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Moscovici A, Nasasra A, Hammerschlag J, Zaharov R, Kirshtein A, Dykman D, Lavy R, Zmora O. The effect of tranexamic acid on blood transfusion in lower gastrointestinal bleeding-A double blind prospective randomised controlled trial. World J Surg 2024; 48:2016-2021. [PMID: 38970213 DOI: 10.1002/wjs.12282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 06/24/2024] [Indexed: 07/08/2024]
Abstract
PURPOSE Acute gastrointestinal bleeding is a common emergency. Tranexamic acid (TXA) reduces clot breakdown by inhibiting the action of plasmin and has been shown to reduce the need for blood transfusion in trauma, surgical procedures, and upper gastrointestinal bleeding. This study examined the efficiency of intravenous TXA in patients with acute lower gastrointestinal bleeding. METHODS Eighty-one patients aged >18 years with lower GI hemorrhage, presenting as active rectal bleeding and anemia (hemoglobin lower than 11 g/dL or a decrease of 2 gr/dl from the patient's base level), were enrolled in this single center, double blind prospective research. Patients were randomly assigned to receive intravenous TXA or placebo from admission until colonoscopy took place. The need for transfusion of packed red blood cells (PRBC) and number of units was recorded and compared between the two groups. RESULTS Eighty-one patients were randomized in this study, thirty-nine in the TXA arm, and forty-two in the placebo arm. Patient characteristics did not differ between the groups. Forty-three out of the 81 patients received blood transfusion; twenty-two were on the placebo arm and twenty-one on the TXA arm (p = 0.89). Twenty-nine patients required 2 or more units, 14 in the TXA arm and 15 in the placebo arm (p = 0.98). CONCLUSIONS Intravenous TXA has no significant effect on blood requirement in patients with lower GI bleeding. There was no difference in the consumption of PRBC units among the patients in the placebo and TXA groups. It seems that tranexamic acid has no significant effect on transfusion of PRBC units in lower GI bleeding.
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Affiliation(s)
- Avihai Moscovici
- Department of Surgery, Shamir Medical Center, Beer Yaacov, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ahmad Nasasra
- Department of Surgery, Shamir Medical Center, Beer Yaacov, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Hammerschlag
- Department of Surgery, Shamir Medical Center, Beer Yaacov, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rafael Zaharov
- Department of Surgery, Shamir Medical Center, Beer Yaacov, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anna Kirshtein
- Department of Surgery, Shamir Medical Center, Beer Yaacov, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Dykman
- Department of Surgery, Shamir Medical Center, Beer Yaacov, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Lavy
- Department of Surgery, Shamir Medical Center, Beer Yaacov, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Zmora
- Department of Surgery, Shamir Medical Center, Beer Yaacov, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Kumar M, Venishetty S, Jindal A, Bihari C, Maiwall R, Vijayaraghavan R, Saggere Muralikrishna S, Arora V, Kumar G, Sarin SK. Tranexamic acid in upper gastrointestinal bleed in patients with cirrhosis: A randomized controlled trial. Hepatology 2024; 80:376-388. [PMID: 38441903 DOI: 10.1097/hep.0000000000000817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 01/22/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND AND AIMS Patients with Child-Turcotte-Pugh class B and C cirrhosis with upper gastrointestinal bleeding (UGIB) have systemic as well as localized (in the mucosa of the esophagus and stomach) fibrinolysis. The aim of this study was to evaluate the efficacy and safety of tranexamic acid in the treatment of acute UGIB in patients with cirrhosis. APPROACH AND RESULTS A total of 600 patients with advanced liver cirrhosis (Child-Turcotte-Pugh class B or C) presenting with UGIB were randomly allocated to either the tranexamic acid (n=300) or the placebo group (n=300). The primary outcome measure was the proportion of patients developing 5-day treatment failure. Failure to control bleeding by day 5 was seen in 19/300 (6.3%) patients in the tranexamic acid group and 40/300 (13.3%) patients in the placebo group ( p =0.006). Esophageal endoscopic variceal ligation (EVL) site as a source of failure to control bleeding by day 5 among patients undergoing first-time esophageal EVL (excluding patients with a previous post-EVL ulcer as a source of bleed) was seen in 11/222 (4.9%) patients in the tranexamic acid group and 27/225 (1212.0%) patients in the placebo group ( p =0.005). However, 5-day and 6-week mortality was similar in the tranexamic acid and placebo groups. CONCLUSIONS Tranexamic acid significantly reduces the failure to control bleeding by day 5 and failure to prevent rebleeding after day 5 to 6 weeks in patients with advanced liver cirrhosis (Child-Turcotte-Pugh class B or C) presenting with UGIB, by preventing bleeding from the EVL site.
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Affiliation(s)
- Manoj Kumar
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Shantan Venishetty
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Ankur Jindal
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Pathology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Rajan Vijayaraghavan
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | | | - Vinod Arora
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Biostatistics, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, India
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Franchini M, Focosi D, Mannucci PM. Tranexamic Acid: An Evergreen Hemostatic Agent. Semin Thromb Hemost 2024; 50:733-738. [PMID: 38335995 DOI: 10.1055/s-0044-1779632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
Tranexamic acid (TXA) is an important antifibrinolytic agent, which inhibits plasminogen activation and fibrinolysis. Several controlled randomized trials have investigated the role of TXA in preventing or decreasing blood loss across different surgical interventions or medical conditions characterized by excessive bleeding, consistently documenting its effectiveness and safety. Although the first clinical use of TXA dates back to more than 60 years ago, TXA remains the focus of intense research. This narrative review summarizes the more recent results and indications on the clinical use of TXA.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantua, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Oliveira LC, Montano-Pedroso JC, Perini FV, Dos Reis Rodrigues R, Donizetti E, Rizzo SRCP, Rabello G, Junior DML. Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Management of critical bleeding. Hematol Transfus Cell Ther 2024; 46 Suppl 1:S60-S66. [PMID: 38553342 PMCID: PMC11069065 DOI: 10.1016/j.htct.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 05/07/2024] Open
Abstract
The management of major bleeding is a critical aspect of modern healthcare and it is imperative to emphasize the importance of applying Patient Blood Management (PBM) principles. Although transfusion support remains a vital component of bleeding control, treating severe bleeding goes beyond simply replacing lost blood. A more comprehensive, multidisciplinary approach is essential to optimize patient outcomes and minimize the risks associated with excessive transfusions.
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Affiliation(s)
- Luciana Correa Oliveira
- Hemocentro de Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil
| | - Juan Carlos Montano-Pedroso
- Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil; Instituto de Assistência Médica do Servidor Público Estadual (Iamspe), São Paulo, SP, Brazil
| | - Fernanda Vieira Perini
- Grupo GSH - Gestor de Serviços de Hemoterapia, São Paulo, SP, Brazil; Associação Beneficente Síria HCOR, São Paulo, SP, Brazil
| | - Roseny Dos Reis Rodrigues
- Hospital Israelita Albert Einstein são Paulo, São Paulo, SP, Brazil; Faculdade de Medicina da Universidade de São Paulo (FM USP), São Paulo, SP, Brazil
| | | | | | - Guilherme Rabello
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Incor - HCFMUSP), São Paulo, SP, Brazil.
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Fowler C, Nasser J, Fera B, Chism L, Pastores SM. Tranexamic Acid in Upper Gastrointestinal Bleeding is Associated With Venous and Arterial Thromboembolic Events. Crit Care Explor 2024; 6:e1060. [PMID: 38481541 PMCID: PMC10936963 DOI: 10.1097/cce.0000000000001060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVES To determine the risk difference of arterial and venous thromboembolic events between patients with upper gastrointestinal bleeding (UGIB) who received and did not receive tranexamic acid. DESIGN Retrospective cohort study. SETTING The TriNetX Analytics (Cambridge, MA) Research Network, a deidentified mixed electronic health record and claims-derived database with over 110 million patients, primarily located in the United States. PATIENTS A total of 2,016,763 patients diagnosed with hematemesis or melena between October 31, 2003, and October 31, 2023. INTERVENTIONS Receipt of tranexamic acid within 7 days of a UGIB diagnosis. MEASUREMENTS AND MAIN RESULTS We measured the incidence of thromboembolic events, both venous (deep venous thrombosis [DVT] and pulmonary embolism [PE]) and arterial (cerebrovascular accident [CVA] and myocardial infarction [MI]), within either 7 days of tranexamic acid (for recipients) or 7 days of UGIB diagnosis (for nonrecipients). Subsequently, we developed similar subcohorts using propensity score matching (PSM) for demographic and comorbidity data and reexamined the incidence of thromboembolic events, both before and after excluding any patients with any prior episodes of the outcomes. In all analyses, tranexamic acid recipients experienced significantly more adverse thromboembolic outcomes, with the post-PSM cohorts' risk difference generating an odds ratio of 1.4 for MI (95% CI, 1.2-1.7), 1.6 in CVA (95% CI, 1.3-1.9), 1.8 in PE (95% CI, 1.5-2.3), and 2.1 in DVT (95% CI, 1.8-2.5); all p values of less than 0.001. CONCLUSIONS Leveraging data from a large, multi-institutional database, we identified a correlation between tranexamic acid use in patients with UGIB and the occurrence of both venous and arterial thromboembolic events. Although the former is well-attested in the literature, the latter finding is more novel, underscoring the need for further prospective research to better characterize the risk-benefit profile of tranexamic acid in the management of gastrointestinal bleeding.
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Affiliation(s)
- Cosmo Fowler
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jason Nasser
- Department of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Brittany Fera
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lauren Chism
- Department of Medicine, Case Western Reserve University-MetroHealth, Cleveland, OH
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
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Chiang HC, Chen PJ, Yang EH, Hsieh MT, Shih IC, Cheng HC, Chang WL, Chen WY, Chiu HC, Kuo HY, Tsai WC, Lo YN, Yang KC, Chiang CM, Chen WC, Huang KK, Tseng HH, Chen CY, Lin XZ, Chuang CH. Precise application of topical tranexamic acid to enhance endoscopic hemostasis for peptic ulcer bleeding: a randomized controlled study (with video). Gastrointest Endosc 2023; 98:755-764. [PMID: 37356632 DOI: 10.1016/j.gie.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/04/2023] [Accepted: 06/14/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND AND AIMS Peptic ulcer recurrent bleeding occurs in 20% to 30% of patients after standard endoscopic hemostasis, particularly within 4 days after the procedure. The application of additional tranexamic acid (TXA) to the ulcer may enhance hemostasis. This study investigated the effectiveness of TXA powder application on bleeding ulcers during endoscopic hemostasis. METHODS This study enrolled patients who had peptic ulcer bleeding between March 2022 and February 2023. After undergoing standard endoscopic therapy, the patients were randomly assigned to either the TXA group or the standard group. In the TXA group, an additional 1.25 g of TXA powder was sprayed endoscopically on the ulcer. Both groups then received 3 days of high-dose (8 mg/h) continuous infusion proton pump inhibitor therapy. Second-look endoscopy was conducted on days 3 to 4. The primary end point of early treatment failure was defined as ulcer recurrent bleeding within 4 days or major stigmata of recent hemorrhage on the second-look endoscopy. RESULTS Sixty patients (30 in each group) with peptic ulcer bleeding and balanced baseline characteristics were randomly assigned to a treatment group. The early treatment failure rate was lower in the TXA group (6.7%) than in the standard group (30%) (P = .042). The freedom from treatment failure periods for 4 and 28 days was significantly longer in the TXA group than in the standard group (P = .023). No adverse events from TXA were recorded. CONCLUSIONS The precise delivery of topical TXA alongside standard endoscopic hemostasis reduced the early treatment failure rate in patients with bleeding peptic ulcers. (Clinical trial registration number: NCT05248321.).
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Affiliation(s)
- Hsueh-Chien Chiang
- Department of Internal Medicine, National Cheng Kung University Hospital; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Jun Chen
- Department of Internal Medicine, National Cheng Kung University Hospital
| | - Er-Hsiang Yang
- Department of Internal Medicine, National Cheng Kung University Hospital
| | - Ming-Tsung Hsieh
- Department of Internal Medicine, National Cheng Kung University Hospital
| | - I-Cheng Shih
- Department of Internal Medicine, National Cheng Kung University Hospital; Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Hsiu-Chi Cheng
- Department of Internal Medicine, National Cheng Kung University Hospital; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Wei-Lun Chang
- Department of Internal Medicine, National Cheng Kung University Hospital; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ying Chen
- Department of Internal Medicine, National Cheng Kung University Hospital; Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hung-Chih Chiu
- Department of Internal Medicine, National Cheng Kung University Hospital
| | - Hsin-Yu Kuo
- Department of Internal Medicine, National Cheng Kung University Hospital; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Chu Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital
| | - Yi-Ning Lo
- Department of Internal Medicine, National Cheng Kung University Hospital
| | - Kai-Chun Yang
- Department of Internal Medicine, National Cheng Kung University Hospital
| | - Chien-Ming Chiang
- Department of Internal Medicine, National Cheng Kung University Hospital
| | - Wei-Chih Chen
- Department of Internal Medicine, National Cheng Kung University Hospital
| | - Kuan-Kai Huang
- Department of Internal Medicine, National Cheng Kung University Hospital
| | - Hsu-Huan Tseng
- Department of Internal Medicine, National Cheng Kung University Hospital
| | - Chiung-Yu Chen
- Department of Internal Medicine, National Cheng Kung University Hospital
| | - Xi-Zhang Lin
- Department of Internal Medicine, National Cheng Kung University Hospital
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Tafoya LA, McGee JC, Kaisler S, Gottula AL, Lauria MJ, Braude DA. Management of Acute Upper Gastrointestinal Bleeding in Critical Care Transport. Air Med J 2023; 42:110-118. [PMID: 36958874 DOI: 10.1016/j.amj.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/31/2023]
Abstract
Upper gastrointestinal bleeding is a relatively common and life-threatening condition encountered by critical care transport crews. It is of paramount importance that transport crews understand the underlying pathophysiology of variceal and nonvariceal gastrointestinal bleeding as well as the nuanced management of this patient population. This article reviews the current clinical evidence on initial resuscitation, medical management, and advanced invasive therapies (such as balloon tamponade devices) that transport crews should be familiar with to manage these patients. In addition, we present a novel method of continuous balloon pressure monitoring of balloon tamponade devices that is applicable to the transport environment.
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Affiliation(s)
- Louis A Tafoya
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM
| | - John C McGee
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Sean Kaisler
- University of New Mexico School of Medicine, Albuquerque, NM; 306th Rescue Squadron, Davis-Monthan Air Force Base, Tucson, AZ
| | - Adam L Gottula
- Department of Emergency Medicine and Anesthesiology, The Harry Max Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
| | - Michael J Lauria
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM.
| | - Darren A Braude
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
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Tranexamic acid is not associated with decreased infection risk after primary shoulder arthroplasty: a cohort study of 9276 patients. J Shoulder Elbow Surg 2023; 32:581-588. [PMID: 36208673 DOI: 10.1016/j.jse.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/30/2022] [Accepted: 09/05/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of tranexamic acid (TXA) is associated with less blood loss and reduced transfusion risk after shoulder arthroplasty surgery. Recent studies have shown lower odds of postoperative infection after hip or knee arthroplasty with its use. The purpose of this study was to determine whether TXA use reduces the risk of infection after primary elective shoulder arthroplasty. METHODS A retrospective cohort study was conducted using data from a US integrated health care system's shoulder arthroplasty registry. Patients aged 18 years who underwent primary elective anatomic total shoulder arthroplasty for osteoarthritis or primary reverse shoulder arthroplasty for rotator cuff arthropathy were included (2013-2020). We compared patients who received preoperative intravenous TXA to those who did not receive TXA by assessing the risk for revision due to deep infection within 5 years' follow-up using multivariable Cox proportional hazard regression. Interaction between TXA and diabetes status was analyzed separately. RESULTS The study sample included 9276 shoulder arthroplasties performed by 153 surgeons at 43 hospitals. The mean age was 70.0 years and 48% were male. The 5-year probability of revision for deep infection was 0.8% and 0.7% for patients with and without TXA, respectively. We failed to observe a difference in infection risk after adjustment for confounders and surgeon differences (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.56-1.80, P = .998). Further, no differences were observed in patients with (HR 1.64, 95% CI 0.42-6.44, P = .481) or without diabetes (HR 0.79, 95% CI 0.40-1.55, P = .488). CONCLUSION In a multicenter cohort of more than 9000 primary shoulder arthroplasty procedures, the use of preoperative TXA was not associated with a decrease in the 5-year probability of revision for deep infection.
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Aydin H, Berikol GB, Erdogan MO, Gemici E, Doğan H. CHAMPS score in predicting mortality of patients with acute nonvariceal upper gastrointestinal bleeding. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20221052. [PMID: 37075441 PMCID: PMC10176634 DOI: 10.1590/1806-9282.20221052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the performance of the Charlson Comorbidity Index ≥2, in-hospital onset, albumin <2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥2, steroid use score in predicting mortality in patients with nonvariceal upper gastrointestinal bleeding and compare it with the Glasgow-Blatchford score; the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score; the age, blood tests, and comorbidities score; and Complete Rockall score. METHODS The data of patients with acute upper gastrointestinal bleeding who visited the emergency department during the study period were obtained from the hospital automation system by using the classification of disease codes and analyzed in this retrospective study. Adult patients with endoscopically confirmed nonvariceal upper gastrointestinal bleeding were included in the study. Patients with bleeding from the tumor, bleeding after endoscopic resection, or missing data were excluded. The prediction accuracy of the Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroid use score was calculated using the area under the receiver operating characteristic curve and compared with that of Glasgow-Blatchford score, the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score, the age, blood tests, and comorbidities score, and Complete Rockall score. RESULTS A total of 805 patients were included in the study, and the in-hospital mortality rate was 6.6%. The performance of the Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroid use score (area under the receiver operating characteristic curve 0.812, 95%CI 0.783-0.839) was better than Glasgow-Blatchford score (area under the receiver operating characteristic curve 0.683, 95%CI 0.650-0.713, p=0.008), and similar to the the age, blood tests, and comorbidities score (area under the receiver operating characteristic curve 0.829, 95%CI 0.801-0.854, p=0.563), the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score (area under the receiver operating characteristic curve 0.794, 95%CI 0.764-0.821, p=0.672), and Complete Rockall score (area under the receiver operating characteristic curve 0.761, 95%CI 0.730-0.790, p=0.106). CONCLUSION The performance of the Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroid use score in predicting in-hospital mortality for our study population is better than Glasgow-Blatchford score and similar to the the age, blood tests, and comorbidities score, the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score, and Complete Rockall score.
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Affiliation(s)
- Hakan Aydin
- University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Research Hospital, Department of Emergency Medicine - Istanbul, Turkey
| | - Göksu Bozdereli Berikol
- University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Research Hospital, Department of Emergency Medicine - Istanbul, Turkey
| | - Mehmet Ozgur Erdogan
- University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Research Hospital, Department of Emergency Medicine - Istanbul, Turkey
| | - Eyüp Gemici
- University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery - Istanbul, Turkey
| | - Halil Doğan
- University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Research Hospital, Department of Emergency Medicine - Istanbul, Turkey
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Dhingra P, Yeung M, Lang E. Tranexamic acid in emergency medicine. An overview of reviews. Intern Emerg Med 2023; 18:211-218. [PMID: 36562900 DOI: 10.1007/s11739-022-03155-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/08/2022] [Indexed: 12/24/2022]
Abstract
Tranexamic acid (TXA) is a common haemorrhage control agent in both emergency department (ED) settings and intra-operatively. While efficacy and potential harms are well-studied, there are no overviews of reviews completed on TXA efficacy in the ED setting. We set out to provide an overview of systematic reviews on TXA efficacy in trauma, gastrointestinal bleeding, and subarachnoid haemorrhage in the ED setting, with outcomes including short and long-term mortality, thromboembolic (TE) events, and whether bleeding continued. Our review is guided by the PRIOR statement. We searched Pubmed, Medline, and EMBASE using broad search terms for systematic reviews, and calculated pooled relative-risk ratios using random and fixed-effects modelling from these studies. A risk-of-bias assessment was also completed for each review. We identified 13 systematic reviews for inclusion, with a variety of different outcomes. We identified improvements in 24-h mortality for trauma (RR 0.88, 95% CI 0.84-0.92) and gastrointestinal bleeds (RR 0.30, 95% CI 0.23-0.39), and decreased long-term gastrointestinal bleed mortality (RR 0.57, 95% CI 0.48-0.69). We also identified an increase in TE risk in gastrointestinal bleeding scenarios (RR 1.45, 95% CI 1.09-1.94), but no other clinical scenarios. TXA is effective in reducing mortality following trauma and gastrointestinal bleeds, however, there is limited evidence at this time to support TXA administration in the context of subarachnoid haemorrhage. TE risk is elevated when used in gastrointestinal bleeds. Selective use in high-risk patients may be warranted. TXA should strongly be considered in management in ED and prehospital settings.
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Affiliation(s)
- Poshika Dhingra
- Department of Emergency Medicine, University of Calgary, 5A105, 7007 14th St. SW, Calgary, AB, T2V 1P9, Canada
| | - Matthew Yeung
- Department of Emergency Medicine, University of Calgary, 5A105, 7007 14th St. SW, Calgary, AB, T2V 1P9, Canada.
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, 5A105, 7007 14th St. SW, Calgary, AB, T2V 1P9, Canada
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Lu C, Zhang Y. Gastrointestinal bleeding during the transcatheter aortic valve replacement perioperative period: A Review. Medicine (Baltimore) 2022; 101:e31953. [PMID: 36482568 PMCID: PMC9726417 DOI: 10.1097/md.0000000000031953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
With the aging of the population, the incidence of senile degenerative valvular heart disease is expected to increase. Transcatheter aortic valve replacement (TAVR) has been used for patients at lower surgical risk with symptomatic severe aortic valve stenosis. Because of the improvements in TAVR technology and increasing experience of the operators, TAVR is regarded as a safe and feasible procedure. Bleeding events during the TAVR perioperative period, especially gastrointestinal (GI) bleeding, have been proven to be related to the long-term prognosis and mortality. Elderly patients with valvular heart disease are susceptible to GI bleeding because of their use of antithrombotic drugs, physical damage of coagulation factors, and GI angiodysplasia. Frequent GI bleeding and low levels of preoperative hemoglobin increase the risk of TAVR, especially for elderly patients. Because of these risks, which are easily overlooked, we should focus more attention on the perioperative management of TAVR. Reasonable screening tools, including blood examinations, risk evaluation scales, and endoscopy, are beneficial to the prevention of complications that can occur during the perioperative period. Additionally, medical therapy can safely help patients at high-risk for bleeding patients throughout the perioperative period. This study aimed to characterize the pathology of TAVR patients and discuss treatment strategies for GI bleeding during the perioperative period.
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Affiliation(s)
- Chuan Lu
- From the Second Hospital of Dalian Medicial University, Shahekou District, Dalian City, China
| | - Yue Zhang
- From the Second Hospital of Dalian Medicial University, Shahekou District, Dalian City, China
- * Correspondence: Yue Zhang, From the Second Hospital of Dalian Medicial University, 467 Zhongshan Road, Shahekou District, Dalian city, China (e-mail: )
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Gyi R, Cho BC, Hensley NB. Patient Blood Management in Vascular Surgery. Anesthesiol Clin 2022; 40:605-625. [PMID: 36328618 DOI: 10.1016/j.anclin.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Patient blood management (PBM) is an evidence-based, multidisciplinary approach aimed at appropriately allocating blood products to patients requiring transfusion while simultaneously minimizing inappropriate transfusions. The 3 pillars of patient blood management are optimizing erythropoiesis, minimizing blood loss, and optimizing physiological reserve of anemia. Benefits seen from PBM include limiting hospital costs and mitigating harm from numerous risks of transfusion.
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Affiliation(s)
- Richard Gyi
- Department of Anesthesiology, Johns Hopkins Hospital, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA
| | - Brian C Cho
- Department of Anesthesiology, Johns Hopkins Hospital, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA; Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA
| | - Nadia B Hensley
- Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA.
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13
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Xu S, Yang L, Wu X, Yang Y, Zhou Y, Ye C. Rapid in situ hepatic hemostasis using a P34HB/tranexamic acid fibrous membrane delivered by a handheld electrospinning apparatus. JOURNAL OF POLYMER RESEARCH 2022. [DOI: 10.1007/s10965-022-03174-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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14
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Investigating the Effect of Tranexamic Acid on the Treatment of Subdural Hematoma: A Systematic Review Study. ARCHIVES OF NEUROSCIENCE 2022. [DOI: 10.5812/ans-127011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Context: Tranexamic acid (TXA) belongs to the family of lysine-derived antifibrinolytics. TXA requires a simple molecular breakdown in the liver to be metabolized and has a high renal excretion. Objectives: This study aimed to determine the effect of TXA on subdural hematoma (SDH) treatment using the SR method. Methods: Following a systematic review design, this study aimed to evaluate the effect of TXA on SDH treatment using studies published from 2000 to 2020. The search was performed by two researchers who were dominant in various types of SR studies and specialized discussion of neurosurgery. A checklist that contained the following items was used to collect the data: surname, year of study, year of publication, population, sample size, age, intervention, and outcomes. Data were also classified and reported using Word software. Results: Initially, 178 articles were identified, out of which 118 were removed due to the relevance of the title and method, 44 due to duplication, six due to following the SR method, and three due to having a case report design. Seven studies were found as eligible, as follows: the study by Wakabayashi et al. with a sample of 199 patients, Kageyama et al.’s study with 21 patients, Wan et al.’s study with 90 patients, Kutty et al.’ study with 27 patients, Tanweer et al.’s study with 14 patients, Yamada et al.’s study with 193 patients, and Lodewijkx et al.’s study with 7 patients. All articles showed that TXA could reduce SH. Conclusions: Regarding the positive effect of TXA on reducing SDH, administration of this medicine is recommended in the treatment of patients with CSDH.
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Tran QK, Tang K, Pourmand A. Tranexamic acid and Gastrointestinal bleed: Effect of the HALT-IT trial on current meta-analysis. Am J Emerg Med 2022; 59:165-167. [PMID: 35778062 DOI: 10.1016/j.ajem.2022.06.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 12/19/2022] Open
Affiliation(s)
- Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States of America; The Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Kaitlyn Tang
- The Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America.
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16
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Tranexamic acid – A narrative review for the emergency medicine clinician. Am J Emerg Med 2022; 56:33-44. [DOI: 10.1016/j.ajem.2022.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/07/2022] [Accepted: 03/14/2022] [Indexed: 02/06/2023] Open
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Ting KH, Shiu BH, Yang SF, Liao PL, Huang JY, Chen YY, Yeh CB. Risk of Mortality among Patients with Gastrointestinal Bleeding with Early and Late Treatment with Tranexamic Acid: A Population-Based Cohort Study. J Clin Med 2022; 11:jcm11061741. [PMID: 35330064 PMCID: PMC8951209 DOI: 10.3390/jcm11061741] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 02/06/2023] Open
Abstract
Tranexamic acid (TXA) is an antifibrinolytic pharmacological agent, but its use in gastrointestinal bleeding remains contentious. Moreover, studies on the timing of TXA administration are limited. We examined whether early TXA administration reduced the risk of mortality in patients with gastrointestinal bleeding in a Taiwanese population. We used the National Health Insurance Research Database to identify patients diagnosed with gastrointestinal bleeding with early and late TXA treatment. We defined early treatment as initial TXA treatment in an emergency department and late treatment as initial TXA treatment after hospitalization. Mortality within 52 weeks was the primary outcome. A multivariable analysis using a multiple Cox regression model was applied for data analysis. Propensity score matching (PSM) was performed to reduce the potential for bias caused by measured confounding variables. Of the 52,949 selected patients with gastrointestinal bleeding, 5127 were assigned to either an early or late TXA treatment group after PSM. The incidence of mortality was significantly decreased during the first and fourth weeks (adjusted HR (aHR): 0.65, 95% CI: 0.56−0.75). A Kaplan−Meier curve revealed a significant decrease in cumulative incidence of mortality in the early TXA treatment group (log-rank test: p < 0.0001). Multiple Cox regression analysis revealed significantly lower mortality in the early TXA treatment group compared with the late treatment group (aHR: 0.64, 95% CI: 0.57−0.73). Thromboembolic events were not significantly associated with early or late TXA treatment (aHR: 1.03, 95% CI: 0.94−1.12). A Kaplan−Meier curve also revealed no significant difference in either venous or arterial events (log-rank test: p = 0.3654 and 0.0975, respectively). In conclusion, early TXA treatment was associated with a reduced risk of mortality in patients with gastrointestinal bleeding compared with late treatment, without an increase in thromboembolic events. The risk of rebleeding and need for urgent endoscopic intervention require further randomized clinical trials.
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Affiliation(s)
- Ke-Hsin Ting
- Division of Cardiology, Department of Internal Medicine, Changhua Christian Hospital, Yunlin Branch, Yunlin 648, Taiwan;
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
| | - Bei-Hao Shiu
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Pei-Lun Liao
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Jing-Yang Huang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Yin-Yang Chen
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Correspondence: (Y.-Y.C.); (C.-B.Y.)
| | - Chao-Bin Yeh
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Correspondence: (Y.-Y.C.); (C.-B.Y.)
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