The effect of tranexamic acid to reduce blood loss and transfusion on off-pump coronary artery bypass surgery: A systematic review and cumulative meta-analysis

Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper

Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.

Synthesis, Characterization and Evaluation of the Antimicrobial and Herbicidal Activities of Some Transition Metal Ions Complexes with the Tranexamic Acid

New tranexamic acid (TXA) complexes of ferric(III), cobalt(II), nickel(II), copper(II) and zirconium(IV) were synthesized and characterized by elemental analysis (CHN), conductimetric (Λ), magnetic susceptibility investigations (μeff), Fourier transform infrared (FT-IR), proton nuclear magnetic resonance (1H-NMR), ultraviolet visible (UV-vis.), optical band gap energy (Eg) and thermal studies (TG/DTG and DTA). TXA complexes were established in 1 : 2 (metal: ligand) stoichiometric ratio according to CHN data. Based on FT-IR and 1H-NMR data the disappeared of the carboxylic proton supported the deprotonating of TXA and linked to metal ions via the carboxylate group's oxygen atom as a bidentate ligand. UV-visible spectra and magnetic moment demonstrated that all chelates have geometric octahedral structures. Eg values indicated that our complexes are more electro conductive. DTA revealed presence of water molecules in inner and outer spheres of the complexes. DTA results showed that endothermic and exothermic peaks were identified in the degradation mechanisms. The ligand and metal complexes were investigated for their antimicrobial and herbicidal efficacy. The Co(II) and Ni(II) complexes showed antimicrobial activity against some tested species. The obtained results showed a promising herbicidal effect of TXA ligand and its metal complexes particularly copper and zirconium against the three tested plants.

The effects of tranexamic acid on platelets in patients undergoing cardiac surgery: a systematic review and meta-analysis

This meta-analysis was designed to evaluate the effects of tranexamic acid (TXA) on platelets in patients undergoing cardiac surgery (CS). Relevant trials were identified by computerized searches of PUBMED, Cochrane Library, EMBASE, OVID, China National Knowledge Infrastructure (CNKI), Wanfang Data and VIP Data till Jun 4th, 2022, were searched using search terms "platelet", "Tranexamic acid", "cardiac surgery", "randomized controlled trial" database search was updated on Jan 1st 2023. Primary outcomes included platelet counts, function and platelet membrane proteins. Secondary outcome included postoperative bleeding. Search yielded 49 eligible trials, which were finally included in the current study. As compared to Control, TXA did not influence post-operative platelet counts in adult patients undergoing on- or off-pump CS, but significantly increased post-operative platelet counts in pediatric patients undergoing on-pump CS [(WMD = 16.72; 95% CI 6.33 to 27.10; P = 0.002)], significantly increased post-operative platelet counts in adults valvular surgery [(WMD = 14.24; 95% CI 1.36 to 27.12; P = 0.03). Additionally, TXA improved ADP-stimulated platelet aggression [(WMD = 1.88; 95% CI 0.93 to 2.83; P = 0.0001)] and improved CD63 expression on platelets [(WMD = 0.72; 95% CI 0.29 to 1.15; P = 0.001)]. The current study demonstrated that TXA administration did not affect post-operative platelet counts in adult patients undergoing either on- or off-pump CABG, but significantly increased post-operative platelet counts in pediatric patients undergoing on-pump CS and adults valvular surgery. Furthermore, TXA improved ADP-stimulated platelet aggression and improved CD63 expression on platelets. To further confirm this, more well designed and adequately powered randomized trials are needed.

Patient Blood Management in Vascular Surgery

Patient blood management (PBM) is an evidence-based, multidisciplinary approach aimed at appropriately allocating blood products to patients requiring transfusion while simultaneously minimizing inappropriate transfusions. The 3 pillars of patient blood management are optimizing erythropoiesis, minimizing blood loss, and optimizing physiological reserve of anemia. Benefits seen from PBM include limiting hospital costs and mitigating harm from numerous risks of transfusion.

A randomized control trial on the role of tranexamic acid in preventing intraoperative bleeding during external dacryocystorhinostomy

Purpose

To evaluate the role of tranexamic acid in controlling intra-operative and immediate post-operative bleeding during external dacryocystorhinostomy.

Methods

This was a double-blinded randomized placebo-controlled trial. All patients diagnosed with primary acquired nasolacrimal duct obstruction presenting between June 2018 to December 2019 were included in the study. All patients in the study group received a single dose of 1 gm tranexamic acid injection intravenously 30 minutes before the surgery, whereas the patients from group B (placebo) received normal saline. The effect of the injection was measured in terms of duration of the surgery, surgical field grading, amount of total blood loss during the surgery, and the need for postoperative nasal packing.

Results

A total of 96 patients were included, of whom 45 were males and 51 were females. The study group (Group A) included 51 patients (27 males and 24 females) and the control group (Group B) included 45 patients (18 males and 27 females). There were no statistically significant differences between the two groups in terms of the duration of surgery (48.43 ± 20.01 minutes vs. 53.38 ± 19.8 minutes, P = 0.228), view of the surgical field (P = 0.084), the amount of intraoperative blood loss (88.63 ± 69.34 mL vs. 88.89 ± 51.93 mL, P = 0.984) and requirement of postoperative nasal packing (54.9% vs 62.2%, P = 0.471).

Conclusion

There seems to be little to justify the role of preoperative intravenous tranexamic acid injection in controlling intra-operative and immediate postoperative bleeding during external dacryocystorhinostomy.

Tranexamic acid: Beyond antifibrinolysis

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.

Defining the Role for Topically Administered Tranexamic Acid in Panniculectomy Surgery

Background

Abdominal panniculectomy after weight loss is a commonly performed procedure with high patient satisfaction yet continues to have a high post-operative complication profile. Several risk-reducing surgical approaches, such as preservation of Scarpa’s fascia, use of tissue adhesives, and progressive tension suture techniques have been described. However, the use of tranexamic acid (TXA) has not been previously reported in panniculectomy surgery.

Objectives

To improve the safety and predictability of this procedure, the authors investigate whether the use of topically administered TXA during panniculectomy surgery reduces seroma, hematoma, and drain duration.

Methods

Consecutive patients who underwent panniculectomy (January 2010 to January 2022) were retrospectively reviewed. Outcome measures included hematoma requiring surgical evacuation, seroma requiring percutaneous aspiration, and drain duration. Patients with thromboembolic diseases and those taking anticoagulation/antiplatelet medications were excluded. Patients who had received TXA were compared with a historical control group who had not received TXA.

Results

A total of 288 consecutive patients were included. Topical TXA was administered in 56 (19.4%) cases. The mean (standard deviation [SD]) follow-up was 43.9 (37.4) months (3.7 years). The median (range) resection weight was 2.6 kg (0.15-19.96 kg). Regarding seroma and hematoma formation, the use of TXA did not reduce the likelihood of developing seroma or hematoma (odds ratio [OR] = 1.7, 95% CI [0.56- 4.8], P = 0.38 and OR = 2.1, 95% CI [0.4-11.8], P = 0.42), respectively. The mean (SD) duration of drains was slightly lower in the TXA group (18.1 [12.1] days vs 19.8 [13.9] days); however, this difference was not statistically significant, albeit clinically significant.

Conclusions

As the use of TXA in plastic surgical procedures continues to expand, the utility of TXA in panniculectomy and abdominoplasty has not been elucidated. Although previous studies report hematoma and seroma risk reduction, the use of TXA was not associated with a statistically significant reduction in seroma, hematoma, or drain duration following panniculectomy surgery. Prospective, randomized controlled studies on the use of TXA in body contouring are needed.

Level of Evidence: 3

Tenets for the Proper Conduct and Use of Meta-Analyses: A Practical Guide for Neurosurgeons

Neurosurgeons today are inundated with rapidly amassing neurosurgical research publications. Systematic reviews and meta-analyses have consequently surged in popularity because, when executed properly, they constitute a high level of evidence and may save busy neurosurgeons many hours of combing and reviewing the literature for relevant articles. Meta-analysis refers to the quantitative (and discretionary) component of systematic reviews. It involves applying statistical techniques to combine effect sizes from multiple studies, which might offer more actionable insights than a systematic review without meta-analysis. Well-executed meta-analyses may prove instructive for clinical practice, but poorly conducted ones sow confusion and have the potential to cause harm. Unfortunately, recent audits have found the conduct and reporting of meta-analyses in neurosurgery (but also other surgical disciplines) to be relatively lackluster in methodologic rigor and compliance to established guidelines. Some of these deficiencies can be easily remedied through better awareness and adherence to prescribed standards-which will be reviewed in this article-but others stem from inherent problems with the source data (e.g., poor reporting of original research) as well as unique constraints faced by surgery as a field (e.g., lack of equipoise for randomized trials, or existence of learning curves for novel surgical procedures, which can lead to temporal heterogeneity), which may require unconventional tools (e.g., cumulative meta-analysis) to address. Therefore, it is also our goal to take stock of the unique issues encountered by surgeons who do meta-analysis and to highlight various techniques-some of which less well-known-to address such challenges.

The role of tranexamic acid in breast and body contouring surgery: a review of the literature

Background: Postoperative seroma and haematoma are two of the most common complications follow-ing large surface area surgeries. A review of the literature was performed to evaluate evidence for the use of tranexamic acid in reducing postoperative seroma and haematoma formation in breast surgery and body contouring surgery. Methods A literature search was performed using MEDLINE, the Cochrane Database of Systematic Review, the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Ef-fect (DARE) and PubMed in English from 1 Jan 1990–30 Mar 2020. The search terms ‘TXA’, ‘breast reduction’, ‘mammaplasty’, ‘breast implants’, ‘breast implantation’, ‘breast reconstruction’, ‘mastectomy’, ‘tissue ex-pansion’, ‘body contouring’, ‘breast’ and ‘abdominoplasty’ were used alone and in combination. Results: A total of six articles were found including three randomised controlled trials, two cohort studies and one retrospective study. Two ongoing trials were found on The Cochrane Central Register of Con-trolled Trials (CENTRAL). No systematic reviews were found. Conclusion: Literature surrounding the use of TXA in breast and body contouring surgery is sparse com-pared to what is available in other surgical sub-specialties. The literature available shows promising results with the use of TXA in controlling haematoma, drain output and seroma formation in breast surgery and body contouring surgery with minimal morbidity in these patient groups.

Tranexamic Acid Administered During Off-Pump Coronary Artery Bypass Graft Surgeries Achieves Good Safety Effects and Hemostasis

BACKGROUND

Tranexamic acid (TXA) administered during off-pump coronary artery bypass (OPCAB) surgeries has achieved good blood control in small cohorts. We aimed to investigate the safety issues and hemostasis associated with TXA administration during OPCAB in a large retrospective cohort study.

METHODS

This study included 19,687 patients with OPCAB from 2009 to 2019. A total of 1,307 patients were excluded because they were younger than 18 years or certain values were missing. Among the remaining 18,380 patients, 10,969 were in the TXA group and 7,411 patients were in the no-TXA group. There were 4,889 patients whose TXA dose was ≥50 mg/kg, and the remaining 6,080 patients had a TXA dose of <50 mg/kg. Propensity score matching (PSM) was performed between the TXA and no-TXA groups and between the high-dose and low-dose groups, and statistical analysis was performed.

RESULTS

Tranexamic acid administration did not increase the risk of hospital death or thromboembolic events. Patients who administered TXA had less blood loss at 24 h (478.32 ± 276.41 vs. 641.28 ± 295.09, p < 0.001) and 48 h (730.59 ± 358.55 vs. 915.24 ± 390.13, p < 0.001) and total blood loss (989.00 ± 680.43 vs. 1,220.01 ± 720.68, p < 0.001) after OPCAB than the patients with non-TXA. Therefore, the risk of total blood exposure [odds ratio (OR) = 0.50, 95% CI 0.47-0.54, p < 0.001] or blood component exposure (p < 0.001) was decreased significantly in the patients who administered TXA. The TXA dosage did not impact the patient survival, thromboembolic events, or blood management.

CONCLUSIONS

The application of TXA was safe and provided blood control in patients with OPCAB, and the dosage did not affect these parameters.

Tranexamic Acid Administered During Off-Pump Coronary Artery Bypass Graft Surgeries Achieves Good Safety Effects and Hemostasis

BACKGROUND

Tranexamic acid (TXA) administered during off-pump coronary artery bypass (OPCAB) surgeries has achieved good blood control in small cohorts. We aimed to investigate the safety issues and hemostasis associated with TXA administration during OPCAB in a large retrospective cohort study.

METHODS

This study included 19,687 patients with OPCAB from 2009 to 2019. A total of 1,307 patients were excluded because they were younger than 18 years or certain values were missing. Among the remaining 18,380 patients, 10,969 were in the TXA group and 7,411 patients were in the no-TXA group. There were 4,889 patients whose TXA dose was ≥50 mg/kg, and the remaining 6,080 patients had a TXA dose of <50 mg/kg. Propensity score matching (PSM) was performed between the TXA and no-TXA groups and between the high-dose and low-dose groups, and statistical analysis was performed.

RESULTS

Tranexamic acid administration did not increase the risk of hospital death or thromboembolic events. Patients who administered TXA had less blood loss at 24 h (478.32 ± 276.41 vs. 641.28 ± 295.09, p < 0.001) and 48 h (730.59 ± 358.55 vs. 915.24 ± 390.13, p < 0.001) and total blood loss (989.00 ± 680.43 vs. 1,220.01 ± 720.68, p < 0.001) after OPCAB than the patients with non-TXA. Therefore, the risk of total blood exposure [odds ratio (OR) = 0.50, 95% CI 0.47-0.54, p < 0.001] or blood component exposure (p < 0.001) was decreased significantly in the patients who administered TXA. The TXA dosage did not impact the patient survival, thromboembolic events, or blood management.

CONCLUSIONS

The application of TXA was safe and provided blood control in patients with OPCAB, and the dosage did not affect these parameters.

Current Practices in Tranexamic Acid Administration for Pediatric Trauma Patients in the United States

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.

Local Infiltration of Tranexamic Acid (TXA) in Liposuction: A Single-Surgeon Outcomes Analysis and Considerations for Minimizing Postoperative Donor Site Ecchymosis

BACKGROUND

Tranexamic acid (TXA) has gained increasing recognition in plastic surgery as a dependable adjunct capable of minimizing blood loss, ecchymosis, and edema. To date, there have been limited data on the utilization of TXA to mitigate liposuction donor site ecchymosis.

OBJECTIVES

The authors sought to investigate whether infiltration of TXA into liposuction donor sites safely reduces postoperative ecchymosis.

METHODS

A single-surgeon retrospective cohort study was performed to analyze patients undergoing autologous fat transfer for breast reconstruction between 2016 and 2019. Following lipoaspiration, patients in the intervention group received 75 mL of TXA (3 g in NaCl 0.9%) infiltrated into the liposuction donor sites, whereas the historical controls did not. Patient demographics, degree of ecchymosis, surgical complications, and thromboembolic events were examined. A blinded assessment of postoperative photographs of the donor sites was performed.

RESULTS

Overall, 120 autologous fat grafting procedures were reviewed. Sixty patients received TXA, whereas 60 patients did not. Patient demographics and comorbidities were similar among the groups. No difference existed between groups regarding donor site locations, tumescent volume, lipoaspirate volume, or time to postoperative photograph. Ten blinded evaluators completed the assessment. The median bruising score of patients who received TXA was significantly lower than that of patients who did not (1.6/10 vs 2.3/10, P = 0.01). Postoperative complications were similar among the groups. Adverse effects of TXA were not observed.

CONCLUSIONS

Patients who received local infiltration of TXA into the liposuction donor sites were found to have less donor site ecchymosis than patients who did not. Further prospective randomized studies are warranted.

LEVEL OF EVIDENCE: 4

Intraoperative tranexamic acid use in patients undergoing excision of intracranial meningioma: Randomized, placebo-controlled trial

Background:

Intracranial meningioma resection is associated with substantial intraoperative bleeding. Intraoperative tranexamic acid (TXA) use can reduce bleeding in a variety of surgical procedures. The objective of this study was to evaluate the effects of TXA treatment on blood loss and transfusion requirements in patient undergoing resection of intracranial meningioma.

Methods:

We conducted a prospective, randomized double-blind clinical study. The patient scheduled to undergo excision of intracranial meningioma were randomly assigned to receive intraoperatively either intravenous TXA or placebo. Patients in the TXA group received intravenous bolus of 20 mg/kg over 20 min followed by an infusion of 1 mg/kg/h up to surgical wound closure. Efficacy was evaluated based on total blood loss and transfusion requirements. Postoperatively, thrombotic complications, convulsive seizure, and hematoma formation were noted.

Results:

Ninety-one patients were enrolled and randomized: 45 received TXA (TXA group) and 46 received placebo (group placebo). Total blood loss was significantly decreased in TXA group compared to placebo (283 ml vs. 576 ml; P < 0.001). Transfusion requirements were comparable in the two groups (P = 0.95). The incidence of thrombotic complications, convulsive seizure, and hematoma formation was similar in the two groups.

Conclusion:

TXA significantly reduces intraoperative blood loss, but did not significantly reduced transfusion requirements in adults undergoing resection of intracranial meningioma.

Optimising bloodless cardiovascular surgery for Jehovah's Witnesses and beyond

Emerging evidence suggests surgical outcomes of patients undergoing cardiovascular surgery that refuse autologous transfusion is comparable to those who accept whole blood product transfusions. There are several methods that can be used to minimize blood loss during cardiovascular surgery. These methods can be categorised into pharmacological measures, including the use of erythropoietin, iron and tranexamic acid, surgical techniques, like the use of polysaccharide haemostat, and devices such as those used in acute normovolaemic haemodilution. More prospective studies with stricter protocols are required to assess surgical outcomes in bloodless cardiac surgery as well as further research into the long-term outcomes of bloodless cardiovascular surgery patients. This review summarizes current evidence on the use of pre-, intra-, and post-operative strategies aimed at the subset of patients who refuse blood transfusion, for example Jehovah's Witnesses.

Tranexamic ACid during PancereaticoDuodenectomy (TAC-PD): study protocol for a multicentre randomised, blind, placebo-controlled trial

INTRODUCTION

Pancreaticoduodenectomy (PD) is a major gastroenterological surgery that results in a substantial amount of blood loss. Several studies have demonstrated that major blood loss during PD is associated with both short-term and long-term poor outcomes. Administration of perioperative tranexamic acid (TXA) has been reported to reduce intraoperative blood loss in various surgeries, including cardiovascular surgery and orthopaedic surgery. Nevertheless, the effect of perioperative TXA use in patients undergoing PD has not been investigated. This study aims to investigate the effect of TXA on blood loss during PD.

METHODS AND ANALYSIS

A multicentre (six hospitals), randomised, blind (patient-blinded, surgeon-blinded, anaesthesiologist-blinded, monitor-blinded), placebo-controlled trial of TXA during PD was started in September 2019. Patients undergoing PD for biliary, duodenal or pancreatic diseases are randomly assigned to the TXA or placebo group. The stratification factors are the institutions and preoperative clinical diagnosis. Before skin incision, the participants in TXA group are administrated 1 g TXA as a loading infusion followed by a maintenance infusion of 125 mg/hour TXA until the end of surgery or 8 hours from the incision. Participants in the placebo group are administrated the same volume of saline that is indistinguishable from the TXA. The primary outcome is blood loss during PD. The secondary outcomes are intraoperative and postoperative (up to day 2) blood transfusions, operation time, anaesthesia time, postoperative laboratory variables, length of hospital stay, in-hospital and 90-day mortality and postoperative complications occurring within 28 days of surgery or requiring readmission. To date, 115 patients of a planned 220 have been enrolled in the study.

ETHICS AND DISSEMINATION

This protocol was approved by the Nagoya University Clinical Research Review Board and is registered with Japan Registry of Clinical Trials on 15 August 2019. The results of this trial will be disseminated through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

jRCTs041190062.

Intravenous Tranexamic Acid in Implant-Based Breast Reconstruction Safely Reduces Hematoma without Thromboembolic Events

BACKGROUND

Antifibrinolytic medications, such as tranexamic acid, have recently garnered increased attention. Despite its ability to mitigate intraoperative blood loss and need for blood transfusion, there remains a paucity of research in breast reconstruction. The authors investigate whether intravenous tranexamic acid safely reduces the risk of hematoma following implant-based breast reconstruction.

METHODS

A single-center retrospective cohort study was performed to analyze all consecutive patients undergoing immediate two-stage implant-based breast reconstruction following mastectomy between 2015 and 2016. The incidence of postoperative hematomas and thromboembolic events among all patients was reviewed. The patients in the intervention group received 1000 mg of intravenous tranexamic acid before mastectomy incision and 1000 mg at the conclusion of the procedure. Fisher's exact test and the Mann-Whitney-Wilcoxon test were used. Multivariate logistic regression models were performed to study the impact of intravenous tranexamic acid after adjusting for possible confounders.

RESULTS

A total of 868 consecutive breast reconstructions (499 women) were reviewed. Overall, 116 patients (217 breasts) received intravenous tranexamic acid, whereas 383 patients (651 breasts) did not. Patient characteristics and comorbidities were similar between the two the groups. Patients who received tranexamic acid were less likely to develop hematomas [n = 1 (0.46 percent)] than patients who did not [n = 19 (2.9 percent)] after controlling for age, hypertension, and type of reconstruction (prepectoral and subpectoral) (p = 0.018). Adverse effects of intravenous tranexamic acid, including thromboembolic phenomena were not observed. Multivariate analysis demonstrated that age and hypertension independently increase risk for hematoma.

CONCLUSIONS

Intravenous tranexamic acid safely reduces risk of hematoma in implant-based breast reconstruction. Further prospective randomized studies are warranted to further corroborate these findings.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Efficacy and Safety of Tranexamic Acid in Bimaxillary Orthognathic Surgery

Background

Tranexamic acid (TXA) has been widely used during craniofacial and orthognathic surgery (OS). However, results of the literature are inconsistent due to specific type of surgery and a small sample of studies. The purpose of this study was to evaluate the role of TXA in bimaxillary OS.

Methods

We performed a comprehensive literature search of PubMed, Cochrane Central Register of Controlled Trials, and EMBASE to identify randomized controlled trials (RCTs) that compared effect of TXA on bimaxillary OS with placebo. Outcomes of interests included intraoperative blood loss, allogenic transfusion, operation time, and volume of irrigation fluid. Random effects models were chosen considering that heterogeneity between studies was anticipated, and I ² statistics were used to test for the presence of heterogeneity.

Results

Totally 6 RCTs were identified. Tranexamic acid resulted in significantly reduced intraoperative blood loss (weighted mean difference [WMD] = -264.82 mL; 95% CI: -380.60 to -149.04 mL) and decreased amounts of irrigation fluid (WMD = -229.23 mL; 95% CI: -399.63 to -58.83 mL). However, TXA had no remarkable impact on risk of allogenic blood transfusion (pooled risk ratio = 0.50; 95% CI: 0.20-1.23), operation time (WMD = -8.71 min; 95% CI: -20.98 to 3.57 min), and length of hospital stay (WMD = -0.24 day; 95% CI: -0.62 to 0.14 day). No TXA-associated severe adverse reactions or complications were observed.

Conclusions

Currently available meta-analysis reveals that TXA is effective in decreasing intraoperative blood loss; however, it does not reduce the risk of allogenic blood transfusion in bimaxillary OS.

Postoperative complications associated with coronary artery bypass graft surgery and their therapeutic interventions

Coronary artery disease is one of the commonest surgery demanding cardiovascular diseases. Coronary artery bypass graft surgery is practiced all over the world for the treatment of coronary artery disease. Systemic trauma during the surgery is associated with a wide range of complications, some of which are fatal. Preoperative risk factors such as age, previous illness and obesity are common predictors of these adverse events. Advances in therapeutic medicine have allowed timely treatment of these adverse events and co-morbidities. This review summarizes some of the most occurring complications associated with coronary artery bypass graft and corresponding treatment options.

Strategies to minimize intraoperative blood loss during major surgery

Background

Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies.

Methods

This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient.

Results

Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays.

Conclusion

Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high-quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.

Early and long-term outcomes of coronary artery bypass surgery with and without use of heart-lung machine and with special respect to renal function - A retrospective study

The aim of our study was to compare early and long-term outcome of patients undergoing either on-pump or off-pump coronary artery bypass grafting with special focus on impairment of renal function. Five hundred ninety-three consecutive patients undergoing coronary artery bypass grafting were retrospectively analyzed. They were assigned either to on-pump (n = 281) or to off-pump (n = 312) group. Early and long-term outcomes were analyzed with special focus on renal function. Basic demographics and preoperative characteristics did not differ between groups (p>0.05) as well as postoperative renal parameters (p>0.05). Postoperative odds ratios (OR) of off-pump group in comparison to on-pump group were higher without reaching significance in terms of incidence of gastrointestinal complications and pneumonia (OR = 2.23 and 1.61, respectively) as well as hazard ratios (HR) on long-term follow-up for mortality and incidence of myocardial infarction (HR = 1.50 and 2.29, respectively). Kaplan-Meier estimation analysis also revealed similar results for both groups in terms of mid- and long-term survival (Breslow p = 0.062 and Log-Rank p = 0.064, respectively) and for incidence of myocardial infarction (Breslow p = 0.102 and Log-Rank p = 0.103, respectively). Our study suggests that use or not use of coronary artery bypass did not influence postoperative renal function. Odds of early outcomes were similar in both groups as well as incidence of myocardial infarction and mortality in long-term follow-up.

Preoperative Tranexamic Acid for Treatment of Bleeding, Edema, and Ecchymosis in Patients Undergoing Rhinoplasty: A Systematic Review and Meta-analysis

Importance

Evidence has emerged on the efficacy of tranexamic acid to control blood loss and postoperative complications after rhinoplasty.

Objective

To investigate the results of tranexamic acid use to reduce intraoperative bleeding, postoperative eyelid edema, and periorbital ecchymosis in rhinoplasty.

Data Sources and Study Selection

For this systematic review of randomized clinical trials, searches were performed in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, Science Direct, Google Scholar, OpenThesis, and ClinicalTrials.gov from inception to December 23, 2017. Key words included tranexamic acid, rhinoplasty, and nasal surgical procedures. The following elements were used to define eligibility criteria: (1) population: patients undergoing rhinoplasty surgery; (2) intervention and controls: tranexamic acid vs placebo solution or no-treatment control group; (3) outcomes: intraoperative bleeding, postoperative eyelid edema and periorbital ecchymosis, and thromboembolic events; and (4) study type: randomized clinical trials.

Data Extraction and Synthesis

Two reviewers extracted data and assessed study quality according to the Cochrane guidelines for randomized clinical trials. Treatment effects were defined as weighted mean difference (WMD) and 95% CIs. The strength of evidence was analyzed using the Grading of Recommendations Assessment, Development, and Evaluation rating system.

Main Outcomes and Measures

Intraoperative bleeding, postoperative eyelid edema and periorbital ecchymosis. To calculate the effect sizes, means and SDs were obtained for each study group and outcome of interest.

Results

Five studies comprising 276 patients were included in the systematic review: 177 patients (64.1%) were women, and mean age was 26.8 (range, 16-42) years. Four studies comprising 246 patients estimated the amount in intraoperative bleeding as a primary outcome and were included in the meta-analysis. Eyelid edema and ecchymosis were evaluated as outcomes in 2 studies. Tranexamic acid was associated with reduced bleeding during rhinoplasty was found (WMD, -42.28 mL; 95% CI, -70.36 to -14.21 mL), with differences (P = .01) between oral (WMD, -61.70 mL; 95% CI, -83.02 to -40.39 mL; I2 = 0%) and intravenous (WMD, -23.88 mL; 95% CI, -45.19 to -2.58 mL; I2 = 56%) administration. Eyelid edema and ecchymosis scores in patients receiving tranexamic acid were significantly lower compared with the control group within the first postoperative week: lower eyelid edema, WMD, -0.76; 95% CI, -1.04 to -0.49 and lower eyelid ecchymosis, WMD, -0.94; 95% CI, -1.80 to -0.08. No cases of thromboembolic events were reported.

Conclusions and Relevance

Current available evidence suggests that preoperative administration of tranexamic acid is safe and may reduce intraoperative bleeding as well as postoperative eyelid edema and ecchymosis in patients undergoing rhinoplasty.

Tranexamic acid in cardiac surgery: a systematic review and meta-analysis (protocol)

INTRODUCTION

Bleeding during cardiac surgery is associated with increased morbidity and mortality. Tranexamic acid is an antifibrinolytic with proven efficacy in major surgeries. Current clinical practice guidelines recommend intraoperative use in cardiac procedures. However, several complications have been reported with tranexamic acid including seizures. This review intends to summarise the evidence examining the efficacy and safety of tranexamic acid in patients undergoing cardiac surgery.

METHODS/DESIGN

We will search MEDLINE, Embase, PubMED, ACPJC, CINAHL and the Cochrane trial registry for eligible randomised controlled trials, the search dates for all databases will be from inception until 1 January 2019, investigating the perioperative use of topical and/or intravenous tranexamic acid as a stand-alone antifibrinolytic agent compared with placebo in patients undergoing open cardiac surgery. We categorised outcomes as patient critical or patient important. Selected patient-critical outcomes are: mortality (intensive care unit, hospital and 30-day endpoints), reoperation within 24 hours, postoperative bleeding requiring transfusion of packed red blood cells, myocardial infarction, stroke, pulmonary embolism, bowel infarction, upper or lower limb deep vein thrombosis and seizures. Those outcomes, we perceived as clinical experts to be most patient valued and patients were not involved in outcomes selection process. We will not apply publication date, language, journal or methodological quality restrictions. Two reviewers will independently screen and identify eligible studies using predefined eligibility criteria and then review full reports of all potentially relevant citations. A third reviewer will resolve disagreements if consensus cannot be achieved. We will present the results as relative risk with 95% CIs for dichotomous outcomes and as mean difference or standardised mean difference for continuous outcomes with 95% CIs. We will assess the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

Formal ethical approval is not required as primary data will not be collected. The results will be disseminated through a peer-reviewed publication TRIAL REGISTRATION NUMBER: CRD42018105904.

Safety, efficacy, and cost-effectiveness of intraoperative blood salvage in OPCABG with different amount of bleeding: a single-center, retrospective study

Background

We sought to evaluate the safety, efficacy, and cost-effectiveness of intraoperative blood salvage (IBS) in off-pump coronary artery bypass grafting (OPCABG) surgery with different amount of bleeding.

Methods

We retrospectively reviewed the medical records of 321 patients who underwent OPCABG between December 2012 and December 2016 at our hospital. Patients treated with IBS or allogeneic blood (AB) transfusions were divided into three groups depending on the amount of bleeding respectively: IBS1 or AB1 group (400–600 ml); IBS2 or AB2 group (600–1000 ml); IBS3 or AB3 group (1000–1500 ml). The intraoperative and postoperative conditions, blood transfusion volume, clinical and hematological outcomes, and total blood transfusion cost were examined.

Results

The amount of allogeneic red blood cell (RBC) transfusion in the IBSs groups were significantly lower than that in the ABs groups (P < 0.01). Furthermore, drainage volume 24 h post-surgery (P < 0.05) and white blood cell count (WBC) 2 day post-surgery (P < 0.01) in IBS3 group were significantly higher compared with the AB3 group. Additionally, when IBS cost was 230 USD per set, the total blood transfusion cost in the IBSs groups was significantly higher than that in the ABs groups (P < 0.01); however, when 199 or 184 USD, only the IBS1 group, rather than IBS2 or IBS3, showed significantly higher cost of the total blood transfusion compared with the AB1 group (P < 0.05).

Conclusions

When the amount of bleeding was 600–1000 ml, IBS can significantly reduce the demand for allogeneic blood, and has no direct adverse effects on coagulation function and recuperation, and is cost-effective in OPCABG.