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Zhang Y, Ding W, Feng Y, An H. Efficacy and safety of intravenous tranexamic acid in microscopic modified radical mastoidectomy: a study protocol for a prospective, randomised, double-blind controlled trial. BMJ Open 2024; 14:e087062. [PMID: 38806427 PMCID: PMC11138308 DOI: 10.1136/bmjopen-2024-087062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 05/17/2024] [Indexed: 05/30/2024] Open
Abstract
INTRODUCTION Radical mastoidectomy is a common procedure for chronic suppurative otitis media, typically performed under a microscope. The smooth operation is closely related to the clarity of the operative field. Our trial is designed to investigate whether the intravenous administration of tranexamic acid (TXA) can improve the clarity of the operative field, reduce the operative time, and increase surgeon satisfaction. METHODS AND ANALYSIS This study is a prospective, randomised, double-blinded, controlled trial that aims to investigate the effects of TXA on patients with otitis media. The trial will include patients between the ages of 18 and 65 who will be randomly assigned to either the TXA group or the control group. In the TXA group, patients will receive 1 g of TXA diluted to 20 mL of normal saline before anaesthesia induction while the control group will receive 20 mL of normal saline. The primary outcome measure will be the Modena Bleeding Score, which will assess the clarity of the surgical field. Secondary outcomes will include the surgeon's satisfaction with surgical conditions, operation time, laboratory measurements (prothrombin time, activated partial thromboplastin time, fibrin degradation products, D-dimer) and levels of inflammatory factors (such as IL-6) at 24 hours postoperatively. In addition, the incidence of general adverse reactions such as postoperative nausea, vomiting and dizziness; serious adverse events such as arterial and venous thromboembolism, myocardial infarction and epilepsy within 90 days will be compared between the two groups. ETHICS AND DISSEMINATION The protocol was approved by the Ethics Committee of Peking University People's Hospital (2021PHB173-001), on 19 July 2021. The trial results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ChiCTR2100049183.
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Affiliation(s)
- Yunpeng Zhang
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Weisi Ding
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Yi Feng
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Haiyan An
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
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Yang X, Wang X, Gao X, Guo X, Hou S, Shi J, Lv Q. What else should hemostatic materials do beyond hemostasis: A review. Mater Today Bio 2024; 25:101008. [PMID: 38495915 PMCID: PMC10940931 DOI: 10.1016/j.mtbio.2024.101008] [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: 11/12/2023] [Revised: 01/27/2024] [Accepted: 02/21/2024] [Indexed: 03/19/2024] Open
Abstract
Massive blood loss due to injury is the leading cause of prehospital deaths in disasters and emergencies. Hemostatic materials are used to realize rapid hemostasis and protect patients from death. Researchers have designed and developed a variety of hemostatic materials. However, in addition to their hemostatic effect, hemostatic materials must be endowed with additional functions to meet the practical application requirements in different scenarios. Here, strategies for modifications of hemostatic materials for use in different application scenarios are listed: effective positioning at the site of deep and narrow wounds to stop bleeding, resistance to high blood pressure and wound movement to maintain wound formation, rapid and easy removal from the wound without affecting further treatment after hemostasis is completed, and continued function when retained in the wound as a dressing (such as antibacterial, antiadhesion, tissue repair, etc.). The problems encountered in the practical use of hemostatic materials and the strategies and progress of researchers will be further discussed in this review. We hope to provide valuable references for the design of more comprehensive and practical hemostatic materials.
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Affiliation(s)
- Xinran Yang
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin 300072, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou 325026, China
| | - Xiudan Wang
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin 300072, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou 325026, China
| | - Xing Gao
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
- Tianjin Hospital, Tianjin 300072, China
| | - Xiaoqin Guo
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin 300072, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou 325026, China
| | - Shike Hou
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin 300072, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou 325026, China
| | - Jie Shi
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin 300072, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou 325026, China
| | - Qi Lv
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin 300072, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou 325026, China
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Song JX, Wu JX, Zhong H, Chen W, Zheng JC. Therapeutic efficacy of tranexamic acid on traumatic brain injury: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2024; 32:18. [PMID: 38454455 PMCID: PMC10921791 DOI: 10.1186/s13049-024-01188-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/25/2024] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE Tranexamic acid (TXA) demonstrates therapeutic efficacy in the management of traumatic brain injury (TBI). The objective of this systematic review and meta-analysis was to evaluate the safety and effectiveness of TXA in patients with TBI. METHODS The databases, namely PubMed, Embase, Web of Science, and Cochrane Library databases, were systematically searched to retrieve randomized controlled trials (RCTs) investigating the efficacy of TXA for TBI from January 2000 to November 2023. RESULTS The present meta-analysis incorporates ten RCTs. Compared to the placebo group, administration of TXA in patients with TBI resulted in a significant reduction in mortality (P = 0.05), hemorrhage growth (P = 0.03), and volume of hemorrhage growth (P = 0.003). However, no significant impact was observed on neurosurgery outcomes (P = 0.25), seizure occurrence (P = 0.78), or pulmonary embolism incidence (P = 0.52). CONCLUSION The administration of TXA is significantly associated with reduced mortality and hemorrhage growth in patients suffering from TBI, while the need of neurosurgery, seizures, and incidence of pulmonary embolism remains comparable to that observed with placebo.
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Affiliation(s)
- Jia-Xing Song
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Jian-Xiang Wu
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Hai Zhong
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Wei Chen
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Jian-Chun Zheng
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China.
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Fitschen-Oestern S, Franke GM, Kirsten N, Lefering R, Lippross S, Schröder O, Klüter T, Müller M, Seekamp A. Does tranexamic acid have a positive effect on the outcome of older multiple trauma patients on antithrombotic drugs? An analysis using the TraumaRegister DGU ®. Front Med (Lausanne) 2024; 11:1324073. [PMID: 38444412 PMCID: PMC10912612 DOI: 10.3389/fmed.2024.1324073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/22/2024] [Indexed: 03/07/2024] Open
Abstract
BackgroundAcute hemorrhage is one of the most common causes of death in multiple trauma patients. Due to physiological changes, pre-existing conditions, and medication, older trauma patients are more prone to poor prognosis. Tranexamic acid (TXA) has been shown to be beneficial in multiple trauma patients with acute hemorrhage in general. The relation of tranexamic acid administration on survival in elderly trauma patients with pre-existing anticoagulation is the objective of this study. Therefore, we used the database of the TraumaRegister DGU® (TR-DGU), which documents data on severely injured trauma patients.MethodsIn this retrospective analysis, we evaluated the TR-DGU data from 16,713 primary admitted patients with multiple trauma and age > =50 years from 2015 to 2019. Patients with pre-existing anticoagulation and TXA administration (996 patients, 6%), pre-existing anticoagulation without TXA administration (4,807 patients, 28.8%), without anticoagulation as premedication but TXA administration (1,957 patients, 11.7%), and without anticoagulation and TXA administration (8,953 patients, 53.6%) were identified. A regression analysis was performed to investigate the influence of pre-existing antithrombotic drugs and TXA on mortality. A propensity score was created in patients with pre-existing anticoagulation, and matching was performed for better comparability of patients with and without TXA administration.ResultsRetrospective trauma patients who underwent tranexamic acid administration were older and had a higher ISS than patients without tranexamic acid donation. Predicted mortality (according to the RISC II Score) and observed mortality were higher in the group with tranexamic acid administration. The regression analysis showed that TXA administration was associated with lower mortality rates within the first 24 h in older patients with anticoagulation as premedication. The propensity score analysis referred to higher fluid requirement, higher requirement of blood transfusion, and longer hospital stay in the group with tranexamic acid administration. There was no increase in complications. Despite higher transfusion volumes, the tranexamic acid group had a comparable all-cause mortality rate.ConclusionTXA administration in older trauma patients is associated with a reduced 24-h mortality rate after trauma, without increased risk of thromboembolic events. There is no relationship between tranexamic acid and overall mortality in patients with anticoagulation as premedication. Considering pre-existing anticoagulation, tranexamic acid may be recommended in elderly trauma patients with acute bleeding.
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Affiliation(s)
| | - Georg Maximilian Franke
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Nora Kirsten
- Department of Trauma Surgery, Hannover Medical School, Hannover, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Sebastian Lippross
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Ove Schröder
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Tim Klüter
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Michael Müller
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Andreas Seekamp
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Kiel, Germany
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Acharya P, Amin A, Nallamotu S, Riaz CZ, Kuruba V, Senthilkumar V, Kune H, Bhatti SS, Sarlat IM, Krishna CV, Asif K, Nashwan AJ, Cheema HA. Prehospital tranexamic acid in trauma patients: a systematic review and meta-analysis of randomized controlled trials. Front Med (Lausanne) 2023; 10:1284016. [PMID: 37928456 PMCID: PMC10623347 DOI: 10.3389/fmed.2023.1284016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023] Open
Abstract
Background Prehospital tranexamic acid (TXA) may hold substantial benefits for trauma patients; however, the data underlying its efficacy and safety is scarce. Methods We searched PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov from inception to July 2023 for all randomized controlled trials (RCTs) investigating prehospital TXA in trauma patients as compared to placebo or standard care without TXA. Data were pooled under a random-effects model using RevMan 5.4 with risk ratio (RR) and mean difference (MD) as the effect measures. Results A total of three RCTs were included in this review. Regarding the primary outcomes, prehospital TXA reduced the risk of 1-month mortality (RR 0.82, 95% CI 0.69-0.97) but did not increase survival with a favorable functional outcome at 6 months (RR 1.00, 95% CI 0.93-1.09). Prehospital TXA also reduced the risk of 24-h mortality but did not affect the risk of mortality due to bleeding and traumatic brain injury. There was no significant difference between the TXA and control groups in the incidence of RBC transfusion, and the number of ventilator- and ICU-free days. Prehospital TXA did not increase the risk of adverse events except for a small increase in the incidence of infections. Conclusion Prehospital TXA is useful in reducing mortality in trauma patients without a notable increase in the risk of adverse events. However, there was no effect on the 6-month favorable functional status. Further large-scale trials are required to validate the aforementioned findings. Systematic review registration PROSPERO (CRD42023451759).
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Affiliation(s)
- Pawan Acharya
- Department of Trauma and Orthopedics, Lister Hospital, Stevenage, United Kingdom
| | - Aamir Amin
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, United Kingdom
| | | | | | - Venkataramana Kuruba
- Department of Orthopedics, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
| | | | - Harika Kune
- Kamineni Institute of Medical Sciences, Narketpally, Telangana, India
| | | | - Iván Moguel Sarlat
- Servicio de Ortopedia y Traumatología, Hospital General Dr Agustín O’Horán, Mérida, Yucatán, Mexico
| | | | - Kainat Asif
- Department of Medicine, Dr. Ruth K. M. Pfau Civil Hospital Karachi, Karachi, Pakistan
| | | | - Huzaifa Ahmad Cheema
- Department of Emergency Medicine, King Edward Medical University, Lahore, Pakistan
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Xiao C, Gao Z, Yu W, Yao K, Cao Y, Long N, Zhang S, Jiang Y. Medullary cavity application of tranexamic acid to reduce blood loss in tibial intramedullary nailing procedures-a randomized controlled trial. INTERNATIONAL ORTHOPAEDICS 2023; 47:2095-2102. [PMID: 37140597 PMCID: PMC10345084 DOI: 10.1007/s00264-023-05824-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/19/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE Studies have shown an average postoperative hidden blood loss (HBL) of 473.29 ml and an average Hb loss of 16.71 g/l after intramedullary nailing. Reducing HBL has become a primary consideration for orthopaedic surgeons. METHODS Patients with only tibial stem fractures who visited the study clinic between December 2019 and February 2022 were randomized into two groups using a computer-generated form. Two grams of tranexamic acid (TXA) (20 ml) or 20 ml of saline was injected into the medullary cavity before implantation of the intramedullary nail. On the morning of the surgery, as well as on days one, three and five after surgery, routine blood tests and analyses of CRP and interleukin-6 were completed. The primary outcomes were total blood loss (TBL), HBL, and blood transfusion, in which the TBL and HBL were calculated according to the Gross equation and the Nadler equation. Three months after surgery, the incidence of wound complications and thrombotic events, including deep vein thrombosis and pulmonary embolism, was recorded. RESULTS Ninety-seven patients (47 in the TXA group and 50 in the NS group) were analyzed; the TBL (252.10 ± 10.05 ml) and HBL (202.67 ± 11.86 ml) in the TXA group were significantly lower than the TBL (417.03 ± 14.60 ml) and HBL (373.85 ± 23.70 ml) in the NS group (p < 0.05). At the three month postoperative follow-up, two patients (4.25%) in the TXA group and three patients (6.00%) in the NS group developed deep vein thrombosis, with no significant difference in the incidence of thrombotic complications (p = 0.944). No postoperative deaths or wound complications occurred in either group. CONCLUSIONS The combination of intravenous and topical TXA reduces blood loss after intramedullary nailing of tibial fractures without increasing the incidence of thrombotic events.
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Affiliation(s)
- Cong Xiao
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Zhixiang Gao
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Wei Yu
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Kai Yao
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Yang Cao
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Nengji Long
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Shaoyun Zhang
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Yishan Jiang
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
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Wang X, Zhang X, Yang X, Guo X, Liu Y, Li Y, Ding Z, Teng Y, Hou S, Shi J, Lv Q. An Antibacterial and Antiadhesion In Situ Forming Hydrogel with Sol-Spray System for Noncompressible Hemostasis. ACS APPLIED MATERIALS & INTERFACES 2023; 15:662-676. [PMID: 36562696 DOI: 10.1021/acsami.2c19662] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Noncompressible hemorrhage is a major cause of posttrauma death and occupies the leading position among potentially preventable trauma-associated deaths. Recently, multiple studies have shown that strongly adhesive materials can serve as hemostatic materials for noncompressible hemorrhage. However, the risk of severe tissue adhesion limits the use of adhesive hydrogels as hemostatic materials. Here, we report a promising material system comprising an injectable sol and liquid spray as a potential solution. Injectable sol is mainly composed of gelatin (GEL) and sodium alginate (SA), which possess hemostasis and adhesive properties. The liquid spray component, a mixture of tannic acid (TA) and calcium chloride (CaCl2), rapidly forms an antibacterial, antiadhesive and smooth film structure upon contact with the sol. In vitro and in vivo experiments demonstrated the bioabsorbable, biocompatible, antibacterial, and antiadhesion properties of the in situ forming hydrogel with a sol-spray system. Importantly, the addition of tranexamic acid (TXA) enhanced hemostatic performance in noncompressible areas and in deep wound hemorrhage. Our study offers a new multifunctional hydrogel system to achieve noncompressible hemostasis.
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Affiliation(s)
- Xiudan Wang
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou325026, China
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin300072, China
| | - Xin Zhang
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin300072, China
| | - Xinran Yang
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou325026, China
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin300072, China
| | - Xiaoqin Guo
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin300072, China
| | - Yanqing Liu
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin300072, China
| | - Yongmao Li
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou325026, China
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin300072, China
| | - Ziling Ding
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin300072, China
| | - Yanjiao Teng
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou325026, China
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin300072, China
| | - Shike Hou
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou325026, China
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin300072, China
| | - Jie Shi
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou325026, China
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin300072, China
| | - Qi Lv
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou325026, China
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin300072, China
- Key Laboratory for Disaster Medicine Technology, Tianjin300072, China
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Andreani L, Del Chiaro A, Ipponi E, Di Sacco F, Caterino M, Capanna R. Use of Tranexamic Acid to Reduce PostOperative Bleeding in Orthopaedic Oncology. Acta Med Litu 2022. [DOI: 10.15388/amed.2022.29.2.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Orthopaedic oncology often causes major blood losses that may put at risk patients’ hemodynamic balance and their overall clinical stability. To this date, transfusion therapy still represents the pivotal treatment to counterbalance the reduction in hemoglobin levels which occur after surgery. Although effective, transfusions are expensive and inevitably associated with a number of complications and therefore other solutions, such as procoagulative drugs, could play an important role to prevent massive blood losses.Material and methods: We reviewed the clinical intercourse of 37 patients who underwent major bone resection due to malignant tumors of the lower limb. Cases were divided in two different groups: group G1 consisting of 12 patients treated intraoperatively with tranexamic acid and group G2 which was made of 25 controls.Results: On average, patients treated with tranexamic acid (G1) required transfusion of 3.9 concentrated blood cells units during surgery and 0.9 units during the postoperative course. Other patients (G2), for their part, required on average 3.1 units intraoperatively and 2.1 units postoperatively. No significant difference was found in intraoperative transfusion rate (p=0.402). Instead, postoperative transfusions were significantly less frequent for patients treated with tranexamic acid (p=0.023). None of the 12 patients treated with tranexamic acid had evidence of Deep Vein Thrombosis.Conclusion: Our outcomes indicate that the use of TXA was effective in reducing blood losses also for major surgical interventions in orthopedic oncology.
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Bivens MJ, Fritz CL, Burke RC, Schoenfeld DW, Pope JV. State-by-state estimates of avoidable trauma mortality with early and liberal versus delayed or restricted administration of tranexamic acid. BMC Emerg Med 2022; 22:191. [PMID: 36463125 PMCID: PMC9719138 DOI: 10.1186/s12873-022-00741-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 11/03/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE Early administration of tranexamic acid (TXA) has been shown to save lives in trauma patients, and some U.S. emergency medical systems (EMS) have begun providing this therapy prehospital. Treatment protocols vary from state to state: Some offer TXA broadly to major trauma patients, others reserve it for patients meeting vital sign criteria, and still others defer TXA entirely pending a hospital evaluation. The purpose of this study is to compare the avoidable mortality achievable under each of these strategies, and to report on the various approaches used by EMS. METHODS We used the National Center for Health Statistics Underlying Cause of Death data to identify a TXA-naïve population of trauma patients who died from 2007 to 2012 due to hemorrhage. We estimated the proportion of deaths where the patient was hypotensive or tachycardic using the National Trauma Data Bank. We used avoidable mortality risk ratios from the landmark CRASH 2 study to calculate lives saved had TXA been given within one hour of injury based on a clinician's gestalt the patient was at risk for significant hemorrhage; had it been reserved only for hypotensive or tachycardic patients; or had it been given between hours one to three of injury, considered here as a surrogate for deferring the question to the receiving hospital. RESULTS Had TXA been given within 1 hour of injury, an average of 3409 deaths per year could have been averted nationally. Had TXA been given between one and three hours after injury, 2236 deaths per year could have been averted. Had TXA only been given to either tachycardic or hypotensive trauma patients, 1371 deaths per year could have been averted. Had TXA only been given to hypotensive trauma patients, 616 deaths per year could have been averted. Similar trends are seen at the individual state level. A review of EMS practices found 15 statewide protocols that allow EMS providers to administer TXA for trauma. CONCLUSION Providing early TXA to persons at risk of significant hemorrhage has the potential to prevent many deaths from trauma, yet most states do not offer it in statewide prehospital treatment protocols.
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Affiliation(s)
- Matthew J. Bivens
- grid.239395.70000 0000 9011 8547Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, MA Boston, USA
| | - Christie L. Fritz
- grid.239395.70000 0000 9011 8547Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, MA Boston, USA
| | - Ryan C. Burke
- grid.239395.70000 0000 9011 8547Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - David W. Schoenfeld
- grid.239395.70000 0000 9011 8547Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, MA Boston, USA
| | - Jennifer V. Pope
- grid.413480.a0000 0004 0440 749XDepartment of Emergency Medicine, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH USA
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Liu J, Chen B, Wu X, Wang H, Zuo X, Lei Y, Huang W. Total Hip Arthroplasty Patients with Distinct Postoperative Fibrinolytic Phenotypes Require Different Antifibrinolytic Strategies. J Clin Med 2022; 11:jcm11236897. [PMID: 36498472 PMCID: PMC9736050 DOI: 10.3390/jcm11236897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/13/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
Bleeding patients exhibit different fibrinolytic phenotypes after injury, and the universal use of tranexamic acid (TXA) is doubted. We aimed to evaluate the efficacy of postoperative antifibrinolytic treatment in total hip arthroplasty (THA) patients with different fibrinolytic phenotypes. A retrospective analysis was conducted in 238 patients who underwent THA. Patients were divided into two groups by different fibrinolytic phenotypes (non-fibrinolytic shutdown and fibrinolytic shutdown), determined by the LY30 level on postoperative day 1 (POD1). The two groups were further stratified into four sub-groups based on different postoperative TXA regimens (Group A received no TXA postoperatively, while Group B did). Hidden blood loss (HBL), decline of hemoglobin (ΔHb), D-dimer (D-D), fibrinogen/fibrin degradation product (FDP), prothrombin time (PT), activated partial thromboplastin time (APTT), and demographics were collected and compared. The clinical baseline data were comparable between the studied groups. In patients who presented non-fibrinolytic shutdown postoperatively, Group B suffered significantly lower HBL and ΔHb than Group A on POD3 and POD5. In patients who presented postoperative fibrinolytic shutdown, Group B failed to benefit from the postoperative administration of TXA when compared to Group A. No difference was found in postoperative levels of D-D, FDP, PT, and APTT. Postoperative antifibrinolytic therapy is beneficial for THA patients who presented non-fibrinolytic shutdown postoperatively, while the efficacy and necessity should be considered with caution in those with fibrinolytic shutdown. LY30 is a promising parameter to distinguish different fibrinolytic phenotypes and guide TXA administration. However, further prospective studies are needed to confirm these findings.
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Affiliation(s)
- Jiacheng Liu
- Orthopedic Laboratory of Chongqing Medical University, Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Bowen Chen
- Orthopedic Laboratory of Chongqing Medical University, Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xiangdong Wu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Han Wang
- Department of Orthopedics, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China
| | - Xiaohai Zuo
- Orthopedic Laboratory of Chongqing Medical University, Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yiting Lei
- Orthopedic Laboratory of Chongqing Medical University, Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Correspondence: (Y.L.); (W.H.)
| | - Wei Huang
- Orthopedic Laboratory of Chongqing Medical University, Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Correspondence: (Y.L.); (W.H.)
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11
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Weng N, Gou Y, Kuang F. Efficacy and safety of tranexamic acid in unicompartmental knee arthroplasty: A systematic review and meta-analysis. Asian J Surg 2022:S1015-9584(22)01512-3. [PMID: 36396576 DOI: 10.1016/j.asjsur.2022.10.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 10/02/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022] Open
Abstract
This meta-analysis aimed to assess whether administration tranexamic acid (TXA) could reduce blood loss and vascular events in patients undergoing unicompartmental knee arthroplasty (UKA). We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and case control trials (CCT) that compared outcomes of patients who did and did not receive TXA during UKA. We searched Cochrane Central Register of including PubMed, EMBASE, Web of Science, the Cochrane Library, Wan Fang data, CBM and CNKI for relevant studies. We assessed the risk of bias of the included studies and calculated pooled risk estimates. The primary outcome was operation time, intraoperative blood loss, postoperative HCT, postoperative HB, transfusion rate, dominant blood loss, postoperative drainage volume, hidden blood loss, total blood loss, postoperative ROM,postoperative VAS score, postoperative complications. Data were using fixed-effects or random-effects models with standard mean differences and risk ratios for continuous and dichotomous variables, respectively. Finally, 9 clinical studies with 744 patients were included in this meta-analysis. Compared with the control group, TXA group could reduced transfusion rate, dominant blood loss, postoperative drainage volume, hidden blood loss, and total blood loss, and increased postoperative HB with statistically significance. The main findings of this meta-analysis are that the transfusion rate, dominant blood loss, postoperative drainage volume, hidden blood loss, total blood loss and postoperative HB in the tranexamic acid group were superior to those in the routine group. Additional high-quality RCTs should be conducted in the future.
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12
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Prudovsky I, Kacer D, Zucco VV, Palmeri M, Falank C, Kramer R, Carter D, Rappold J. Tranexamic acid: Beyond antifibrinolysis. Transfusion 2022; 62 Suppl 1:S301-S312. [PMID: 35834488 DOI: 10.1111/trf.16976] [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: 11/30/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 11/30/2022]
Abstract
Tranexamic acid (TXA) is a popular antifibrinolytic drug widely used in hemorrhagic trauma patients and cardiovascular, orthopedic, and gynecological surgical patients. TXA binds plasminogen and prevents its maturation to the fibrinolytic enzyme plasmin. A number of studies have demonstrated the broad life-saving effects of TXA in trauma, superior to those of other antifibrinolytic agents. Besides preventing fibrinolysis and blood loss, TXA has been reported to suppress posttraumatic inflammation and edema. Although the efficiency of TXA transcends simple inhibition of fibrinolysis, little is known about its mechanisms of action besides the suppression of plasmin maturation. Understanding the broader effects of TXA at the cell, organ, and organism levels are required to elucidate its potential mechanisms of action transcending antifibrinolytic activity. In this article, we provide a brief review of the current clinical use of TXA and then focus on the effects of TXA beyond antifibrinolytics such as its anti-inflammatory activity, protection of the endothelial and epithelial monolayers, stimulation of mitochondrial respiration, and suppression of melanogenesis.
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Affiliation(s)
- Igor Prudovsky
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, USA
| | - Doreen Kacer
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, USA
| | - Victoria Vieira Zucco
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, USA
| | - Monica Palmeri
- Maine Medical Center Cardiovascular Institute, Maine Medical Center, Portland, Maine, USA
| | - Carolyne Falank
- Department of Trauma, Maine Medical Center, Maine Medical Center, Portland, Maine, USA
| | - Robert Kramer
- Maine Medical Center Cardiovascular Institute, Maine Medical Center, Portland, Maine, USA
| | - Damien Carter
- Department of Trauma, Maine Medical Center, Maine Medical Center, Portland, Maine, USA
| | - Joseph Rappold
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, USA.,Department of Trauma, Maine Medical Center, Maine Medical Center, Portland, Maine, USA
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13
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Stevens J, Phillips R, Reppucci ML, Pickett K, Moore H, Bensard D. Does the mechanism matter? Comparing thrombelastography between blunt and penetrating pediatric trauma patients. J Pediatr Surg 2022; 57:1363-1369. [PMID: 34588132 DOI: 10.1016/j.jpedsurg.2021.09.010] [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: 04/01/2021] [Revised: 06/25/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND/PURPOSE The utility of thrombelastography (TEG) in pediatric trauma remains unknown, and differences in coagulopathy between blunt and penetrating mechanisms are not established. We aimed to compare TEG patterns in pediatric trauma patients with blunt solid organ injuries (BSOI) and penetrating injuries to determine the role of mechanism in coagulopathy. METHODS Highest-level pediatric trauma activations with BSOI or penetrating injuries and admission TEG at two pediatric trauma centers were included. TEG abnormalities were defined by each institution's normative values and compared separately by injury mechanism and evidence of shock (elevated SIPA) using Kruskal-Wallis or Fisher's exact tests. RESULTS Of 118 patients included, 64 had BSOI and 54 had penetrating injuries. There were no significant differences in TEG abnormalities between the BSOI and penetrating injury groups. Patients with shock were more likely to have decreased alpha-angles (30.9% vs. 8.0%, p = 0.01) and decreased maximum amplitude (MA) (44.1% vs. 8.0%, p < 0.001) compared to those without shock, regardless of mechanism of injury. CONCLUSIONS TEG abnormalities were not significantly different between the BSOI and penetrating groups, but there were significant differences in alpha-angle and MA in those with shock, independent of mechanism. Hemodynamic status, rather than mechanism of injury, may be more predictive of coagulopathy in pediatric trauma patients. LEVEL OF EVIDENCE/STUDY TYPE Level III, retrospective.
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Affiliation(s)
- Jenny Stevens
- Division of Pediatric Surgery, Department of General Surgery, Children's Hospital Colorado Anschutz Medical Campus, University of Colorado, 13123 E 16th Ave, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Ryan Phillips
- Division of Pediatric Surgery, Department of General Surgery, Children's Hospital Colorado Anschutz Medical Campus, University of Colorado, 13123 E 16th Ave, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marina L Reppucci
- Division of Pediatric Surgery, Department of General Surgery, Children's Hospital Colorado Anschutz Medical Campus, University of Colorado, 13123 E 16th Ave, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kaci Pickett
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hunter Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Department of General Surgery, Children's Hospital Colorado Anschutz Medical Campus, University of Colorado, 13123 E 16th Ave, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
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Gkiatas I, Kontokostopoulos AP, Tsirigkakis SE, Kostas-Agnantis I, Gelalis I, Korompilias A, Pakos E. Topical use of tranexamic acid: Are there concerns for cytotoxicity? World J Orthop 2022; 13:555-563. [PMID: 35949709 PMCID: PMC9244960 DOI: 10.5312/wjo.v13.i6.555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/23/2022] [Accepted: 06/14/2022] [Indexed: 02/06/2023] Open
Abstract
Tranexamic acid (TXA) has revolutionized modern blood management in orthopaedic surgery, especially in total joint arthroplasty, by significantly reducing blood loss and transfusion rates. It is an antifibrinolytic agent and a synthetic derivative of the amino acid lysine, which can inhibit the activation of plasminogen and the fibrin breakdown process. The administration of TXA can be intravenous (IV), topical, and oral. In patients where the IV administration is contraindicated, topical use is preferred. Topical administration of the drug theoretically increases concentration at the operative site with reduced systemic exposure, reduces cost, and gives the surgeon the control of the administration. According to recent studies, topical administration of TXA is not inferior compared to IV administration, in terms of safety and efficacy. However, there are concerns regarding the possible toxicity in the cartilage tissue with the topical use of TXA mainly in hemiarthroplasty operations of the hip, unilateral knee arthroplasties, total knee arthroplasties where the patella is not resurfaced, and other intraarticular procedures, like anterior cruciate ligament reconstruction. The purpose of the present review is to present all the recent updates on the use of TXA focusing on the toxicity on chondrocytes and the articular cartilage that may or may not be provoked by the topical use of TXA.
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Affiliation(s)
- Ioannis Gkiatas
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
| | | | - Spyridon E Tsirigkakis
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
| | | | - Ioannis Gelalis
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
| | - Anastasios Korompilias
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
| | - Emilios Pakos
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
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Wu B, Chen S, Sun K, Xu X. Complications Associated with Rhinoplasty: An Umbrella Review of Meta-analyses. Aesthetic Plast Surg 2022; 46:805-817. [PMID: 34590168 DOI: 10.1007/s00266-021-02612-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/19/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND An increasing number of studies have investigated the effect of various methods in avoiding complications in rhinoplasty. Our study aims to analyze the connections between various choices in rhinoplasty and the rate of multiple complications by summarizing results in related meta-analyses. MATERIALS AND METHODS Through Pubmed, MEDLINE, Embase, and the Cochrane Database were associated systematic reviews searched to gather and review the available evidence of different plans and health outcomes in rhinoplasty for this umbrella review. RESULTS The study included 14 systematic reviews with 128 meta-analyses of randomized clinical trials. Edema and ecchymosis were the two most investigated outcomes. The implementations of steroid, tranexamic acid, periosteal preservation, external approach in lateral osteotomy, and piezoelectric osteotomy were linked with significantly lower incidence of several complications. Multiple administration of steroids was found to be associated with fewer complications in a prolonged time. CONCLUSIONS With summarized evidence of complications related to rhinoplasty, this research can help surgeons to avert patients from suffering complications and optimize cosmetic outcomes. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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16
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Easter J, Petruzella F. Updates in pediatric emergency medicine for 2021. Am J Emerg Med 2022; 56:244-253. [DOI: 10.1016/j.ajem.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/03/2022] [Accepted: 02/14/2022] [Indexed: 10/19/2022] Open
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17
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Liu J, Wang H, Wu X, Lei Y, Huang W. Not all patients benefit from the postoperative antifibrinolytic treatment: clinical evidence against the universal use of tranexamic acid following total knee arthroplasty. J Orthop Surg Res 2022; 17:59. [PMID: 35093142 PMCID: PMC8800271 DOI: 10.1186/s13018-022-02958-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 01/21/2022] [Indexed: 11/15/2022] Open
Abstract
Background The empirical use of tranexamic acid (TXA) for bleeding remains controversial because of the distinct fibrinolytic phenotypes observed after injury. This study sought to assess the efficacy of postoperative TXA in patients presenting with different fibrinolytic phenotypes after total knee arthroplasty (TKA). Methods This retrospective study included 270 patients who underwent primary TKA. The patients were divided into two groups: Group A, received no postoperative TXA, and Group B, received postoperative TXA; they were further categorized into four subgroups based on postoperative fibrinolytic phenotypes (non-fibrinolytic shutdown [NFSD] and fibrinolytic shutdown [FSD]). Fibrinolytic phenotypes were determined using percentage of clot lysis 30 min after maximum strength (LY30) level measured on postoperative day 1 (POD1). Data on perioperative hidden blood loss (HBL), decrease in the hemoglobin level (ΔHb), allogeneic blood transfusion (ABT) rate, fibrin degradation product (FDP) level, D-dimer (D-D) level, prothrombin time (PT), and activated partial thromboplastin time (APTT) as well as clinical baseline data were collected and compared. Results No differences in baseline clinical data were noted. Among patients presenting with NFSD, those in Group B had significantly lower HBL and ΔHb on POD1 and POD3 than those in Group A. Among patients presenting with FSD, perioperative HBL and ΔHb were similar between the two groups. No differences were observed in perioperative ABT rate, FDP level, D-D level, PT, and APTT. Conclusions Patients exhibit various fibrinolytic phenotypes after TKA. Postoperative antifibrinolytic strategies may be beneficial for patients presenting with NFSD, but not for those presenting with FSD. The LY30 level may guide targeted TXA administration after TKA. However, well-designed prospective randomized controlled trials are needed to obtain more robust data.
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18
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Thota B, Marinica A, Oh MW, Cripps MW, Moon TS. The Use of Tranexamic Acid in Trauma. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00509-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Agrawal NA, Hillier K, Kumar R, Izaddoost SA, Rohrich RJ. A Review of Venous Thromboembolism Risk Assessment and Prophylaxis in Plastic Surgery. Plast Reconstr Surg 2022; 149:121e-129e. [PMID: 34851883 DOI: 10.1097/prs.0000000000008663] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Venous thromboembolism is a significant cause of postoperative death and morbidity. While prophylactic and treatment regimens exist, they usually come with some risk of clinically relevant bleeding and, thus, must be considered carefully for each individual patient. METHODS This special topic article represents a review of current evidence regarding venous thromboembolism risk, biology, and prevention in plastic surgery patients. The specific types and duration of available prophylaxis are also reviewed. The balance of venous thromboembolism risk must be weighed against the risk of hemorrhage. RESULTS Though alternatives exist, the most validated risk assessment tool is the 2005 modification of the Caprini Risk Assessment Model. Controversies remain regarding recommendations for outpatient and low risk cosmetic patients. The authors additionally make recommendations for high-risk patients regarding the use of tranexamic acid, estrogen therapy, anesthesia, and prophylaxis regimens. CONCLUSION Our profession has made great strides in understanding the science behind venous thromboembolism, risk stratification for patients, and prophylactic regimens; yet, continued studies and definitive data are needed.
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Affiliation(s)
- Nikhil A Agrawal
- From the Baylor College of Medicine, Division of Plastic Surgery; Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School; Memorial Plastic Surgery; and Dallas Plastic Surgery Institute
| | - Kirsty Hillier
- From the Baylor College of Medicine, Division of Plastic Surgery; Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School; Memorial Plastic Surgery; and Dallas Plastic Surgery Institute
| | - Riten Kumar
- From the Baylor College of Medicine, Division of Plastic Surgery; Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School; Memorial Plastic Surgery; and Dallas Plastic Surgery Institute
| | - Shayan A Izaddoost
- From the Baylor College of Medicine, Division of Plastic Surgery; Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School; Memorial Plastic Surgery; and Dallas Plastic Surgery Institute
| | - Rod J Rohrich
- From the Baylor College of Medicine, Division of Plastic Surgery; Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School; Memorial Plastic Surgery; and Dallas Plastic Surgery Institute
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20
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van Wessem KJP, Jochems D, Leenen LPH. The effect of prehospital tranexamic acid on outcome in polytrauma patients with associated severe brain injury. Eur J Trauma Emerg Surg 2021; 48:1589-1599. [PMID: 34775510 PMCID: PMC8590807 DOI: 10.1007/s00068-021-01827-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/01/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) has shown to be beneficial in selected patients with hemorrhagic shock. Recently, TXA has gained interest in isolated traumatic brain injury (TBI) patients with variable results. There are limited data on TXA in polytrauma with associated TBI. This study investigated the role of TXA in severely injured patients with associated severe TBI. METHODS A 7.5-year prospective cohort study was performed to investigate the relation between prehospital TXA and mortality in consecutive trauma patients with associated severe TBI (Abbreviated Injury Scale (AIS)head ≥ 3) admitted to a Level-1 Trauma Center ICU. Indication for prehospital TXA administration was (suspicion of) hemorrhagic shock, and/or systolic blood pressure (SBP) ≤ 90 mmHg. Demographics, data on physiology, resuscitation, and outcomes were prospectively collected. RESULTS Two hundred thirty-four patients (67% males) with median age of 49 years and ISS 33 (98% blunt injuries) were included. Thirteen patients (6%) developed thromboembolic complications; mortality rate was 24%. Fifty-one percent of patients received prehospital TXA. TXA patients were younger, had more deranged physiology on arrival, and received more crystalloids and blood products ≤ 24 h. There was, however, no difference in overall outcome between TXA patients and no-TXA patients. CONCLUSIONS Despite having a more deranged physiology TXA patients had similar outcome compared to no-TXA patients who were much older. Thromboembolic complication rate was low. Prehospital tranexamic acid has no evident effect on outcome in polytrauma patients with associated critical brain injury.
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Affiliation(s)
- Karlijn J. P. van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Denise Jochems
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Luke P. H. Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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21
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Kaur G, Selhi HS, Delmotra NJ, Singh J. Tranexamic acid and reduction of blood transfusion in lower limb trauma surgery: a randomized controlled study. SICOT J 2021; 7:53. [PMID: 34709175 PMCID: PMC8552698 DOI: 10.1051/sicotj/2021053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/09/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Post-operative blood loss in lower limb trauma fractures increases morbidity. Very few studies have evaluated the efficacy of Tranexamic Acid (TXA) in reducing blood loss and the consequent requirement of blood transfusion in the Indian population. METHODS This was a randomized controlled study of 100 patients with lower limb trauma. Fifty patients were given 1 g of TXA before surgery, and 50 patients were not given TXA. The requirement of blood transfusion, fall in Hb, the number of days admitted in the hospital after surgery were recorded, and evidence of deep vein thrombosis (DVT) was monitored. RESULTS Baseline demographics between the groups were comparable. The required blood transfusion and fall in Hb in patients receiving intra-operative TXA were significantly lower than those not given TXA (p < 0.0001). There was no significant difference in the length of hospital stay between the two groups (p = 0.6). There was no significant difference in the incidence of DVT in both groups. DISCUSSION TXA helps reduce the morbidity of trauma patients by reducing the requirement for blood transfusion. Its use is safe in lower limb trauma surgery and lowers the cost of therapy to the patient.
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Affiliation(s)
- Gurleen Kaur
- Professor, Department of Pharmacology, Adesh Medical College & Hospital, Kurukshetra, Haryana 136135, India
| | - Harpal Singh Selhi
- Professor, Department of Orthopaedics, Dayanand Medical College & Hospital, Ludhiana, Punjab 141001, India
| | - Naresh Jyoti Delmotra
- Professor & Head, Department of Pharmacology, Adesh Medical College & Hospital, Kurukshetra, Haryana 136135, India
| | - Jaspreet Singh
- Assistant Professor, Department of Orthopaedics, Government Medical College, Patiala, Punjab 147001, India
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22
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Current Practices in Tranexamic Acid Administration for Pediatric Trauma Patients in the United States. J Trauma Nurs 2021; 28:21-25. [PMID: 33417398 DOI: 10.1097/jtn.0000000000000553] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although controversial, early administration of tranexamic acid (TXA) has been shown to reduce mortality in adult patients with major trauma. Tranexamic acid has also been successfully used in elective pediatric surgery, with significant reduction in blood loss and transfusion requirements. There are limited data to guide its use in pediatric trauma patients. We sought to determine the current practices for TXA administration in pediatric trauma patients in the United States. METHODS A survey was conducted of all the American College of Surgeons-verified Level I and II trauma centers in the United States. The survey data underwent quantitative analysis. RESULTS Of the 363 Level I and II qualifying centers, we received responses from 220 for an overall response rate of 61%. Eighty of 99 verified pediatric trauma centers responded for a pediatric trauma center response rate of 81%. Of all responding centers, 148 (67%) reported they care for pediatric trauma patients, with an average of 513 pediatric trauma patients annually. The pediatric trauma centers report caring for an average of 650 pediatric trauma patients annually. Of all centers caring for pediatric trauma, 52 (35%) report using TXA, with the most common initial dosing being 15 mg/kg (68%). A follow-up infusion was utilized by 45 (87%) of the programs, most commonly dosed at 2 mg/kg/hr × 8 hr utilized by 24 centers (54%). CONCLUSION Although the clinical evidence for TXA in pediatric trauma patients is limited, we believe that consideration should be given for use in major trauma with hemodynamic instability or significant risk for ongoing hemorrhage. If available, resuscitation should be guided by thromboelastography to identify candidates who would most benefit from antithrombolytic administration. This represents a low-cost/low-risk and high-yield therapy for pediatric trauma patients.
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Effect of Tranexamic Acid Administration on Postoperative Ecchymosis and Edema in Excision of Lipomas. Dermatol Surg 2021; 47:345-348. [PMID: 33625153 DOI: 10.1097/dss.0000000000002680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous studies have shown that systemic tranexamic acid reduces bleeding during soft tissue surgeries and reduces postoperative ecchymosis and edema experienced by surgical patients. OBJECTIVE To evaluate the effect of postoperative tranexamic acid administration on the reduction of ecchymosis and edema after lipoma surgery. MATERIALS AND METHODS A total of 40 patients who underwent lipoma excision were included in the comparative analysis. In the tranexamic acid group (n = 20), 1 g of tranexamic acid was administered daily for 5 consecutive postoperative days. Tranexamic acid was not administered to the control group (n = 20). The severity of ecchymosis and edema at the first visit after surgery was rated on a 4-point scale by 2 blinded dermatologists. RESULTS The mean interval of the initial visit after surgery was 1.1 ± 0.5 (range: 1-4) days. Mean ecchymosis scores were significantly lower in the tranexamic acid group (0.5 ± 0.8) than in the control group (1.2 ± 1.0) (p < .05). No statistical difference was seen in mean edema scores between groups (0.5 ± 0.6 in tranexamic acid vs 0.7 ± 0.8 in control). CONCLUSION We observed that postoperative administration of tranexamic acid significantly decreased ecchymosis in lipoma excision.
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Matthay ZA, Hellmann ZJ, Callcut RA, Matthay EC, Nunez-Garcia B, Duong W, Nahmias J, LaRiccia AK, Spalding MC, Dalavayi SS, Reynolds JK, Lesch H, Wong YM, Chipman AM, Kozar RA, Penaloza L, Mukherjee K, Taghlabi K, Guidry CA, Seng SS, Ratnasekera A, Motameni A, Udekwu P, Madden K, Moore SA, Kirsch J, Goddard J, Haan J, Lightwine K, Ontengco JB, Cullinane DC, Spitzer SA, Kubasiak JC, Gish J, Hazelton JP, Byskosh AZ, Posluszny JA, Ross EE, Park JJ, Robinson B, Abel MK, Fields AT, Esensten JH, Nambiar A, Moore J, Hardman C, Terse P, Luo-Owen X, Stiles A, Pearce B, Tann K, Abdul Jawad K, Ruiz G, Kornblith LZ. Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg 2021; 91:24-33. [PMID: 34144557 PMCID: PMC8243874 DOI: 10.1097/ta.0000000000003121] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- Zachary A Matthay
- From the Department of Surgery at Zuckerberg San Francisco General Hospital, University of California San Francisco (Z.A.M., Z.J.H., R.A.C., B.N.-G., L.Z.K., E.E.R., J.J.P., B.R., M.K.A., A.T.F.), San Francisco, California; Department of Epidemiology and Biostatistics, University of California San Francisco (E.C.M), San Francisco, California; Department of Laboratory Medicine, University of California, San Francisco (J.H.E., A.N., J.M.), San Francisco, California; Department of Surgery, University of California Irvine (W.D., J.N.), Irvine, Orange, California; Department of Surgery, Ohio Health Grant Medical Center (A.K.L., M.C.S.), Columbus, Ohio; Department of Surgery, University of Kentucky (S.S.D., J.K.R.), Lexington, Kentucky; Department of Surgery, Miami Valley Hospital (H.L., Y.W., C.H.), Dayton, Ohio; Department of Surgery, R Adams Cowley Shock Trauma Center (A.M.C., R.A.K., P.T.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery, Loma Linda Medical Center (L.P., K.M., X.L.-O.), Loma Linda, California; Department of Surgery, University of Kansas Medical Center (K.T., C.A.G.), Kansas City, Kansas; Department of Surgery, Crozer-Chester Medical Center (S.S.S., A.R.), Upland, Pennsylvania; Department of Surgery, WakeMed Health and Hospitals (A.M., P.U., A.S., B.P., K.T.), Raleigh, North Carolina; Department of Surgery, University of New Mexico School of Medicine (K.M., S.A.M.), Albuquerque, New Mexico; Department of Surgery, Wellspan York Hospital (J.G.), York, Pennsylvania; Department of Surgery, Ascension Via Christi Hospitals St. Francis (J.K., J.H., K.L.), Wichita, Kansas; Department of Surgery, Maine Medical Center (J.B.O., D.C.C.), Portland, Maine; Department of Surgery, South Shore Hospital/Brigham and Women's Hospital (S.A.S., J.C.K.), Boston, Massachusetts; Department of Surgery, Penn State Hershey Medical Center (J.G., J.P.H.), Hershey, Pennsylvania; Department of Surgery, Northwestern University Feinberg School of Medicine (A.Z.B., J.A.P.), Chicago, Illinois; Department of Surgery, University of California (R.A.C.), UC Davis, Sacramento, California; Department of Surgery, Ryder Trauma Center (K.A.J., G.R.), University of Miami Miller School of Medicine, Miami, Florida; and Washington University School of Medicine St. Louis (J.K.), Missouri
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Cunningham G, Hughes J, Borner B, Mattern O, Taha ME, Smith MM, Young AA, Cass B. A single dose of tranexamic acid reduces blood loss after reverse and anatomic shoulder arthroplasty: a randomized controlled trial. J Shoulder Elbow Surg 2021; 30:1553-1560. [PMID: 33421559 DOI: 10.1016/j.jse.2020.11.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hematoma formation and the need for blood transfusions are commonly reported complications after shoulder arthroplasty. Tranexamic acid (TXA) has been widely used in hip and knee arthroplasty to decrease perioperative blood loss. The role of TXA is still being established in shoulder arthroplasty. MATERIALS AND METHODS We conducted a double-blind randomized controlled trial comparing intravenous TXA vs. placebo in 60 patients undergoing primary anatomic or reverse shoulder arthroplasty. Of these patients, 29 received a placebo whereas 31 received a single dose of 2 g of intravenous TXA. Patient demographic characteristics, as well as drain tube output, blood loss, hematoma formation, transfusion requirement, length of hospital stay, and pain score, were recorded. Patients were followed up for 12 weeks to assess for complications. RESULTS Patients who received TXA had a lower drain tube output at all time points: 41 mL vs. 133 mL at 6 hours, 75 mL vs. 179 mL at 12 hours, and 94 mL vs. 226 mL at 24 hours (P < .001 for all). They also had a higher postoperative hemoglobin (Hb) level (12.3 g/dL vs. 11.4 g/dL, P = .009), lower change in Hb level (1.7 g/dL vs. 2.3 g/dL, P = .011), lower total Hb loss (0.078 g vs. 0.103 g, P = .042), lower blood volume loss (0.55 L vs. 0.74 L, P = .021), higher postoperative hematocrit level (36.7% vs. 34.6%, P = .020), and lower hematocrit change (5.4% vs. 7.6%, P = .022). There was no significant difference in pain score or length of hospital stay, and no patients required a transfusion. CONCLUSION A single dose of 2 g of intravenous TXA decreases blood loss and drain tube output in primary anatomic and reverse arthroplasty of the shoulder. No differences were detected in the occurrence of complications, need for transfusion, pain score, or length of hospital stay. With the mounting evidence now available, patients undergoing elective primary shoulder arthroplasty should be given intravenous TXA to decrease perioperative blood loss.
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Affiliation(s)
- Gregory Cunningham
- Division of Orthopaedic and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland; Shoulder Center, Hirslanden Clinique la Colline, Geneva, Switzerland
| | - Jeffery Hughes
- Sydney Shoulder Research Institute, Sydney, NSW, Australia
| | - Benoit Borner
- Division of Orthopaedic and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland.
| | - Owen Mattern
- The Orthopaedic Group, Melbourne, VIC, Australia
| | - Mohy E Taha
- Division of Orthopaedics and Trauma Surgery, Basel University Hospital, Basel, Switzerland
| | - Margaret M Smith
- Institute of Bone and Joint Research, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Allan A Young
- Sydney Shoulder Research Institute, Sydney, NSW, Australia
| | - Benjamin Cass
- Sydney Shoulder Research Institute, Sydney, NSW, Australia
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Bleeding Disorders in Primary Fibrinolysis. Int J Mol Sci 2021; 22:ijms22137027. [PMID: 34209949 PMCID: PMC8268566 DOI: 10.3390/ijms22137027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/07/2021] [Accepted: 06/18/2021] [Indexed: 11/24/2022] Open
Abstract
Fibrinolysis is a complex enzymatic process aimed at dissolving blood clots to prevent vascular occlusions. The fibrinolytic system is composed of a number of cofactors that, by regulating fibrin degradation, maintain the hemostatic balance. A dysregulation of fibrinolysis is associated with various pathological processes that result, depending on the type of abnormality, in prothrombotic or hemorrhagic states. This narrative review is focused on the congenital and acquired disorders of primary fibrinolysis in both adults and children characterized by a hyperfibrinolytic state with a bleeding phenotype.
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van Wessem KJP, Leenen LPH. Does Liberal Prehospital and In-Hospital Tranexamic Acid Influence Outcome in Severely Injured Patients? A Prospective Cohort Study. World J Surg 2021; 45:2398-2407. [PMID: 33914131 PMCID: PMC8083099 DOI: 10.1007/s00268-021-06143-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 12/12/2022]
Abstract
Background Early hemorrhage control is important in trauma-related death prevention. Tranexamic acid (TXA) has shown to be beneficial in patients in hemorrhagic shock, although widespread adoption might result in incorrect TXA administration leading to increased morbidity and mortality. Methods A 7-year prospective cohort study with consecutive trauma patients admitted to a Level-1 Trauma Center ICU was performed to investigate administration of both pre- and in-hospital TXA and its relation to morbidity and mortality. Indication for prehospital and in-hospital TXA administration was (suspicion of) hemorrhagic shock, and/or systolic blood pressure (SBP) ≤ 90 mmHg. Demographics, data on physiology, resuscitation and outcomes were prospectively collected. Results Four hundred and twenty-two patients (71% males, median ISS 29, 95% blunt injuries) were included. Even though TXA patients were more severely injured with more deranged physiology, no differences in outcome were noted. Overall, thrombo-embolic complication rate was 8%. In half the patients, hemorrhagic shock was the indication for prehospital TXA, whereas 79% of in-hospital TXA was given based on suspicion of hemorrhagic shock. Thirteen percent of patients with SBP ≤ 90 mmHg in ED received no TXA at all. Based on SBP alone, 22% of prehospital TXA and 25% of in-hospital TXA were justified. Conclusions Despite being more severely injured, TXA patients had similar outcome compared to patients without TXA. Thrombo-embolic complication rate was low despite liberal use of both prehospital and in-hospital TXA. Caution should be exercised in selecting patients for TXA, although this might be challenging based on SBP alone in patients who do not yet show signs of deranged physiology on arrival in ED. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-021-06143-y.
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Affiliation(s)
- Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Napolitano LM. Hemostatic defects in massive transfusion: an update and treatment recommendations. Expert Rev Hematol 2021; 14:219-239. [PMID: 33267678 DOI: 10.1080/17474086.2021.1858788] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Acute hemorrhage is a global healthcare issue, and remains the leading preventable cause of death in trauma. Acute severe hemorrhage can be related to traumatic, peripartum, gastrointestinal, and procedural causes. Hemostatic defects occur early in patients requiring massive transfusion. Early recognition and treatment of hemorrhage and hemostatic defects are required to save lives and to achieve optimal patient outcomes. AREAS COVERED This review discusses current evidence and trials aimed at identifying the optimal treatment for hemostatic defects in hemorrhage and massive transfusion. Literature search included PubMed and Embase. EXPERT OPINION Patients with acute hemorrhage requiring massive transfusion commonly develop coagulopathy due to specific hemostatic defects, and accurate diagnosis and prompt correction are required for definitive hemorrhage control. Damage control resuscitation and massive transfusion protocols are optimal initial treatment strategies, followed by goal-directed individualized resuscitation using real-time coagulation monitoring. Distinct phenotypes exist in trauma-induced coagulopathy, including 'Bleeding' or 'Thrombotic' phenotypes, and hyperfibrinolysis vs. fibrinolysis shutdown. The trauma 'lethal triad' (hypothermia, coagulopathy, acidosis) has been updated to the 'lethal diamond' (including hypocalcemia). A number of controversies in optimal management exist, including whole blood vs. component therapy, use of factor concentrates vs. blood products, optimal use of tranexamic acid, and prehospital plasma and tranexamic acid administration.
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Affiliation(s)
- Lena M Napolitano
- Department of Surgery, University of Michigan Health System, University Hospital, Ann Arbor, Michigan, USA
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Neff LP, Beckwith MA, Russell RT, Cannon JW, Spinella PC. Massive Transfusion in Pediatric Patients. Clin Lab Med 2020; 41:35-49. [PMID: 33494884 DOI: 10.1016/j.cll.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Massive transfusion in pediatric patients is infrequent but associated with much higher mortality than in adults. Blood transfusion and hematology has conceptualized ideas such as blood failure and the interplay of the blood-endothelium interface to understand coagulopathy in the context of hemorrhagic shock. Researchers are still searching for an appropriate definition of what constitutes a pediatric massive transfusion. There is no universally accepted protocol for massive transfusion and how to address the many complications that can arise. Pharmacologic adjuncts to resuscitation may prove beneficial in reducing coagulopathy during pediatric massive transfusion, but high-quality evidence has not yet emerged.
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Affiliation(s)
- Lucas P Neff
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest University School of Medicine, 5th Floor, Watlington Hall, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
| | - Michael Aaron Beckwith
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1922 7th Avenue South, KB 120, Birmingham, AL 35294, USA
| | - Robert T Russell
- Pediatric General Surgery, Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder, Suite 300, Birmingham, AL 35233, USA
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Penn Presbyterian Medical Center, 51 North 39th Street, Suite 120 MOB, Philadelphia, PA 19104, USA
| | - Philip C Spinella
- Division of Critical Care Medicine, Department of Pediatrics, The Washington University of Saint Louis, 4905 Children's Place, St Louis, MO 63110, USA
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Vishwanathan K, Chhajwani S, Gupta A, Vaishya R. Evaluation and management of haemorrhagic shock in polytrauma: Clinical practice guidelines. J Clin Orthop Trauma 2020; 13:106-115. [PMID: 33680808 PMCID: PMC7919934 DOI: 10.1016/j.jcot.2020.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022] Open
Abstract
Haemorrhagic shock is the most common preventable cause of early mortality in polytrauma patients. Road traffic injuries are the most common cause for polytrauma and most commonly include orthopaedic injuries. Hence, orthopaedic trainees and junior orthopaedic surgeons need to be well aware of evaluation and management of haemorrhagic shock in the multiple injured patient. The present narrative review discusses evaluation and current principles in management of haemorrhagic shock in a polytrauma patient. A classification system for haemorrhagic shock based on ATLS guidelines has been described along with novel use of colour coding to facilitate better and effective use of the classification. A treatment algorithm has also been presented for quick reference. The emphasis is to avoid overloading with crystalloid fluids, replacing with blood and blood products (Balanced resuscitation), permissive hypotension, prevent and acutely treat lethal conditions such as hypothermia, acidosis and coagulopathy. The management of haemorrhagic shock in polytrauma patient is quite challenging and require a detailed knowledge of its management. An arbitrary and haphazard management of these patients may lead to severe complications. We have mentioned the broad principles of management of hypovolemic shock in a polytrauma patient.
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Affiliation(s)
- Karthik Vishwanathan
- Department of Orthopaedics, Parul Institute of Medical Sciences and Research, Parul University, Vadodara, India
- Corresponding author. Department of Orthopaedics, Parul Institute of Medical Sciences and Research, Faculty of Medicine, Parul University, P.O Limda, Waghodia, Vadodara, 391760, India.
| | - Sunil Chhajwani
- Department of Anaesthesia and Critical Care, Pramukhswami Medical College, Karamsad, India
| | - Amit Gupta
- Division of Trauma Surgery & Critical Care, J.P.N. Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Vaishya
- Department of Orthopaedics & Joint Replacement, Indraprastha Apollo Hospitals, New Delhi, India
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Analysis of serum tranexamic acid in patients undergoing open heart surgery. Clin Biochem 2020; 87:74-78. [PMID: 33188769 DOI: 10.1016/j.clinbiochem.2020.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 10/07/2020] [Accepted: 10/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Tranexamic acid is a drug used during open cardiac surgery to prevent blood loss. The blood levels of 10-100 µg/mL are reported to be in the therapeutic range and higher levels are linked to increased incidence of adverse effects. The aim of this study was to optimize and validate an LC-MS/MS method for serum tranexamic acid and measure its levels in patients from the DEPOSITION Pilot trial in order to prove the concept that topical administration will yield lower serum concentration. METHODS The method development was carried out in several steps including sample preparation, and optimization of chromatography and tandem mass spectrometry parameters. Method validation including day-to-day precision with 4 QC levels, limit of detection, sample stability, carryover, and concentration-signal linearity was carried out. Ninety patient samples were analyzed using the validated method. RESULTS Fast and efficient LC-MS/MS method for analysis of tranexamic acid in serum was developed. The run time was 7 min with the total time of one hour including the sample preparation. The method precision was acceptable (%CV = 10.5-12.6%) with no sample carryover observed. The matrix effect on the analytical sensitivity was negligible and the lower limit of detection was 0.5 µg/mL. The difference in the mean adjusted concentrations between topical (45 patients) and intravenous (45 patients) groups was statistically significant (0.1154 µg/mL/kg vs. 0.2542 µg/mL/kg, p < 0.0001) CONCLUSIONS: Rapid and simple LC-MS/MS method for analysis of tranexamic acid was optimized and validated. The laboratory has played a crucial role in proving the concept that topical administration yields significantly lower systemic levels of tranexamic acid, and thus decreases the risk of adverse outcomes in patients undergoing open cardiac surgery.
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Spinella PC, Thomas KA, Turnbull IR, Fuchs A, Bochicchio K, Schuerer D, Reese S, Coleoglou Centeno AA, Horn CB, Baty J, Shea SM, Meledeo MA, Pusateri AE, Levy JH, Cap AP, Bochicchio GV. The Immunologic Effect of Early Intravenous Two and Four Gram Bolus Dosing of Tranexamic Acid Compared to Placebo in Patients With Severe Traumatic Bleeding (TAMPITI): A Randomized, Double-Blind, Placebo-Controlled, Single-Center Trial. Front Immunol 2020; 11:2085. [PMID: 33013880 PMCID: PMC7506112 DOI: 10.3389/fimmu.2020.02085] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/30/2020] [Indexed: 01/08/2023] Open
Abstract
Background The hemostatic properties of tranexamic acid (TXA) are well described, but the immunological effects of TXA administration after traumatic injury have not been thoroughly examined. We hypothesized TXA would reduce monocyte activation in bleeding trauma patients with severe injury. Methods This was a single center, double-blinded, randomized controlled trial (RCT) comparing placebo to a 2 g or 4 g intravenous TXA bolus dose in trauma patients with severe injury. Fifty patients were randomized into each study group. The primary outcome was a reduction in monocyte activation as measured by human leukocyte antigen-DR isotype (HLA-DR) expression on monocytes 72 h after TXA administration. Secondary outcomes included kinetic assessment of immune and hemostatic phenotypes within the 72 h window post-TXA administration. Results The trial occurred between March 2016 and September 2017, when data collection ended. 149 patients were analyzed (placebo, n = 50; 2 g TXA, n = 49; 4 g TXA, n = 50). The fold change in HLA-DR expression on monocytes [reported as median (Q1–Q3)] from pre-TXA to 72 h post-TXA was similar between placebo [0.61 (0.51–0.82)], 2 g TXA [0.57 (0.47–0.75)], and 4 g TXA [0.57 (0.44–0.89)] study groups (p = 0.82). Neutrophil CD62L expression was reduced in the 4 g TXA group [fold change: 0.73 (0.63–0.97)] compared to the placebo group [0.97 (0.78–1.10)] at 24 h post-TXA (p = 0.034). The fold decrease in plasma IL-6 was significantly less in the 4 g TXA group [1.36 (0.87–2.42)] compared to the placebo group [0.46 (0.19–1.69)] at 72 h post-TXA (p = 0.028). There were no differences in frequencies of myeloid or lymphoid populations or in classical complement activation at any of the study time points. Conclusion In trauma patients with severe injury, 4 g intravenous bolus dosing of TXA has minimal immunomodulatory effects with respect to leukocyte phenotypes and circulating cytokine levels. Clinical Trial Registration www.ClinicalTrials.gov, identifier NCT02535949.
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Affiliation(s)
- Philip C Spinella
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Kimberly A Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Isaiah R Turnbull
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Anja Fuchs
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Kelly Bochicchio
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Douglas Schuerer
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Stacey Reese
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Adrian A Coleoglou Centeno
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Christopher B Horn
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Jack Baty
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, United States
| | - Susan M Shea
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - M Adam Meledeo
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Anthony E Pusateri
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, United States
| | - Andrew P Cap
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Grant V Bochicchio
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
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Cerebrovascular Complications of Pediatric Blunt Trauma. Pediatr Neurol 2020; 108:5-12. [PMID: 32111560 PMCID: PMC7306436 DOI: 10.1016/j.pediatrneurol.2019.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 12/02/2019] [Accepted: 12/08/2019] [Indexed: 12/13/2022]
Abstract
Ischemic and hemorrhagic stroke can occur in the setting of pediatric trauma, particularly those with head or neck injuries. The risk of stroke appears highest within the first two weeks after trauma. Stroke diagnosis may be challenging due to lack of awareness or concurrent injuries limiting detailed neurological assessment. Other injuries may also complicate stroke management, with competing priorities for blood pressure, ventilator management, or antithrombotic timing. Here we review epidemiology, clinical presentation, and diagnostic approach to blunt arterial injuries including dissection, cerebral sinovenous thrombosis, mineralizing angiopathy, stroke from abusive head trauma, and traumatic hemorrhagic stroke. Owing to the complexities and heterogeneity of concomitant injuries in stroke related to trauma, a single pathway for stroke management is impractical. Therefore providers must understand the goals and possible costs or consequences of stroke management decisions to individualize patient care. We discuss the physiological principles of cerebral perfusion and oxygen delivery, considerations for ventilator strategy when stroke and lung injury are present, and current available evidence of the risks and benefits of anticoagulation to provide a framework for multidisciplinary discussions of cerebrovascular injury management in pediatric patients with trauma.
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Tranexamic acid administration is associated with an increased risk of posttraumatic venous thromboembolism. J Trauma Acute Care Surg 2020; 86:20-27. [PMID: 30239375 DOI: 10.1097/ta.0000000000002061] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is used as a hemostatic adjunct for hemorrhage control in the injured patient and reduces early preventable death. However, the risk of venous thromboembolism (VTE) has been incompletely explored. Previous studies investigating the effect of TXA on VTE vary in their findings. We performed a propensity matched analysis to investigate the association between TXA and VTE following trauma, hypothesizing that TXA is an independent risk factor for VTE. METHODS This retrospective study queried trauma patients presenting to a single Level I trauma center from 2012 to 2016. Our primary outcome was composite pulmonary embolism or deep vein thrombosis. Mortality, transfusion, intensive care unit and hospital lengths of stay were secondary outcomes. Propensity matched mixed effects multivariate logistic regression was used to determine adjusted odds ratio (aOR) and 95% confidence intervals (95% CI) of TXA on outcomes of interest, adjusting for prespecified confounders. Competing risks regression assessed subdistribution hazard ratio of VTE after accounting for mortality. RESULTS Of 21,931 patients, 189 pairs were well matched across propensity score variables (standardized differences <0.2). Median Injury Severity Score was 19 (interquartile range, 12-27) and 14 (interquartile range, 8-22) in TXA and non-TXA groups, respectively (p = 0.19). Tranexamic acid was associated with more than threefold increase in the odds of VTE (aOR, 3.3; 95% CI, 1.3-9.1; p = 0.02). Tranexamic acid was not significantly associated with survival (aOR, 0.86; 95% CI, 0.23-3.25; p = 0.83). Risk of VTE remained elevated in the TXA cohort despite accounting for mortality (subdistribution hazard ratio, 2.42; 95% CI, 1.11-5.29; p = 0.03). CONCLUSION Tranexamic acid may be an independent risk factor for VTE. Future investigation is needed to identify which patients benefit most from TXA, especially given the risks of this intervention to allow a more individualized treatment approach that maximizes benefits and mitigates potential harms. LEVEL OF EVIDENCE Therapeutic, level III.
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Ghaffarpasand F, Abbasi HR, Bolandparvaz S, Paydar S, Dehghankhalili M. Tranexamic Acid; A Glittering Player in the Field of Trauma. Bull Emerg Trauma 2020; 8:53-55. [PMID: 32420388 PMCID: PMC7211392 DOI: 10.30476/beat.2020.46443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Fariborz Ghaffarpasand
- Research Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran.,Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Reza Abbasi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Shahram Paydar
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Franchini M, Mannucci PM. The never ending success story of tranexamic acid in acquired bleeding. Haematologica 2020; 105:1201-1205. [PMID: 32336684 PMCID: PMC7193503 DOI: 10.3324/haematol.2020.250720] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/16/2020] [Indexed: 12/13/2022] Open
Abstract
Tranexamic acid (TXA) is an anti-fibrinolytic agent that acts by inhibiting plasminogen activation and fibrinolysis. Although its first clinical use dates back more than 50 years, this hemostatic agent is still the object of intense clinical and developmental research. In particular, renewed interest in TXA has arisen following evidence that it has a beneficial effect in reducing blood loss in a variety of medical and surgical conditions at increased risk of bleeding. Given this characteristic, TXA is currently considered a mainstay of Patient Blood Management programs aimed at reducing patients’ exposure to allogeneic blood transfusion. Importantly, recent large randomized controlled trials have consistently documented that the use of TXA confers a survival advantage in a number of globally critical clinical conditions associated with acute bleeding, including traumatic injury and post-partum hemorrhage, without increasing the thromboembolic risk.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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A Retrospective Study of Transfusion Requirements in Trauma Patients Receiving Tranexamic Acid. J Trauma Nurs 2020; 26:128-133. [PMID: 31483769 DOI: 10.1097/jtn.0000000000000437] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The Military Application of Tranexamic Acid in Trauma Emergency Resuscitation Study (MATTERs) and Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage-2 (CRASH-2) studies demonstrate that tranexamic acid (TXA) reduces mortality in patients with traumatic hemorrhage. However, their results, conducted in foreign countries and U.S. military soldiers, provoke concerns over generalizability to civilian trauma patients in the United States. We report the evaluation of patient outcomes and transfusion requirements following treatment with TXA by a civilian air medical program. We conducted a retrospective chart review of trauma patients transported by air service to a Level 1 trauma center. For the purposes of intervention evaluation, patients meeting this criterion for the 2 years (2012-2014) prior to therapy implementation were compared with patients treated during the 2-year study period (2014-2016). Goals were to evaluate morbidity, mortality, transfusion requirements, and length of stay. During the review, 52 control (non-TXA) and 43 study (TXA) patients were identified as meeting inclusion criteria. Patients in the control group were found to be less acute, which correlated with shorter hospitals stays. There was reduced mortality for patients receiving TXA in spite of their increased acuity and decreased likelihood of survival. Trauma patients from this cohort study receiving TXA demonstrate decreased mortality in spite of increased acuity. This increased acuity is associated with increased transfusion requirements. Future research should evaluate patient selection with concern for fibrinolysis and provider bias. Randomized controlled trial is needed to evaluate the role of TXA administration in the United States.
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da Luz LT, Shah PS, Strauss R, Mohammed AA, D'Empaire PP, Tien H, Nathens AB, Nascimento B. Does the evidence support the importance of high transfusion ratios of plasma and platelets to red blood cells in improving outcomes in severely injured patients: a systematic review and meta-analyses. Transfusion 2019; 59:3337-3349. [PMID: 31614006 PMCID: PMC6900194 DOI: 10.1111/trf.15540] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 08/13/2019] [Accepted: 08/21/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Deaths by exsanguination in trauma are preventable with hemorrhage control and resuscitation with allogeneic blood products (ABPs). The ideal transfusion ratio is unknown. We compared efficacy and safety of high transfusion ratios of FFP:RBC and PLT:RBC with low ratios in trauma. STUDY DESIGN AND METHODS Medline, Embase, Cochrane, and Controlled Clinical Trials Register were searched. Observational and randomized data were included. Risk of bias was assessed using validated tools. Primary outcome was 24-h and 30-day mortality. Secondary outcomes were exposure to ABPs and improvement of coagulopathy. Meta-analysis was conducted using a random-effects model. Strength and evidence quality were graded using GRADE profile RESULTS: 55 studies were included (2 randomized and 53 observational), with low and moderate risk of bias, respectively, and overall low evidence quality. The two RCTs showed no mortality difference (odds ratio [OR], 1.35; 95% confidence interval [CI], 0.40-4.59). Observational studies reported lower mortality in high FFP:RBCs ratio (OR, 0.38 [95% CI, 0.22-0.68] for 1:1 vs. <1:1; OR, 0.42 [95% CI, 0.22-0.81] for 1:1.5 vs. <1:1.5; and OR, 0.47 [95% CI, 0.31-0.71] for 1:2 vs. <1:2, respectively). Meta-analyses in observational studies showed no difference in exposure to ABPs. No data on coagulopathy for meta-analysis was identified. CONCLUSIONS Meta-analyses in observational studies suggest survival benefit and no difference in exposure to ABPs. No survival benefit in RCTs was identified. These conflicting results should be interpreted with caution. Studies are mostly observational, with relatively small sample sizes, nonrandom treatment allocation, and high potential for confounding. Further research is warranted.
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Affiliation(s)
| | - Prakesh S. Shah
- Department of PediatricsMount Sinai HospitalTorontoOntarioCanada
| | - Rachel Strauss
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | | | - Pablo Perez D'Empaire
- Department Anesthesia, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Homer Tien
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Avery B. Nathens
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Barto Nascimento
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
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Pape HC, Halvachizadeh S, Leenen L, Velmahos GD, Buckley R, Giannoudis PV. Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020. Injury 2019; 50:1656-1670. [PMID: 31558277 DOI: 10.1016/j.injury.2019.09.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient. METHODS I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome. INCLUSION CRITERIA adult patients, ISS > 16, admission < less than 24 h post trauma. Exclusion: Oncological diseases, genetic disorders that affect the musculoskeletal system. Parameters evaluated were mortality, ICU stay, ICU complications (Sepsis, Pneumonia, Multiple organ failure). RESULTS I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation. CONCLUSIONS Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.
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Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - S Halvachizadeh
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - L Leenen
- Department of Trauma, University Medical Centre Utrecht, Suite G04.228, Heidelberglaan 100, 3585 GA, Utrecht, the Netherlands.
| | - G D Velmahos
- Dept. of Trauma, Emergency Surgery and Critical Care, Harvard University, Mass. General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - R Buckley
- Section of Orthopedic Trauma, University of Calgary, Foothills Medical Center, 0490 McCaig Tower, 3134 University Drive NW Calgary, Alberta, T2N 5A1, Canada.
| | - P V Giannoudis
- Trauma & Orthopaedic Surgery, Clarendon Wing, A Floor, Great George Street, Leeds General Infirmary University Hospital, University of Leeds, Leeds, LS1 3EX, UK.
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Krebs NM, VanWagner MJ, Marchewka T, Faraj U, Vitale CR. Tranexamic Acid in the Treatment of Hip Fractures: A Clinical Review. Spartan Med Res J 2019; 3:7026. [PMID: 33655149 PMCID: PMC7746023 DOI: 10.51894/001c.7026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Although regularly used as a method to reduce blood loss in elective orthopedic procedures (e.g., total hip and knee arthroplasty), there currently is little evidence concerning the optimal dosage, timing and route for the use of tranexamic acid to reduce postoperative blood loss in hip fracture repair. SUMMARY OF THE EVIDENCE The current literature suggests that tranexamic acid may be used to reduce postoperative blood loss in addition to reducing the risk of requiring blood transfusions following the surgical repair of hip fractures. Furthermore, it may have the potential to improve patient outcomes and decrease the overall costs of caring for this patient population. CONCLUSIONS Further studies are needed to truly gauge the effect of tranexamic acid on long-term patient outcomes and hospital costs.
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Affiliation(s)
- Nathan M Krebs
- McLaren Macomb Orthopedic Surgery Resident, Michigan State University Statewide Campus System
| | - Michael J VanWagner
- McLaren Macomb Orthopedic Surgery Resident, Michigan State University Statewide Campus System
| | - Tiffany Marchewka
- Michigan State University College of Osteopathic Medicine Medical Student
| | - Usama Faraj
- Michigan State University College of Osteopathic Medicine Medical Student
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Guerado E, Bertrand ML, Cano JR, Cerván AM, Galán A. Damage control orthopaedics: State of the art. World J Orthop 2019; 10:1-13. [PMID: 30705836 PMCID: PMC6354106 DOI: 10.5312/wjo.v10.i1.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023] Open
Abstract
Damage control orthopaedics (DCO) originally consisted of the provisional immobilisation of long bone - mainly femur - fractures in order to achieve the advantages of early treatment and to minimise the risk of complications, such as major pain, fat embolism, clotting, pathological inflammatory response, severe haemorrhage triggering the lethal triad, and the traumatic effects of major surgery on a patient who is already traumatised (the “second hit” effect). In recent years, new locations have been added to the DCO concept, such as injuries to the pelvis, spine and upper limbs. Nonetheless, this concept has not yet been validated in well-designed prospective studies, and much controversy remains. Indeed, some researchers believe the indiscriminate application of DCO might be harmful and produce substantial and unnecessary expense. In this respect, too, normalised parameters associated with the acid-base system have been proposed, under a concept termed early appropriate care, in the view that this would enable patients to receive major surgical procedures in an approach offering the advantages of early total care together with the apparent safety of DCO. This paper discusses the diagnosis and treatment of severely traumatised patients managed in accordance with DCO and highlights the possible drawbacks of this treatment principle.
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Affiliation(s)
- Enrique Guerado
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Maria Luisa Bertrand
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Juan Ramon Cano
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Ana María Cerván
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Adolfo Galán
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
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Michael Fitzpatrick G. Novel platelet products under development for the treatment of thrombocytopenia or acute hemorrhage. Transfus Apher Sci 2018; 58:7-11. [PMID: 30718153 DOI: 10.1016/j.transci.2018.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Controlling hemorrhage has been a focus of survival since man recognized that the loss of blood led to death. Papyri from 1600 BCE describe methods for hemorrhage control including; direct pressure, ligature and the use of sutures. Multiple studies have demonstrated the survival advantage of early transfusion of whole blood or red cells and plasma. The added survival impact of early transfusion of platelets was recently reported in a substudy of the prospective Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial. Early transfusion of platelets demonstrated a statistically significant survival benefit at 24 h and 30 days post-injury. [1] Platelet availability is limited due to the short shelf life (5-7 days) and storage requirements (room temperature with constant agitation). Providing platelets or platelet derived products for prehospital treatment and to rural and some urban hospitals is an unmet medical need. The interest in novel and alternative platelet products has grown over the past decade and the status of novel platelet products is presented herein. Development, approval, and distribution of hemostatically effective approved platelet products for prehospital use and routine stockage in rural and urban centers could significantly increase survival rates in bleeding patients.
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Kim JS, Wang IJ, Yeom SR, Cho SJ, Kim JH, Seok JP, Lee SH, Bae BG, Min MK. Usefulness of Rotational Thromboelastometry as a Mortality Predictor of Hyperfibrinolysis in Patients with Severe Trauma. Acute Crit Care 2018; 33:162-169. [PMID: 31723880 PMCID: PMC6786692 DOI: 10.4266/acc.2018.00199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/02/2018] [Accepted: 08/17/2018] [Indexed: 12/30/2022] Open
Abstract
Background Hemorrhage is the major cause of traumatic death and the leading cause of preventable death. Hyperfibrinolysis is associated with trauma severity. Viscoelastic hemostatic assays show complete clot formation dynamics. The present study was designed to identify the relationship between hyperfibrinolysis and mortality, metabolic acidosis, and coagulopathy in patients with trauma. Methods Patients with severe trauma (injury severity score [ISS] of 15 or higher) who were assessed using rotational thromboelastometry (ROTEM) were included in the present study from January 2017 to December 2017. Variables were obtained from the Korea Trauma Database or the medical charts of the patients. To identify whether hyperfibrinolysis is an independent predictor of mortality, univariate and multivariate Cox regression analyses were performed. Results During the 1-year study period, 190 patients were enrolled. In total, 21 (11.1%) had hyperfibrinolysis according to the ROTEM analysis and 46 (24.2%) died. Patients with hyperfibrinolysis had a higher ISS (P=0.014) and mortality rate (P<0.001) than did those without hyperfibrinolysis. In multivariate Cox analysis, hyperfibrinolysis (hazard ratio [HR], 4.960; 95% confidence interval [CI], 2.447 to 10.053), age (HR, 1.033; 95% CI, 1.013 to 1.055), lactic acid level (HR, 1.085; 95% CI, 1.003 to 1.173), and ISS (HR, 1.037; 95% CI, 1.004 to 1.071) were independent predictors of mortality. Conclusions Hyperfibrinolysis is associated with increased mortality, worse metabolic acidosis, and severe coagulopathy and is an independent predictor of mortality in patients with trauma.
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Affiliation(s)
- Ji Soo Kim
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Il Jae Wang
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Seok Ran Yeom
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Suck Ju Cho
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Jae Hun Kim
- Department of Trauma Surgery, Pusan National University Hospital, Busan, Korea
| | - June Pill Seok
- Department of Trauma Surgery, Pusan National University Hospital, Busan, Korea
| | - Seong Hwa Lee
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Byung Gwan Bae
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Mun Ki Min
- Department of Emergency Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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Thorne JG, James PD, Reid RL. Heavy menstrual bleeding: is tranexamic acid a safe adjunct to combined hormonal contraception? Contraception 2018; 98:1-3. [DOI: 10.1016/j.contraception.2018.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 02/14/2018] [Accepted: 02/15/2018] [Indexed: 10/17/2022]
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Franchini M, Mannucci PM. Primary hyperfibrinolysis: Facts and fancies. Thromb Res 2018; 166:71-75. [PMID: 29665524 DOI: 10.1016/j.thromres.2018.04.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/28/2018] [Accepted: 04/11/2018] [Indexed: 12/12/2022]
Abstract
Fibrinolysis is a complex process that controls both hemostasis and thrombosis. The regulation of the fibrinolytic system is mediated through a wide array of cofactors and inhibitors that maintain the hemostatic balance in a delicate equilibrium. As a consequence, disturbances in the fibrinolysis pathway are associated with various disease states, ranging from thrombotic to hemorrhagic clinical phenotypes. In particular, a number of inherited and acquired disorders are associated with an enhanced fibrinolysis leading to a bleeding tendency that in some cases may be life-threatening. Hyperfibrinolysis has been classified into primary and secondary forms but such differentiation, which may have important treatment implications, is still controversial. This narrative review will be focused on inherited and acquired conditions associated with primary hyperfibrinolysis.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy; Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, Italy.
| | - Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, Italy
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Flint AWJ, McQuilten ZK, Wood EM. Massive transfusions for critical bleeding: is everything old new again? Transfus Med 2018; 28:140-149. [PMID: 29607593 DOI: 10.1111/tme.12524] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 08/11/2017] [Accepted: 03/07/2018] [Indexed: 12/19/2022]
Abstract
Massive transfusion or major haemorrhage protocols have been widely adopted in the treatment of critically bleeding patients. Following evidence that higher ratios of transfused plasma and platelets to red blood cells may offer survival benefits in military trauma patients, these ratios are now commonly incorporated into massive transfusion protocols. They more closely resemble the effects of whole blood transfusion, which in the second half of last century was largely replaced by individual blood component transfusion based on laboratory-guided indicators. However, high-quality evidence to guide transfusion support for critically bleeding patients across the range of bleeding contexts is lacking, including for both trauma and non-trauma patients. More data on major haemorrhage support and clinical outcomes are needed to inform guidelines and practice.
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Affiliation(s)
- A W J Flint
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Royal Australian Navy, Australian Defence Force, Canberra, Australian Capital Territory, Australia
| | - Z K McQuilten
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Health, Melbourne, Victoria, Australia
| | - E M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Health, Melbourne, Victoria, Australia
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47
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Increased risk of fibrinolysis shutdown among severely injured trauma patients receiving tranexamic acid. J Trauma Acute Care Surg 2018; 84:426-432. [DOI: 10.1097/ta.0000000000001792] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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49
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Bommiasamy AK, Schreiber MA. Damage control resuscitation: how to use blood products and manage major bleeding in trauma. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- A. K. Bommiasamy
- Department of Surgery; Oregon Health & Science University; Portland OR USA
| | - M. A. Schreiber
- Department of Surgery; Oregon Health & Science University; Portland OR USA
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