1
|
Mergoum AM, Mergoum AS, Larson NJ, Dries DJ, Cook A, Blondeau B, Rogers FB. Tranexamic Acid Use in the Surgical Arena: A Narrative Review. J Surg Res 2024; 302:208-221. [PMID: 39106732 DOI: 10.1016/j.jss.2024.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/02/2024] [Accepted: 07/07/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION Tranexamic acid (TXA) is a potent antifibrinolytic drug that inhibits the activation of plasmin by plasminogen. While not a new medication, TXA has quickly gained traction across a variety of surgical subspecialties to prevent and treat bleeding. Knowledge on the use of this drug is essential for the modern surgeon to continue to provide excellent care to their patients. METHODS A comprehensive review of the PubMed database was conducted of articles published within the last 10 y (2014-2024) relating to TXA and its use in various surgical subspecialties. Seminal studies regarding the use of TXA older than 10 y were included from the author's archives. RESULTS Indications for TXA are not limited to trauma alone, and TXA is utilized across a variety of surgical subspecialties from neurosurgery to hepatic surgery to control hemorrhage. Overall, TXA is well tolerated with common dose-dependent adverse effects, including headache, nasal symptoms, dizziness, nausea, diarrhea, and fatigue. More severe adverse events are rare and easily mitigated by not exceeding a dose of 50 mg/kg. CONCLUSIONS The administration of TXA as an adjunct to treat trauma saves lives. The ability of TXA to induce seizures is dose dependent with identifiable risk factors, making this serious adverse effect predictable. As for the potential for TXA to cause thrombotic events, uncertainty remains. If this association is proven to be real, the risk will likely be small, since the use of TXA is still advantageous in most situations because of its efficacy for a more common concern, bleeding.
Collapse
Affiliation(s)
| | - Adel S Mergoum
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | - Alan Cook
- Department of Surgery, University of Texas at Tyler School of Medicine, Tyler, Texas
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | | |
Collapse
|
2
|
Gendler S, Gelikas S, Talmy T, Lipsky AM, Avital G, Nadler R, Radomislensky I, Ahimor A, Glassberg E, Mozer Glassberg Y, Almog O, Yazer MH, Benov A. Prehospital Tranexamic Acid Administration in Pediatric Trauma Patients: A Propensity-Matched Analysis of the Israeli Defense Forces Registry. Pediatr Crit Care Med 2023; 24:e236-e243. [PMID: 36752620 DOI: 10.1097/pcc.0000000000003202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVES Tranexamic acid (TXA) administration confers a survival benefit in bleeding trauma patients; however, data regarding its use in pediatric patients are limited. This study evaluates the prehospital treatment with TXA in pediatric trauma patients treated by the Israel Defense Forces Medical Corps (IDF-MC). DESIGN Retrospective, cohort study using the Israel Defense Forces registry, 2011-2021. PATIENTS Pediatric trauma patients less than 18 years old. We excluded patients pronounced dead at the scene. INTERVENTIONS None. SETTING All cases of pediatric trauma in the registry were assessed for treatment with TXA. Propensity score matching was used to assess the association between prehospital TXA administration and mortality. MEASUREMENTS AND MAIN RESULTS Overall, 911 pediatric trauma patients were treated with TXA by the IDF-MC teams; the median (interquartile) age was 10 years (5-15 yr), and 72.8% were male. Seventy patients (7.6%) received TXA, with 52 of 70 (74%) receiving a 1,000 mg dose (range 200-1,000 mg). There were no prehospital adverse events associated with the use of TXA (upper limit of 95% CI for 0/70 is 4.3%). Compared with pediatric patients who did not receive TXA, patients receiving TXA were more likely to suffer from shock (40% vs 10.7%; p < 0.001), sustain more penetrating injuries (72.9% vs 31.7%; p < 0.001), be treated with plasma or crystalloids (62.9% vs 11.4%; p < 0.001), and undergo more lifesaving interventions (24.3% vs 6.2%; p < 0.001). The propensity score matching failed to identify an association between TXA and lesser odds of mortality, although a lack of effect (or even adverse effect) could not be excluded (non-TXA: 7.1% vs TXA: 4.3%, odds ratio = 0.584; 95% CI 0.084-3.143; p = 0.718). CONCLUSIONS Although prehospital TXA administration in the pediatric population is feasible with adverse event rate under 5%, more research is needed to determine the appropriate approach to pediatric hemostatic resuscitation and the role of TXA in this population.
Collapse
Affiliation(s)
- Sami Gendler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Shaul Gelikas
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Tomer Talmy
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Ari M Lipsky
- Department of Emergency Medicine, HaEmek Medical Center, Afula, Israel
| | - Guy Avital
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Roy Nadler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Irina Radomislensky
- The National Center for Trauma & Emergency Medicine Research, Gertner Institute, Ramat Gan, Israel
| | - Alon Ahimor
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Elon Glassberg
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- The Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Yael Mozer Glassberg
- Institute of Pediatric Gastroenterology, Nutrition and Liver Diseases, Schneider Children Medical Center of Israel, Petah Tikva, Israel
| | - Ofer Almog
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
- The Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
- Department of Pathology, Tel Aviv University, Tel Aviv, Israel
| | - Avi Benov
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| |
Collapse
|
3
|
Prehospital Tranexamic Acid in Major Pediatric Trauma Within a Physician-Led Emergency Medical Services System: A Multicenter Retrospective Study. Pediatr Crit Care Med 2022; 23:e507-e516. [PMID: 35876375 DOI: 10.1097/pcc.0000000000003038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Describe prehospital tranexamic acid (TXA) use and appropriateness within a major trauma pediatric population, and identify the factors associated with its use. DESIGN Multicenter, retrospective study, 2014-2020. SETTING Data were extracted from a multicenter French trauma registry including nine trauma centers within a physician-led prehospital emergency medical services (EMS) system. PATIENTS Patients less than 18 years old were included. Those who did not receive prehospital intervention by a mobile medical team and those with missing data on TXA administration were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Nine-hundred thirty-four patients (median [interquartile range] age: 14 yr [9-16 yr]) were included, and 68.6% n = 639) were male. Most patients were involved in a road collision (70.2%, n = 656) and suffered a blunt trauma (96.5%; n = 900). Patients receiving TXA (36.6%; n = 342) were older (15 [13-17] vs 12 yr [6-16 yr]) compared with those who did not. Patient severity was higher in the TXA group (Injury Severity Score 14 [9-25] vs 6 [2-13]; p < 0.001). The median dosage was 16 mg/kg (13-19 mg/kg). TXA administration was found in 51.8% cases ( n = 256) among patients with criteria for appropriate use. Conversely, 32.4% of patients ( n = 11) with an isolated severe traumatic brain injury (TBI) also received TXA. Age (odds ratio [OR], 1.2; 95% CI, 1.1-1.2), A and B prehospital severity grade (OR, 7.1; 95% CI, 4.1-12.3 and OR, 4.5; 95% CI, 2.9-6.9 respectively), and year of inclusion (OR, 1.2; 95% CI, 1.1-1.3) were associated with prehospital TXA administration. CONCLUSIONS In our physician-led prehospital EMS system, TXA is used in a third of severely injured children despite the lack of high-level of evidence. Only half of the population with greater than or equal to one criteria for appropriate TXA use received it. Conversely, TXA was administered in a third of isolated severe TBI. Further research is warranted to clarify TXA indications and to evaluate its impact on mortality and its safety profile to oversee its prescription.
Collapse
|
4
|
Manoukian MAC, Tancredi DJ, Nishijima DK. Effect of age on the efficacy of tranexamic acid: An analysis of heterogeneity of treatment effect within the CRASH-2 dataset. Am J Emerg Med 2021; 53:37-40. [PMID: 34971920 DOI: 10.1016/j.ajem.2021.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/07/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Trauma is a major cause of morbidity and mortality in older adults and will become more common as the population ages. Tranexamic acid (TXA) is a lysine analogue frequently used in the setting of significant trauma with hemorrhage. The aim of this study is to investigate the heterogeneity of treatment effect of TXA as it relates to patient age during trauma care. METHODS We included patients from the CRASH-2 trial who were randomized within 3 h of injury. Patients were stratified into age groups <26 years, 26 to 35 years, 36 to 45 years, 46 to 55 years, and >55 years. Multiple logistic regression models were utilized to evaluate adjusted odds ratios (OR) with 95% confidence intervals (CI) for mortality. Heterogeneity of treatment effect was evaluated using Akaike and Bayesian information criteria to determine the optimum logistic regression model after which a Wald Chi-square test was utilized to evaluate statistical significance. RESULTS On univariate analysis, TXA administration decreased mortality within the <26 years cohort (decrease of 2.1%, 95% CI 0.2 to 4.0), 46 to 55 years cohort (decrease 6.7%, 95% CI 2.7 to 10.7), and >55 years cohort (decrease of 5.3%, 95% CI 0.4 to 10.3). On adjusted analysis, when compared to the 36 to 45 years cohort, the <26 year cohort experienced a decreased mortality (OR 0.72, 95% CI 0.62 to 0.85) whereas the >55 year cohort experienced increased mortality (OR 1.8, 95% CI 1.5 to 2.2). Assessment for heterogeneity of treatment effect of TXA administration between groups approached but did not reach statistical significance (p = 0.11). CONCLUSIONS Mortality related to trauma increases with age, however, there does not appear to be heterogeneity of treatment effect for TXA administration among different age groups.
Collapse
Affiliation(s)
- Martin A C Manoukian
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA, United States of America.
| | - Daniel J Tancredi
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA, United States of America; Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA, United States of America
| | - Daniel K Nishijima
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA, United States of America
| |
Collapse
|
5
|
Al-Jeabory M, Szarpak L, Attila K, Simpson M, Smereka A, Gasecka A, Wieczorek W, Pruc M, Koselak M, Gawel W, Checinski I, Jaguszewski MJ, Filipiak KJ. Efficacy and Safety of Tranexamic Acid in Emergency Trauma: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:1030. [PMID: 33802254 PMCID: PMC7958951 DOI: 10.3390/jcm10051030] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 12/01/2022] Open
Abstract
In trauma patients, bleeding can lead to coagulopathy, hemorrhagic shock, and multiorgan failure, and therefore is of fundamental significance in regard to early morbidity. We conducted a meta-analysis to evaluate the efficacy and safety of tranexamic acid (TXA) in civil and military settings and its impact on in-hospital mortality (survival to hospital discharge or 30-day survival), intensive care unit and hospital length of stay, incidence of adverse events (myocardial infarct and neurological complications), and volume of blood product transfusion. The systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic review of the literature using PubMed, Scopus, EMBASE, Web of Science, and the Cochrane Central Register and Controlled Trials (CENTRAL) database was conducted from inception to 10 January 2021. In-hospital mortality was reported in 14 studies and was 15.5% for the TXA group as compared with 16.4% for the non-TXA group (OR = 0.81, 95% CI 0.62-1.06, I2 = 83%, p = 0.12). In a civilian TXA application, in-hospital mortality in the TXA and non-TXA groups amounted to 15.0% and 17.1%, respectively (OR = 0.69, 95% CI 0.51-0.93, p = 0.02, I2 = 78%). A subgroup analysis of the randomized control trial (RCT) studies showed a statistically significant reduction in in-hospital mortality in the TXA group (14.3%) as compared with the non-TXA group (15.7%, OR = 0.89, 95% CI 0.83-0.96, p = 0.003, I2 = 0%). To summarize, TXA used in civilian application reduces in-hospital mortality. Application of TXA is beneficial for severely injured patients who undergoing shock and require massive blood transfusions. Patients who undergo treatment with TXA should be monitored for clinical signs of thromboembolism, since TXA is a standalone risk factor of a thromboembolic event and the D-dimers in traumatic patients are almost always elevated.
Collapse
Affiliation(s)
- Mahdi Al-Jeabory
- Outcomes Research Unit, Polish Society of Disaster Medicine, P.O. Box 78, 05-090 Raszyn, Poland
| | - Lukasz Szarpak
- Maria Sklodowska-Curie Bialystok Oncology Center, 15-027 Bialystok, Poland
| | - Kecskes Attila
- NATO Centre of Excellence for Military Medicine, 1555 Budapest, Hungary
| | | | - Adam Smereka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Aleksandra Gasecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Wojciech Wieczorek
- Department of Emergency Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Michal Pruc
- Outcomes Research Unit, Polish Society of Disaster Medicine, P.O. Box 78, 05-090 Raszyn, Poland
| | - Maciej Koselak
- Maria Sklodowska-Curie Medical Academy in Warsaw, 03-411 Warsaw, Poland
| | - Wladyslaw Gawel
- Department of Surgery, The Silesian Hospital in Opava, 746 01 Opava, Czech Republic
| | - Igor Checinski
- Department of Emergency Medical Service, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Milosz J Jaguszewski
- First Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Krzysztof J Filipiak
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| |
Collapse
|