexamic acid (TXA) could affect bleeding related to septorhinoplasty operation.

MATERIAL AND METHODS

This double-blind controlled trial study finally evaluated 198 candidates for septorhinoplasty repair who were randomly allocated to two groups: TXA receivers (5 mg/kg) and control group (received 5 mg/kg of saline 0.9 %). Then cumulative volume of hemorrhage was calculated by adding total volume of suctioned blood and numbers of fully blood-filled surgical gauzes (15 mL in each). Additionally postoperative 24 h volume of hemorrhage was measured by counting number of bloody surgical gauzes.

RESULTS

Of all participants, 90 % were female. The mean age was 26 ± 7 years. Total cumulative volume of hemorrhage during surgery was significantly diminished when topical TXA was applied (p < 0.0001). Additionally drier field of operation was illustrated postoperatively in patients received topical TXA (2 % & 28 % in TXA and saline 0.9 % receivers, respectively) (p < 0.001).

CONCLUSION

Using topical TXA could decrease bleeding volume and make surgical field of septorhinoplasty drier either during surgery or postoperatively.

Nasal Packing in the Emergency Department: A Practical Review for Emergency Providers

We performed a narrative review of epistaxis management in the emergency department. First, we examined the pathophysiology, the current types of treatment that are available to emergency clinicians. When nasal packing is indicated, we examined the efficacy of nasal packing in addition to other topical treatment such as tranexamic acid and the evidence of prophylactic antibiotics. We detailed current studies involving tranexamic acid and prophylactic antibiotics for nasal packing. Finally, we introduced an epistaxis clinical care pathway, based on current evidence, to aid emergency clinicians with their clinical decision-making processes.

Efficacy of topical tranexamic acid in epistaxis: A systematic review and meta-analysis

INTRODUCTION

Epistaxis is a very common presentation in the emergency department (ED), accounting for approximately 1 in 200 ED visits in the United States. Currently, standard practice includes the initial use of topical anesthetics and vasoconstrictors, followed by more invasive treatments such as nasal packing, cauterization or surgical ligation for refractory cases. Over the years several studies have investigated the potential use of topical Tranexamic Acid (TXA) in the management of epistaxis. We have conducted a meta-analysis to assess the efficacy of topical TXA versus other standard practices or placebo in the management of epistaxis.

METHODS

PubMed and Scopus databases were searched from inception to April 2021. We included randomized controlled trials and observational studies investigating the efficacy of TXA in bleeding cessation in epistaxis in adults. The primary outcome measured was the prevalence of bleeding cessation after treatment at first assessment. Other outcomes were bleeding reoccurrence between 24 and 72 h and at 7-8 days. A random-effects model was used to estimate odds ratio (OR) for outcomes.

RESULTS

A total of eight studies were included in the analysis, including seven randomized trials and one retrospective study. We included a total of 1299 patients, 596 (46%) received TXA while 703 (54%) received control treatment (placebo, lidocaine plus vasoconstrictors or local anesthetics). Patients who were treated with TXA were 3.5 times (OR 3.5, 95% CI 1.3-9.7) more likely to achieve bleeding cessation at the first assessment. Patients treated with TXA had 63% (OR 0.37, 95% CI 0.20-0.66) less likelihood of returning due to rebleeding at 24-72 h.

CONCLUSION

Topical TXA is associated with better bleeding cessation rates after treatment compared to the standard practices.

[Epistaxis-overview and current aspects]

Nosebleeds (epistaxis) are usually minor. Medical intervention is only necessary in about 6% of cases. The source of bleeding is frequently located in the anterior region of the nose (Kiesselbach's plexus). The estimated lifetime prevalence of epistaxis is 60%. Diffuse epistaxis is often a manifestation of systemic disease. Epistaxis is the leading symptom of Rendu-Osler-Weber disease (hereditary hemorrhagic telangiectasia, HHT). If intervention is required, the first-choice of treatment is bidigital compression for several minutes. Common therapeutic measures include local hemostasis using electrocoagulation or chemical agents, e.g., silver nitrate. Resorbable anterior nasal tampons or tampons with a smooth surface are also frequently employed. In case of failed surgical closure of the sphenopalatine artery, angiographic embolization is the method of choice.

Tranexamic acid in otorhinolaryngology - A contemporary review

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.

Tranexamic acid for the prevention and treatment of bleeding in surgery, trauma and bleeding disorders: a narrative review

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.

Perioperative Tranexamic Acid for ACTH-Secreting Pituitary Adenomas: Implementation Protocol Results and Trial Prospectus

OBJECTIVE

Primary resection of adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma has become a front-line standard-of-care treatment for Cushing disease. However, surgical intervention can be challenging because of elevated blood pressure, as well as direct cortisol impacts on endothelial cells, vascular permeability, and tissue friability-potentially resulting in increased intraoperative bleeding. Tranexamic acid (TXA) is a well-studied, widely used intravenous hemostatic; however, the potential benefit during resection of ACTH-secreting pituitary adenoma is unstudied. The purpose of this study was to define an institutional protocol for perioperative administration of TXA in patients undergoing endoscopic endonasal approach for resection of ACTH-secreting pituitary adenoma, and to study the implementation of our novel protocol in a prospective fashion.

METHODS

Criteria for preoperative TXA were defined by age, medical history, and risk factors. Descriptive statistics were reported for all patients receiving perioperative TXA.

RESULTS

Thirty patients met inclusion criteria and underwent perioperative administration of TXA, using a standardized dosing protocol of a 10 mg/kg bolus in 30 minutes prior to incision, followed by maintenance infusion of 2 mg/kg/hour for the duration of the procedure. No incidence of myocardial infarction or postoperative thromboembolic events were noted. Subjective assessments indicated satisfaction with the patient selection protocol, and meaningful reduction in the extent of intraoperative bleeding.

CONCLUSIONS

Perioperative TXA represents a potentially efficacious approach for control of intraoperative bleeding during endonasal resection of ACTH-secreting tumors. Careful preoperative patient selection is emphasized, given the potential for thromboembolic complications; however, initial experience with our institutional protocol suggests a favorable risk/benefit profile when this treatment is applied judiciously.

The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial

STUDY OBJECTIVE

Epistaxis is a common emergency department (ED) presentation and, if simple first aid measures fail, can lead to a need for anterior nasal packing. Tranexamic acid is an agent that contributes to blood clot stability. The aim of this study is to investigate the effectiveness of topical intranasal tranexamic acid in adult patients presenting to the ED with persistent epistaxis, and whether it reduces the need for anterior nasal packing.

METHODS

From May 5, 2017, to March 31, 2019, a double-blind, placebo-controlled, multicenter, 1:1, randomized controlled trial was conducted across 26 EDs in the United Kingdom. Participants with spontaneous epistaxis, persisting after simple first aid and the application of a topical vasoconstrictor, were randomly allocated to receive topical tranexamic acid or placebo. The primary outcome was the need for anterior nasal packing of any kind during the index ED attendance. Secondary outcome measures included hospital admission, need for blood transfusion, recurrent epistaxis, and any thrombotic events requiring any hospital reattendance within 1 week.

RESULTS

The study sample consisted of 496 participants with spontaneous epistaxis, persisting after simple first aid and application of a topical vasoconstrictor. In total, 211 participants (42.5%) received anterior nasal packing during the index ED attendance, including 111 of 254 (43.7%) in the tranexamic acid group versus 100 of 242 (41.3%) in the placebo group. The difference was not statistically significant (odds ratio 1.107; 95% confidence interval 0.769 to 1.594; P=.59). Furthermore, there were no statistically significant differences between tranexamic acid and placebo for any of the secondary outcome measures.

CONCLUSION

In patients presenting to an ED with atraumatic epistaxis that is uncontrolled with simple first aid measures, topical tranexamic acid applied in the bleeding nostril on a cotton wool dental roll is no more effective than placebo at controlling bleeding and reducing the need for anterior nasal packing.

The addition of silver nitrate cautery to antiseptic nasal cream for patients with epistaxis: A systematic review and meta-analysis

OBJECTIVE

To compare the outcomes of the addition of silver nitrate cautery versus antiseptic cream alone in paediatric patients with recurrent epistaxis.

METHODS

A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines and a search of electronic information was conducted to identify all Randomised Controlled Trials (RCTs) and non-randomised studies comparing the outcomes of the addition of silver nitrate cautery versus antiseptic cream alone in paediatric patients with recurrent epistaxis. Treatment success and persistence of bleeding were primary outcome measures. Secondary outcome measures included treatment side effects. Fixed effects modelling was used for the analysis.

RESULTS

Four studies enrolling 240 patients were identified. There was no significant difference between silver nitrate cautery group and antiseptic cream alone group in terms of complete resolution (Odds Ratio [OR] = 1.07, P = 0.81), the partial resolution (OR = 1.02, P = 0.96) and persistence of bleeding (OR = 0.91, P = 0.71). For secondary outcomes, antiseptic nasal cream was associated with few side effects such as rash in one case and several complaints of bad smell or taste.

CONCLUSIONS

The addition of silver nitrate cautery is not superior to the use of antiseptic cream alone in paediatric patients with recurrent epistaxis as it does not improve treatment success or persistence of bleeding.

Nasal Powder Formulation of Tranexamic Acid and Hyaluronic Acid for the Treatment of Epistaxis

PURPOSE

The aim of this study was to develop a nasal powder formulation of the antifibrinolytic drug, tranexamic acid (TXA), in combination with the wound-healing agent hyaluronic acid (HA) for the local treatment of epistaxis (nose bleeding).

METHODS

Formulations of TXA alone and with different concentrations of HA were freeze-dried and characterised according to their physicochemical properties. Aerosol performance was assessed to ensure nasal deposition with minimal lung deposition. Nasal epithelial cells were used to assess cytotoxicity, transport across the nasal epithelium, antioxidant, wound-healing and anti-inflammatory properties of all formulations.

RESULTS

Formulations containing TXA and HA were produced and found to be mostly deposited in the nasal cavity (more than 90%). Formulation of TXA + 0.3%HA showed wound reduction of 29.3% when assessed in ALI culture. At this concentration, formulations also reduced ROS production in RPMI 2650, and IL-8 production in primary nasal epithelial cells. Furthermore, for formulations containing HA, the higher viscosity may lead to larger residence time in the nasal cavity.

CONCLUSIONS

Combination of TXA with HA shows promising results for the treatment of nasal epistaxis.

Regenerated oxidised cellulose versus calcium alginate in controlling bleeding from malignant breast cancer wounds: randomised control trial study protocol

OBJECTIVE

Malignant wounds due to breast cancer can present with recurrent episodes of bleeding in the tumour tissue. This study will compare the efficacy of a calcium alginate dressing (Biatain, Coloplast A/S, Denmark) and a regenerated oxidised cellulose dressing (Surgicel, Ethicon, LLC, Puerto Rico).

PROTOCOL

A total of 24 patients with breast cancer and bleeding, malignant wounds will be enrolled in the randomised, controlled, open study, conducted at a hospital specialising in breast cancer treatment and at another hospital specialising in palliative care. Patients over 18 years old, with bleeding and willing to undergo venipuncture for blood collection will be included. All enrolled patients will be randomised for allocation to an experimental group (regenerated oxidised cellulose dressing) or a control group (calcium alginate dressing). The main intervention will consist of the application of the haemostatic product, assessment of digital pressure and estimation of the time required for haemostasis.

OUTCOMES

Key outcome measures will be the percentage of patients with haemostasis within 20 minutes, observation of haemostasis after three, five and 10 minutes, in addition to recurrence of bleeding and the quantity of product used.

DISCUSSION

To our knowledge, this is the first study to evaluate the effectiveness of haemostatic products in malignant wounds. This type of wound is poorly explored in the literature and, among its signs and symptoms, bleeding is poorly studied. The completion of this study will provide a more robust rationale for clinical decision-making related to the control of bleeding in malignant breast cancer wounds in the context of evidence-based nursing practices.

Clinical Practice Guideline: Nosebleed (Epistaxis)

OBJECTIVE

Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds.

PURPOSE

The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome. (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation, about examination of the nasal cavity and nasopharynx using nasal endoscopy, was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.

Role of Tranexamic Acid in the Clinical Setting

Tranexamic acid (TXA) is labeled as an antifibrinolytic agent that decreases mortality, reduces blood loss after trauma or surgery, and lowers transfusion requirements in trauma patients with bleeding. This review of the literature is related to TXA use in a variety of settings, with a specific focus on trauma patients, to assess therapeutic efficacy and safety. As seen in large, randomized, placebo-controlled trials, TXA has been shown to decrease mortality over placebo in trauma patients, It is also noted to have good safety parameters upon administration and should be recommended for use in trauma patients with bleeding. Further studies are warranted for the use of TXA in gastrointestinal bleeding and pediatric trauma.

Effect of Local Tranexamic Acid on Hemostasis in Rhytidectomy

Importance: Hematoma is the most common complication in rhytidectomy. Tranexamic acid (TXA) is an antifibrinolytic that may be a useful tool to reduce intraoperative bleeding and postoperative hematoma risk. Objective: To determine whether local TXA reduces intraoperative bleeding and postoperative drain output in rhytidectomy. Design, Setting, and Participants: Retrospective cohort study of patients undergoing deep plane rhytidectomy with platysmaplasty. Beginning January 1, 2019, we began adding 1 cc (100 mg) of TXA to every 10 cc of local anesthetic and tumescent solution. Patients were, therefore, separated into two cohorts: control and TXA. Primary outcomes include postoperative day 1 (POD1) drain output, days to drain removal, percentage drains removed POD1, and percentage POD1 drain output <25 cc. Secondary outcomes include minor hematoma, major hematoma, Nitro-bid use, intraoperative estimated blood loss (EBL), and thromboembolic events. Results: POD1 drain output reduced from 50.4 cc in control group versus 14.8 cc with TXA (p < 0.001). Average day of drain removal reduced from 1.8 days in control group versus 1.2 days with TXA (p = 0.001). Percentage of drains removed on POD1 was increased from 34.4% in control group to 77.3% with TXA (p < 0.001). Percentage of POD1 drain output <25 cc was increased from 21.9% in control group to 95.5% with TXA (p < 0.001). Intraoperative EBL <50 cc increased from 25% in control group to 75% with TXA (p < 0.001). No statistically significant difference was observed between control and TXA in rates of minor hematoma, major hematoma, Nitro-bid use, or thromboembolic events. Conclusions and Relevance: Local TXA used in rhytidectomy significantly reduces intraoperative blood loss, postoperative drain output, and time to drain removal. No significant difference was observed in postoperative complication rates.

The Role of Tranexamic Acid in the Management of an Acutely Hemorrhaging Patient

Background: Acute hemorrhage, both traumatic and nontraumatic, leads to significant morbidity and mortality, both in the United States and globally. Traditional treatment of acute hemorrhage is focused on hemostasis and blood product replacement. Tranexamic acid is an antifibrinolytic agent that may reduce acute hemorrhage through inhibition of plasminogen. Newer research suggests that coagulopathy, specifically fibrinolysis, may contribute significantly to the pathology of acute hemorrhage. Methods: We searched the PubMed database for relevant articles from 2000 to 2018 for the terms "tranexamic acid," "TXA," "antifibrinolytic," "hyperfibrinolysis," and "coagulopathy." Our search was limited to studies published in the English language. Results: A total of 53 studies were included in this review. These articles suggest a potential role for tranexamic acid in the management of acute intracranial hemorrhage, epistaxis, hematuria, postpartum hemorrhage, gastrointestinal hemorrhage, and trauma-related hemorrhage. A theoretical risk of thrombotic events following tranexamic acid use exists, though large clinical trials suggest this risk remains exceedingly small. Conclusions: Recent studies suggest a mortality benefit with tranexamic acid following acute hemorrhage. First responders such as emergency medical technicians and emergency department clinicians should consider tranexamic acid as an adjunct therapy in the management of acute, severe traumatic and nontraumatic hemorrhage.

Management of bleeding in palliative care patients in the general internal medicine ward: a systematic review

BACKGROUND

Palliative care patients, those suffering from at least one chronic lifelong medical condition and hospice care patients, those with a life expectancy less than 6 months, are regularly hospitalised in general internal medicine wards. By means of a clinical case, this review aims to equip the internist with an approach to bleeding in this population. Firstly, practical advice on platelet transfusions will be provided. Secondly, the management of bleeding in site-specific situations will be addressed (from the ENT/pulmonary sphere, gastrointestinal - urogenital tract and cutaneous ulcers). Finally, an algorithm pertaining to the management of catastrophic bleeding is proposed.

METHODS

Electronic databases, including EMBASE, Pubmed, Google Scholar and the Cochrane Library were studied as primary resources, in association with local guidelines, to identify papers exploring platelet transfusions and alternative management of site-specific bleeding in palliative care patients.

RESULTS

Haemorrhagic complications are frequent in palliative care patients in the internal medicine ward. Current guidelines propose a therapeutic-only platelet transfusion policy. Nonetheless, prophylactic and/or therapeutic transfusion remains a physician-dependent decision. Site-specific therapeutic options are based on expert opinion and case reports. While invasive measures may be pertinent in certain situations, their application must be compatible with patient goals. Catastrophic bleeding requires caregivers' comforting presence; pharmacological management is secondary.

CONCLUSION

Literature is lacking regarding management of bleeding in the palliative care population hospitalised in an acute medical setting. Recommendations are of limited quality, the majority based on case reports or expert opinion. Further studies, exploring for example the impact on patient quality of life, are desirable to improve the management of this frequently encountered complication.

Comparative Effectiveness of Topically Administered Tranexamic Acid Versus Topical Oxymetazoline Spray for Achieving Hemostasis in Epistaxis

BACKGROUND

The use of tranexamic acid (TXA) has recently gained popularity as a treatment modality for epistaxis in the emergency department. Previous studies have compared topical TXA to nasal packing. However, topical TXA has not yet been compared with topical oxymetazoline in the treatment of epistaxis.

OBJECTIVES

This study compares the efficacy of the intravenous formulation of TXA applied topically vs. the vasoconstrictor oxymetazoline applied topically in achieving hemostasis in patients presenting to the emergency department with anterior epistaxis.

METHODS

In this prospective study, patients presenting to the emergency department with the chief complaint of epistaxis, and meeting inclusion criteria, were allocated into 2 treatment groups; topical oxymetazoline vs. topical application of the intravenous preparation of TXA. Patients were assessed for time to hemostasis in the emergency department as well as the occurrence of rebleeding within the next 48 h after discharge.

RESULTS

Hemostasis was achieved in 14 (78%) of the 18 patients in the TXA group compared with 7 (35%) of the 20 patients in the oxymetazoline group. While there were occurrences of rebleeding in the emergency department before discharge and at 48 h in both groups, 11 patients in the TXA group had no recurrence of bleeding compared with 5 in the oxymetazoline group.

CONCLUSION

This study demonstrated that the topical application of the intravenous preparation of TXA is more effective than topical oxymetazoline for achievement of hemostasis in anterior epistaxis. This has clinical significance toward preventing an avoidable need for escalation of treatment that could include applying nasal packing or cautery as well as preventing avoidable return emergency department visits. These outcomes would increase cost, potentially increase patient discomfort, and prolong emergency department throughput time.

The many roles of tranexamic acid: An overview of the clinical indications for TXA in medical and surgical patients

Clinically significant bleeding can occur as a consequence of surgery, trauma, obstetric complications, anticoagulation, and a wide variety of disorders of hemostasis. As the causes of bleeding are diverse and not always immediately apparent, the availability of a safe, effective, and non-specific hemostatic agent is vital in a wide range of clinical settings, with antifibrinolytic agents often utilized for this purpose. Tranexamic acid (TXA) is one of the most commonly used and widely researched antifibrinolytic agents; its role in postpartum hemorrhage, menorrhagia, trauma-associated hemorrhage, and surgical bleeding has been well defined. However, the utility of TXA goes beyond these common indications, with accumulating data suggesting its ability to reduce bleeding and improve clinical outcomes in the face of many different hemostatic challenges, without a clear increase in thrombotic risk. Herein, we review the literature and provide practical suggestions for clinical use of TXA across a broad spectrum of bleeding disorders.

Nebulized Tranexamic Acid for the Use of Epistaxis: A Case Report

BACKGROUND

Tranexamic acid is an antifibrinolytic agent and functions as a competitive inhibitor of plasminogen activation, promoting hemostasis. Topical application of tranexamic acid for the control of epistaxis has been described in the literature, mainly through administration with gauze and packing. There is limited evidence for the use of tranexamic acid via alternative routes of administration such as nebulization.

CASE REPORT

We describe a patient who presented to the emergency department with epistaxis who was treated with nebulized tranexamic acid. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case provides an alternative treatment modality using nebulizing tranexamic acid to help manage epistaxis in patients that cannot be managed with topical antifibrinolytic therapy administered by other means.

Topical tranexamic acid (TXA) for the management of a bleeding arteriovenous fistula

Tranexamic acid (TXA) is increasing in use in the Emergency Department (ED). While its topical uses have largely been observed in the management of epistaxis, other applications are utilized. We present a case of an 84 year old male with a bleeding arteriovenous fistula, responsive to topical application of tranexamic acid. This case report demonstrates another novel application of TXA in emergency care.

Serum Concentrations and Pharmacokinetics of Tranexamic Acid after Two Means of Topical Administration in Massive Weight Loss Skin-Reducing Surgery

Supplemental Digital Content is available in the text.

Background:

Topical administration of tranexamic acid to reduce bleeding is receiving increasing attention, as it is inexpensive, simple, and possibly beneficial in most surgery. Concerns regarding potential systemic adverse effects such as thromboembolic events and seizures may prevent general use of tranexamic acid. Although serum concentrations after topical application are assumed to be low, proper pharmacokinetic studies of tranexamic acid after topical application are lacking.

Methods:

The authors have investigated systemic absorption of tranexamic acid after two means of topical administration in patients undergoing abdominoplasty after massive weight loss: a bolus of 200 ml of 5 mg/ml into the wound cavity versus moistening the wound surface with 20 ml of 25 mg/ml. Twelve patients were recruited in each group. Serum concentrations achieved were compared with those after administration of 1 g as an intravenous bolus to arthroplasty patients. Serial blood samples for tranexamic acid analysis were obtained for up to 24 hours.

Results:

After intravenous administration, the peak serum concentration was 66.1 ± 13.0 µg/ml after 6 ± 2 minutes. Peak serum concentration after topical moistening was 5.2 ± 2.6 µg/ml after 80 ± 33 minutes, and in the topical bolus group, it was 4.9 ± 1.8 µg/ml after 359 ± 70 minutes. Topical moistening resulted in homogenous and predictable absorption across the individuals included, whereas topical bolus administration caused variable and unpredictable serum concentrations.

Conclusion:

Topical administration of tranexamic acid in patients undergoing abdominoplasty results in low serum concentrations, which are highly unlikely to cause systemic effects.

Thrombin-generating potential, plasma clot formation, and clot lysis are impaired in patients with bleeding of unknown cause

BACKGROUND

In a large proportion of patients with a mild to moderate bleeding tendency no diagnosis can be established (bleeding of unknown cause, BUC).

OBJECTIVES

To investigate possible dysfunctions in thrombin generation and plasma clot formation and lysis in patients with BUC from the Vienna Bleeding Biobank (VIBB).

PATIENTS AND METHODS

Thrombin generation and plasma clot properties of 382 BUC patients were compared to those of 100 healthy controls and 16 patients with factor VIII (FVIII) activity ≤50%.

RESULTS

Thrombin generation was significantly impaired in BUC patients compared to healthy controls, exhibiting a prolonged lag time and time to peak and decreased maximum thrombin generation, velocity index, and area under the curve (AUC). The assessment of clot formation and lysis in BUC patients revealed a lower clot formation rate (Vmax), resulting in a longer TTP, increased absorbance (ΔAbs), and a shorter clot lysis time (CLT) than in healthy controls. Comparing patients with FVIII activity ≤ 50% to those with BUC, parameters of thrombin generation and clot formation and lysis were either stronger or comparably impaired. Bleeding severity did not correlate with parameters of thrombin generation, clot formation, or clot lysis.

CONCLUSION

Patients with BUC have an impaired hemostatic capacity reflected by a lower thrombin-generation potential, a lower clot formation rate, increased clot turbidity, and shorter clot lysis time, which might contribute to their increased bleeding tendency. Assays monitoring these parameters can alert physicians of hemostatic impairment and should be considered in situations where traditional hemostatic lab tests fail to reveal the clinical bleeding tendency.

Management of Severe Bleeding in Patients Treated With Oral Anticoagulants: Proceedings Monograph From the Emergency Medicine Cardiac Research and Education Group-International Multidisciplinary Severe Bleeding Consensus Panel October 20, 2018

In this Emergency Medicine Cardiac Research and Education Group (EMCREG)-International Proceedings Monograph from the October 20, 2018, EMCREG-International Multidisciplinary Consensus Panel on Management of Severe Bleeding in Patients Treated With Oral Anticoagulants held in Orlando, FL, you will find a detailed discussion regarding the treatment of patients requiring anticoagulation and the reversal of anticoagulation for patients with severe bleeding. For emergency physicians, critical care physicians, hospitalists, cardiologists, internists, surgeons, and family physicians, the current approach and disease indications for treatment with anticoagulants such as coumadin, factor IIa, and factor Xa inhibitors are particularly relevant. When a patient treated with anticoagulants presents to the emergency department, intensive care unit, or operating room with severe, uncontrollable bleeding, achieving rapid, controlled hemostasis is critically important to save the patient's life. This EMCREG-International Proceedings Monograph contains multiple sections reflecting critical input from experts in Emergency Cardiovascular Care, Prehospital Emergency Medical Services, Emergency Medicine Operations, Hematology, Hospital Medicine, Neurocritical Care, Cardiovascular Critical Care, Cardiac Electrophysiology, Cardiology, Trauma and Acute Care Surgery, and Pharmacy. The first section provides a description of the current indications for the treatment of patients using oral anticoagulants including coumadin, the factor IIa (thrombin) inhibitor dabigatran, and factor Xa inhibitors such as apixaban and rivaroxaban. In the remaining sections, the treatment of patients presenting to the hospital with major bleeding becomes the focus. The replacement of blood components including red blood cells, platelets, and clotting factors is the critically important initial treatment for these individuals. Reversing the anticoagulated state is also necessary. For patients treated with coumadin, infusion of vitamin K helps to initiate the process of protein synthesis for the vitamin K-dependent coagulation proteins II, VII, IX, and X and the antithrombotic protein C and protein S. Repletion of clotting factors for the patient with 4-factor prothrombin complex concentrate, which includes factors II (prothrombin), VII, IX, and X and therapeutically effective concentrations of the regulatory proteins (protein C and S), provides real-time ability to slow bleeding. For patients treated with the thrombin inhibitor dabigatran, treatment using the highly specific, antibody-derived idarucizumab has been demonstrated to reverse the hypocoagulable state of the patient to allow blood clotting. In May 2018, andexanet alfa was approved by the US Food and Drug Administration to reverse the factor Xa anticoagulants apixaban and rivaroxaban in patients with major bleeding. Before the availability of this highly specific agent, therapy for patients treated with factor Xa inhibitors presenting with severe bleeding usually included replacement of lost blood components including red blood cells, platelets, and clotting factors and 4-factor prothrombin complex concentrate, or if not available, fresh frozen plasma. The evaluation and treatment of the patient with severe bleeding as a complication of oral anticoagulant therapy are discussed from the viewpoint of the emergency physician, neurocritical and cardiovascular critical care intensivist, hematologist, trauma and acute care surgeon, hospitalist, cardiologist, electrophysiologist, and pharmacist in an approach we hope that the reader will find extremely practical and clinically useful. The clinician learner will also find the discussion of the resumption of oral anticoagulation for the patient with severe bleeding after effective treatment important because returning the patient to an anticoagulated state as soon as feasible and safe prevents thrombotic complications. Finally, an EMCREG-International Severe Bleeding Consensus Panel algorithm for the approach to management of patients with life-threatening oral anticoagulant-associated bleeding is provided for the clinician and can be expanded in size for use in a treatment area such as the emergency department or critical care unit.

Evaluating Effectiveness of Nasal Compression With Tranexamic Acid Compared With Simple Nasal Compression and Merocel Packing: A Randomized Controlled Trial

STUDY OBJECTIVE

The primary objective of this study is to compare the effectiveness of 3 treatment protocols to stop anterior epistaxis: classic compression, nasal packing, and local application of tranexamic acid. It also aims to determine the frequency of rebleeding after each of these protocols.

METHODS

This single-center, prospective, randomized controlled study was conducted with patients who had spontaneous anterior epistaxis. The study compared the effect of 3 treatment options, tranexamic acid with compression but without nasal packing, nasal packing (Merocel), and simple nasal external compression, on the primary outcome of stopping anterior epistaxis bleeding within 15 minutes.

RESULTS

Among the 135 patients enrolled, the median age was 60 years (interquartile range 25% to 75%: 48 to 72 years) and 70 patients (51.9%) were women. The success rate in the compression with tranexamic acid group was 91.1% (41 of 45 patients); in the nasal packing group, 93.3% (42 of 45 patients); and in the compression with saline solution group, 71.1% (32 of 45 patients). There was an overall statistically significant difference among the 3 treatment groups but no significant difference in pairwise comparison between the compression with tranexamic acid and nasal packing groups. In regard to no rebleeding within 24 hours, the study found rates of 86.7% in the tranexamic acid group, 74% in the nasal packing group, and 60% in the compression with saline solution group.

CONCLUSION

Applying external compression after administering tranexamic acid through the nostrils by atomizer stops bleeding as effectively as anterior nasal packing using Merocel. In addition, the tranexamic acid approach is superior to Merocel in terms of decreasing rebleeding rates.

Management of idiopathic epistaxis in adults: what's new?

Epistaxis is one of the most common complaints presenting to emergency departments. The aim of this study is to systematically review and critically evaluate the evidence relating to treatment of idiopathic epistaxis for guiding best practice. A comprehensive review of the English language literature was performed using PubMed, Embase, Cochrane Library and Central electronic databases. The inclusion criteria were: retrospective or prospective or randomised controlled clinical trials which included outcomes in the management of idiopathic epistaxis. Twenty-three articles met inclusion criteria and were reviewed. Nasal packing still represents the first-line approach to epistaxis, although, at present, it appears that there is clear evidence in the literature to suggest that it is less effective and associated with more admissions and longer hospital stays than endoscopic electrocoagulation-based management of epistaxis. In conclusion, cauterisation should be the first-line approach for its high cost-effectiveness rate and low risk of complications. Further research is urgently needed to assess the efficacy of new biomaterials.

Novel use of tranexamic acid to reduce the need for Nasal Packing in Epistaxis (NoPac) randomised controlled trial: research protocol

INTRODUCTION

Patients presenting to emergency departments (EDs) with epistaxis uncontrolled by subsequent simple first aid measures or application of topical vasoconstrictors will typically undergo anterior nasal packing. Packing is effective, but can be extremely painful and unpleasant and patients usually need hospital admission. Tranexamic acid (TXA) is a cheap, safe, readily available antifibrinolytic agent known to be beneficial in a variety of clinical settings where uncontrolled bleeding may be a problem. Anecdotal evidence suggests that topical TXA may be of value in persistent epistaxis; however, further evaluation is required.

METHODS AND ANALYSIS

This is a multicentre, double-blind, parallel group, randomised, controlled trial comparing the use of topical intranasal TXA with indistinguishable placebo in adults presenting to UK EDs with persistent atraumatic epistaxis. Follow-up is at 1 week by structured telephone review. The primary outcome measure is the subsequent need for anterior nasal packing in the ED. Key secondary outcomes include the need for hospital admission, blood transfusion and/or further treatment for epistaxis during the index ED attendance. Recruiting 450 patients will provide 90% power to demonstrate an absolute reduction in packing rate from 95% to 85%. An improvement of this magnitude would be of significant benefit to patients and healthcare providers and justify a change to standard practice. Given the low cost of TXA and its short administration time, a full economic evaluation is not being undertaken.

ETHICS AND DISSEMINATION

The study has been approved by the South West-Bristol Research Ethics Committee (reference 17/SW/0010). We aim to publish the findings in a high impact, international peer-reviewed journal. Results will also be shared with the Hereditary Haemorrhagic Telangiectasia foundation and telangiectasia UK for dissemination through appropriate related forums.

TRIAL REGISTRATION NUMBER

ISRCTN34153772 and EudraCT No: 2016-001530-10.

Tranexamic acid for patients with nasal haemorrhage (epistaxis)

BACKGROUND

Epistaxis (nosebleed) most commonly affects children and the elderly. The majority of episodes are managed at home with simple measures. In more severe cases medical intervention is required to either cauterise the bleeding vessel, or to pack the nose with various materials. Tranexamic acid is used in a number of clinical settings to stop bleeding by preventing clot breakdown (fibrinolysis). It may have a role in the management of epistaxis as an adjunct to standard treatments, reducing the need for further intervention.

OBJECTIVES

To determine the effects of tranexamic acid (oral, intravenous or topical) compared with placebo, no additional intervention or any other haemostatic agent in the management of patients with epistaxis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register (via CRS Web); Central Register of Controlled Trials (CENTRAL) (via CRS Web); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 29 October 2018.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of tranexamic acid (in addition to usual care) compared with usual care plus placebo, usual care alone or usual care plus any other haemostatic agent, to control epistaxis in adults or children.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were control of epistaxis: re-bleeding (as measured by the proportion of patients re-bleeding within a period of up to 10 days) and significant adverse effects (seizures, thromboembolic events). Secondary outcomes were control of epistaxis as measured by the time to stop initial bleeding (the proportion of patients whose bleeding is controlled within a period of up to 30 minutes); severity of re-bleeding (as measured by (a) the proportion of patients requiring any further intervention and (b) the proportion of patients requiring blood transfusion); length of hospital stay and other adverse effects. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included six RCTs (692 participants). The overall risk of bias in the studies was low. Two studies assessed oral administration of tranexamic acid, given regularly over several days, and compared it to placebo. In the other four studies, a single application of topical tranexamic acid was compared with placebo (one study) and a combination of epinephrine and lidocaine or phenylephrine (three studies). All participants were adults.Tranexamic acid versus placeboFor our primary outcome, control of epistaxis: re-bleeding (proportion re-bleeding within 10 days), we were able to pool data from three studies. The pooled result demonstrated a benefit of tranexamic acid compared to placebo, the risk of re-bleeding reducing from 67% to 47% (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.56 to 0.90; three studies; 225 participants; moderate-quality evidence).When we compared the effects of oral and topical tranexamic acid separately the risk of re-bleeding with oral tranexamic acid reduced from 69% to 49%, RR 0.73 (95% CI 0.55 to 0.96; two studies, 157 participants; moderate-quality evidence) and with topical tranexamic acid it reduced from 66% to 43%, RR 0.66 (95% CI 0.41 to 1.05; single study, 68 participants). We rated the quality of evidence provided by the single study as low, therefore it is uncertain whether topical tranexamic acid is effective in stopping bleeding in the 10-day period after a single application.No study specifically sought to identify and report our primary outcome: significant adverse effects (i.e. seizures, thromboembolic events).The secondary outcome time to stop initial bleeding (proportion with bleeding controlled within 30 minutes) was measured in one study using topical tranexamic acid and there was no evidence of a difference at 30 minutes (RR 0.79, 95% CI 0.56 to 1.11; 68 participants; low-quality evidence).No studies reported the proportion of patients requiring any further intervention (e.g. repacking, surgery, embolisation).One study of oral tranexamic acid reported the proportion of patients requiring blood transfusion and found no difference between groups: 5/45 (11%) versus 6/44 (14%) (RR 0.81, 95% CI 0.27 to 2.48; 89 participants; low-quality evidence).Two studies reported hospital length of stay. One study reported a significantly shorter stay in the oral tranexamic acid group (mean difference (MD) -1.60 days, 95% CI -2.49 to -0.71; 68 participants). The other study found no evidence of a difference between the groups.Tranexamic acid versus other haemostatic agentsWhen we pooled the data from three studies the proportion of patients whose bleeding stopped within 10 minutes was significantly higher in the topical tranexamic acid group compared to the group receiving another haemostatic agent (70% versus 30%: RR 2.35, 95% CI 1.90 to 2.92; 460 participants) (moderate-quality evidence).Adverse effects across all studiesFive studies recorded 'adverse effects' in a general way. None found any difference between the groups in the occurrence of minor adverse effects (e.g. mild nausea and diarrhoea, 'bad taste' of gel). In one study a patient developed a superficial thrombophlebitis of both legs following discharge, however it is not reported in which group this occurred. No "other serious adverse effect" was reported in any study.

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that there is probably a reduction in the risk of re-bleeding with the use of either oral or topical tranexamic acid in addition to usual care in adult patients with epistaxis, compared to placebo with usual care. However, the quality of evidence relating solely to topical tranexamic acid was low (one study only), so we are uncertain whether or not topical tranexamic acid is effective in stopping bleeding in the 10-day period after a single application. We found moderate-quality evidence that topical tranexamic acid is probably better than other topical agents in stopping bleeding in the first 10 minutes.There have been only three RCTs on this subject since 1995. Since then there have been significant changes in nasal cauterisation and packing techniques (for example, techniques including nasal endoscopy and more invasive approaches such as endoscopic sphenopalatine artery ligation). New trials would inform us about the effectiveness of tranexamic acid in light of these developments.

Topical Tranexamic Acid for the Treatment of Acute Epistaxis: A Systematic Review and Meta-analysis

Objective: To compare topical tranexamic acid (TXA) with control groups for the treatment of acute epistaxis assessing bleeding cessation, discharge within 2 hours, rebleeding rates, complication rates, and patient satisfaction. Data Sources: PubMed, CINAHL, LILACS, Scopus, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched from inception to November 2018. Study Selection and Data Extraction: All randomized controlled trials comparing topical TXA with control groups for the treatment of acute epistaxis in humans were included. There were no age, language, or date restrictions. Data were double extracted into a predefined worksheet, and quality analysis was performed using the Cochrane Risk of Bias tool. Data Synthesis: Three studies (n = 408 patients) were identified. Topical TXA was not associated with a statistically significant difference in cessation of bleeding within 30 minutes. However, more patients were discharged within 2 hours of arrival, there were fewer episodes of rebleeding within both the first 24 hours and at 1 week, and there was higher patient satisfaction in the TXA group. There was no difference identified in complication rates. Relevance to Patient Care and Clinical Practice: This review compares topical TXA with control groups for epistaxis and discusses the risks and benefits of adding this therapy to usual care. Conclusions: Topical TXA appears to be a reasonable option for the treatment of acute epistaxis, with reduced rebleeding rates, shorter discharge times, and minimal risk of complications. Topical TXA may be considered as part of the treatment of acute epistaxis.