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Alzahrani A, Alkofide H, Joharji H, Korayem GB, Aljohani S, Alshareef H, AlFaifi M, Alalawi H, Sulaiman KA. Evaluation of the Safety and Effectiveness of Topical Intrapleural Application of Tranexamic Acid in Thoracic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Appl Thromb Hemost 2023; 29:10760296231218215. [PMID: 38115686 PMCID: PMC10734325 DOI: 10.1177/10760296231218215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/01/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVES Bleeding remains a common complication post-thoracic surgery. Although intravenous tranexamic acid (TXA) has been shown to decrease blood loss, its use has been associated with adverse effects. Accordingly, topical TXA has been proposed as an alternative to reduce bleeding with fewer systemic complications. METHODS We searched Medline, Embase, and Cochrane Central databases for randomized controlled trials (RCTs) comparing topical TXA versus control (i.e., placebo) in patients undergoing thoracic procedures. The primary outcome was total postoperative blood loss at 24 hours. Secondary outcomes included were the number of red blood cell (RBC) transfusions, and hospital length of stay (LOS). Meta-analyses were pooled using mean difference with inverse-variance weighting and random-effects. RESULTS Out of the 575 unique studies that were screened, we identified three randomized controlled trials (RCTs) involving 399 patients. Out of the three RCTs analyzed, two studies, accounting for 67% of the total, were found to have a low risk of bias. The primary outcome of 24-h post-operative blood loss was significantly lower in patients who received TXA (mean difference [MD] -93.6 ml, 95% CI -121.8 to -65.4 ml, I2 = 45%). In addition, the need for RBC transfusion was significantly lower in the topical TXA group compared to control (MD -0.5 units, 95% CI -0.8 to -0.3 units, I2 = 60%). However, there was no significant difference in the hospital length of stay (LOS) (MD -0.3 days, 95% CI -0.9 to 0.4 days, I2 = 0%). These results remained consistent after several sensitivity analyses. The use of topical intrapleural tranexamic acid has also been found to be safe without any significant safety concerns. CONCLUSION Topical intrapleural TXA reduces blood loss and the need for blood transfusions during thoracic surgery. In addition, there is no evidence of the increased safety concerns associated with its use. Larger trials are necessary to validate these findings and evaluate the safety and efficacy of different dosages.
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Affiliation(s)
- Amer Alzahrani
- Division of Thoracic Surgery, Department of Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
- King Faisal Specialist Hospital and Research Centre Organ Transplant Center of Excellence, Riyadh, Saudi Arabia
| | - Hadeel Alkofide
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Drug Regulation Research Affairs Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hala Joharji
- King Faisal Specialist Hospital and Research Centre Organ Transplant Center of Excellence, Riyadh, Saudi Arabia
| | - Ghazwa B. Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Sarah Aljohani
- Department of Pharmaceutical Services, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Hanan Alshareef
- Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
| | - Mashael AlFaifi
- Pharmaceutical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Hassan Alalawi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khalid Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia
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Hurskainen T, Deng MX, Etherington C, Burns JK, Martin Calderon L, Moher D, Edwards W, Boet S. Tranexamic acid for prevention of bleeding in cesarean delivery: An overview of systematic reviews. Acta Anaesthesiol Scand 2022; 66:3-16. [PMID: 34514595 DOI: 10.1111/aas.13981] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/20/2021] [Accepted: 08/24/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Bleeding is the leading cause of maternal mortality in the world. Tranexamic acid reduces bleeding in trauma and surgery. Several systematic reviews of randomized trials have investigated tranexamic acid in the prevention of bleeding in cesarean delivery. However, the conclusions from systematic reviews are conflicting. This overview aims to summarize the evidence and explore the reasons for conflicting conclusions across the systematic reviews. METHODS A comprehensive literature search of Medline, Embase, and Cochrane Database of Systematic Reviews was conducted from inception to April 2021. Screening, data extraction, and quality assessments were performed by two independent reviewers. A Measurement Tool to Assess Reviews 2 and the Risk of Bias Assessment Tool for Systematic Reviews were used for study appraisal. A qualitative synthesis of evidence is presented. RESULTS In all, 14 systematic reviews were included in our analysis. Across these reviews, there were 32 relevant randomized trials. A modest reduction in blood transfusions and bleeding outcomes was found by most systematic reviews. Overall confidence in results varied from low to critically low. All of the included systematic reviews were at high risk of bias. Quality of evidence from randomized trials was uncertain. CONCLUSIONS Systematic reviews investigating prophylactic tranexamic acid in cesarean delivery are heterogeneous in terms of methodological and reporting quality. Tranexamic acid may reduce blood transfusion and bleeding outcomes, but rigorous well-designed research is needed due to the limitations of the included studies. Data on safety and adverse effects are insufficient to draw conclusions.
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Affiliation(s)
- Tomi Hurskainen
- Department of Anesthesiology The Ottawa HospitalUniversity of Ottawa Ottawa Ontario Canada
- Division of Anesthesiology Department of Anesthesiology, Intensive Care and Pain Medicine Helsinki University Hospital Helsinki Finland
| | - Mimi X. Deng
- School of Medicine University of Ottawa Ottawa Ontario Canada
| | - Cole Etherington
- Ottawa Hospital Research Institute – Centre for Practice Changing Research Ottawa Ontario Canada
| | - Joseph K. Burns
- Clinical Research Assistant Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada
| | | | - David Moher
- Knowledge Synthesis Group Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada
- School of Epidemiology and Public Health University of Ottawa Ottawa Ontario Canada
| | - Wesley Edwards
- Department of Anesthesia and Pain Medicine The Ottawa Hospital Ottawa Ontario Canada
- Faculty of Medicine University of Ottawa Ottawa Ontario Canada
| | - Sylvain Boet
- Department of Anesthesiology and Pain Medicine The Ottawa Hospital Research InstituteThe Ottawa HospitalGeneral Campus Ottawa Ontario Canada
- Department of Innovation in Medical Education The Ottawa Hospital Research InstituteThe Ottawa HospitalGeneral Campus Ottawa Ontario Canada
- Faculty of Medicine Francophone Affairs Ottawa Ontario Canada
- Institut du savoir Montfort Ottawa Ontario Canada
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Balík M, Košina J, Hušek P, Broďák M, Čečka F. Safety and Efficacy of Using Tranexamic Acid at the Beginning of Robotic-Assisted Radical Prostatectomy in a Double-Blind Prospective Randomized Pilot Study. ACTA MEDICA (HRADEC KRÁLOVÉ) 2021; 63:176-182. [PMID: 33355078 DOI: 10.14712/18059694.2020.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The prophylactic administration of tranexamic acid has been shown to be appropriate for procedures with a high risk of perioperative bleeding in cardiac surgery and orthopaedics. In urology the ambiguous results have been reported. Our goal was to evaluate the effect of tranexamic acid administration in robotic-assisted radical prostatectomy (RARP). A pilot, prospective, double-blind, randomized study was conducted to evaluate this effect. METHODS The study included 100 patients who received RARP in the period from April 2017 to January 2018. The patients were randomly assigned to study and control groups of 50 patients each. RESULTS The median follow-up was 6 months. Lower haemoglobin level drop weighted for gram of operated prostate was observed in the study group when treating the dorsal vein complex (DVC) at the beginning of the procedure (p = 0.004 after 3 hours and p < 0.001 after 24 hours). There was no evidence of any serious side effect of tranexamic acid. CONCLUSION We demonstrated the safety of tranexamic acid at RARP. In addition, we showed that administration of tranexamic acid at the beginning of RARP significantly reduces the decrease in haemoglobin after the procedure when treating the DVC at the beginning of the procedure.
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Affiliation(s)
- Michal Balík
- Department of Urology, Faculty of Medicine and University Hospital Hradec Králové, Czech Republic
| | - Josef Košina
- Department of Urology, Faculty of Medicine and University Hospital Hradec Králové, Czech Republic
| | - Petr Hušek
- Department of Urology, Faculty of Medicine and University Hospital Hradec Králové, Czech Republic
| | - Miloš Broďák
- Department of Urology, Faculty of Medicine and University Hospital Hradec Králové, Czech Republic
| | - Filip Čečka
- Department of Surgery, Faculty of Medicine and University Hospital Hradec Králové, Czech Republic.
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Montroy J, Hutton B, Fergusson DA, Tinmouth A, Lavallée LT, Cagiannos I, Morash C, Flaman A, Breau RH. Lysine analogue use during cancer surgery: a survey from a Canadian tertiary care centre. Curr Oncol 2020; 27:e560-e568. [PMID: 33380871 PMCID: PMC7755431 DOI: 10.3747/co.27.6613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background When used during surgery, antifibrinolytic hemostatic agents such as lysine analogues are effective at reducing blood loss and the need for transfusions. Despite proven efficacy, use of hemostatic agents remains low during some surgeries. Our objective was to explore surgeon opinions about, and use of lysine analogues in, oncologic surgeries at a large tertiary care academic institution. Methods We administered a survey to surgeons who perform high-transfusion-risk oncologic surgeries at a large academic hospital in Ottawa, Ontario. Design and distribution of the survey followed a modified Dillman method. To ensure that the survey questionnaire was relevant, clear, and concise, we performed informant interviews, cognitive interviews, and pilot-testing. The final survey consisted of 19 questions divided into 3 sections: respondent demographics, use of hemostatic agents, and potential clinical trial opinions. Results Of 28 surgeons, 24 (86%) participated. When asked to indicate the frequency of lysine analogue use, "never" accounted for 46% of the responses, and "rarely" (<10% of the time) accounted for 23% of the responses. Reasons for never using included "unfamiliar with benefits" and "prefer alternatives." Fifteen surgeons (63%) felt that a trial was needed to demonstrate the efficacy and safety of lysine analogues in their cancer field. Conclusions Our survey found that lysine analogues are infrequently used during oncologic surgeries at our institution. Many surgeons are unfamiliar with the benefits and side effects of lysine analogues and, alternatively, use topical hemostatic agents. Our results demonstrate that future trials exploring the efficacy and safety of lysine analogues in oncologic surgery are needed.
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Affiliation(s)
- J Montroy
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
| | - B Hutton
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
| | - D A Fergusson
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
- University of Ottawa, School of Epidemiology and Public Health, The Ottawa Hospital, Ottawa, ON
| | - A Tinmouth
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
| | - L T Lavallée
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
- University of Ottawa, School of Epidemiology and Public Health, The Ottawa Hospital, Ottawa, ON
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON
| | - I Cagiannos
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON
| | - C Morash
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON
| | - A Flaman
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
| | - R H Breau
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
- University of Ottawa, School of Epidemiology and Public Health, The Ottawa Hospital, Ottawa, ON
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON
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Abstract
Objective: To review the mechanism of action, pharmacology, dosing, and complications of tranexamic acid (TXA) and consolidate current evidence for TXA in gynecologic surgery.Methods: A literature search of PubMed, Ovid (MEDLINE), Google Scholar, and Elsevier was performed, in addition to a targeted search of cited references involving TXA and gynecologic surgery. Preference was given to systematic reviews and randomized control trials (RCTs).Results: TXA reversibly binds to plasminogen, preventing clot degradation. RCTs on hysterectomy, myomectomy, cervical conisation, hysteroscopy, and surgery for cervical and ovarian cancer were identified, as were case reports on TXA use for ectopic pregnancy. During hysterectomy, TXA reduces blood loss (two RCTs, n = 432, mean difference -66.0 mL and 180 mL), blood transfusion (1 RCT, n = 100, 12% vs. 42%, p < .00001). For myomectomy, a systematic review and meta-analysis showed a statistically significant decrease in blood loss with TXA (two RCTs, mean difference -213.1 mL, 95% CI: -242.4 mL to -183.7 mL). Following cervical conisation, TXA decreased the risk of delayed hemorrhage (four RCTs, RR 0.23, 95% CI: 0.11-0.50). A single RCT for cervical and ovarian cancer surgery demonstrated a decrease mean blood loss of 120 mL-135 mL and 210 mL, respectively, and fewer blood transfusions for the latter (OR 0.44, upper 95% CI: 0.97, p = .02). Less robust data suggest a possible benefit from TXA during hysteroscopy and surgery for ectopic pregnancies. Most commonly, 1 g of intravenous TXA is given intraoperatively.Conclusion: TXA is a safe adjunct that can be considered in a variety of gynecologic surgeries to decrease blood loss and risk of blood transfusion.
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Affiliation(s)
- Andrew Zakhari
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Ari Paul Sanders
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
- Department of Obstetrics and Gynecology, Peter Lougheed Centre, University of Calgary, Calgary, Canada
| | - Meir Jonathon Solnik
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
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O'Donnell JS, Lavin M. Perioperative management of patients with von Willebrand disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:604-609. [PMID: 31808837 PMCID: PMC6913501 DOI: 10.1182/hematology.2019000065] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Surgical procedures represent a serious hemostatic challenge for patients with von Willebrand disease (VWD), and careful perioperative management is required to minimize bleeding risk. Risk stratification includes not only the nature of the surgery to be performed but the baseline plasma von Willebrand factor (VWF) levels, bleeding history, and responses to previous challenges. Baseline bleeding scores (BSs) may assist in identification of patients with a higher risk of postsurgical bleeding. There remains a lack of consensus between best practice guidelines as to the therapeutic target and assays to be monitored in the postoperative period. Hemostatic levels are maintained until bleeding risk abates: usually 3 to 5 days for minor procedures and 7 to 14 days for major surgery. Hemostatic supplementation is more complex in VWD than in other bleeding disorders owing to the combined but variable deficiency of both plasma VWF and factor VIII (FVIII) levels. For emergency surgery, coadministration of VWF and FVIII is required to ensure hemostasis; however, for elective procedures, early infusion of VWF replacement therapy will stabilize endogenous FVIII. Because endogenous FVIII production is unaffected in patients with VWD, repeated VWF supplementation (particularly with plasma-derived FVIII-containing products) may lead to accumulation of FVIII. Frequent monitoring of plasma levels and access to hemostatic testing are, therefore, essential for patients undergoing major surgery, particularly with more severe forms of VWD.
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Affiliation(s)
- James S O'Donnell
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland; and
- National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | - Michelle Lavin
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland; and
- National Coagulation Centre, St. James' Hospital, Dublin, Ireland
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Steinmetzer T, Pilgram O, Wenzel BM, Wiedemeyer SJA. Fibrinolysis Inhibitors: Potential Drugs for the Treatment and Prevention of Bleeding. J Med Chem 2019; 63:1445-1472. [PMID: 31658420 DOI: 10.1021/acs.jmedchem.9b01060] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hyperfibrinolytic situations can lead to life-threatening bleeding, especially during cardiac surgery. The approved antifibrinolytic agents such as tranexamic acid, ε-aminocaproic acid, 4-aminomethylbenzoic acid, and aprotinin were developed in the 1960s without the structural insight of their respective targets. Crystal structures of the main antifibrinolytic targets, the lysine binding sites on plasminogen's kringle domains, and plasmin's serine protease domain greatly contributed to the structure-based drug design of novel inhibitor classes. Two series of ligands targeting the lysine binding sites have been recently described, which are more potent than the most-widely used antifibrinolytic agent, tranexamic acid. Furthermore, four types of promising active site inhibitors of plasmin have been developed: tranexamic acid conjugates targeting the S1 pocket and primed sites, substrate-analogue linear homopiperidylalanine-containing 4-amidinobenzylamide derivatives, macrocyclic inhibitors addressing nonprimed binding regions, and bicyclic 14-mer SFTI-1 analogues blocking both, primed and nonprimed binding sites of plasmin. Furthermore, several allosteric plasmin inhibitors based on heparin mimetics have been developed.
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Affiliation(s)
- Torsten Steinmetzer
- Department of Pharmacy, Institute of Pharmaceutical Chemistry , Philipps University Marburg , Marbacher Weg 6 , D-35032 Marburg , Germany
| | - Oliver Pilgram
- Department of Pharmacy, Institute of Pharmaceutical Chemistry , Philipps University Marburg , Marbacher Weg 6 , D-35032 Marburg , Germany
| | - Benjamin M Wenzel
- Department of Pharmacy, Institute of Pharmaceutical Chemistry , Philipps University Marburg , Marbacher Weg 6 , D-35032 Marburg , Germany
| | - Simon J A Wiedemeyer
- Department of Pharmacy, Institute of Pharmaceutical Chemistry , Philipps University Marburg , Marbacher Weg 6 , D-35032 Marburg , Germany
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Breau RH, Lavallée LT, Cnossen S, Witiuk K, Cagiannos I, Momoli F, Bryson G, Kanji S, Morash C, Turgeon A, Zarychanski R, Mallick R, Knoll G, Fergusson DA. Tranexamic Acid versus Placebo to Prevent Blood Transfusion during Radical Cystectomy for Bladder Cancer (TACT): Study Protocol for a Randomized Controlled Trial. Trials 2018; 19:261. [PMID: 29716640 PMCID: PMC5930484 DOI: 10.1186/s13063-018-2626-3] [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: 11/02/2017] [Accepted: 04/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Radical cystectomy for bladder cancer is associated with a high risk of needing red blood cell transfusion. Tranexamic acid reduces blood loss during cardiac and orthopedic surgery, but no study has yet evaluated tranexamic acid use during cystectomy. METHODS A randomized, double-blind (surgeon-, anesthesiologist-, patient-, data-monitor-blinded), placebo-controlled trial of tranexamic acid during cystectomy was initiated in June 2013. Prior to incision, the intervention arm participants receive a 10 mg/kg loading dose of intravenously administered tranexamic acid, followed by a 5 mg/kg/h maintenance infusion. In the control arm, the patient receives an identical volume of normal saline that is indistinguishable from the intervention. The primary outcome is any blood transfusion from the start of surgery up to 30 days post operative. There are no strict criteria to mandate the transfusion of blood products. The decision to transfuse is entirely at the discretion of the treating physicians who are blinded to patient allocation. Physicians are allowed to utilize all resources to make transfusion decisions, including serum hemoglobin concentration and vital signs. To date, 147 patients of a planned 354 have been randomized to the study. DISCUSSION This protocol reviews pertinent data relating to blood transfusion during radical cystectomy, highlighting the need to identify methods for reducing blood loss and preventing transfusion in patients receiving radical cystectomy. It explains the clinical rationale for using tranexamic acid to reduce blood loss during cystectomy, and outlines the study methods of our ongoing randomized controlled trial. TRIAL REGISTRATIONS Canadian Institute for Health Research (CIHR) Protocol: MOP-342559; ClinicalTrials.gov, ID: NCT01869413. Registered on 5 June 2013.
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Affiliation(s)
- Rodney H Breau
- Ottawa Hospital Research Institute, Ottawa, ON, Canada. .,Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada.
| | - Luke T Lavallée
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sonya Cnossen
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kelsey Witiuk
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ilias Cagiannos
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Franco Momoli
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Gregory Bryson
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Ottawa and Ottawa Hospital, Ottawa, ON, Canada
| | - Salmaan Kanji
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Christopher Morash
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Alexis Turgeon
- CHU de Québec, Université Laval, Québec City, QC, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Section of Medical Oncology and Haematology, University of Manitoba, Winnipeg, MB, Canada
| | | | - Greg Knoll
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
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Montroy J, Hutton B, Moodley P, Fergusson NA, Cheng W, Tinmouth A, Lavallée LT, Fergusson DA, Breau RH. The efficacy and safety of topical tranexamic acid: A systematic review and meta-analysis. Transfus Med Rev 2018; 32:S0887-7963(17)30151-7. [PMID: 29567052 DOI: 10.1016/j.tmrv.2018.02.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/05/2018] [Accepted: 02/10/2018] [Indexed: 12/21/2022]
Abstract
Tranexamic acid (TXA) is an effective hemostatic agent used for the reduction of blood loss and transfusion. However, the safety profile of TXA remains in question due to a potential increased risk of venous thromboembolism. By applying TXA topically as opposed to intravenously, systemic absorption may be reduced and unwanted side-effects mitigated. The objective of our review is to investigate the efficacy and safety of topically applied tranexamic acid compared to both placebo, and the intravenous administration. Cochrane Central Register of Controlled Trials, MEDLINE, Embase, ISI Web of Science, PubMed, and Clinicaltrials.gov were searched from inception to November, 2016. We included randomized controlled trials that compared topical tranexamic acid to either placebo (or standard care) or intravenous administration, in adult patients. Surgical and non-surgical trials were included. Abstract, full-text selection, data extraction and risk of bias assessment were all performed in duplicate. In total, 67 studies involving 6,034 patients met inclusion criteria. The majority of trials evaluated orthopedic procedures. Compared to placebo, the administration of topical TXA significantly reduced the odds of receiving a blood transfusion (pooled OR 0.28, 95% CI 0.20 to 0.38; P < 0.001) and significantly reduced mean blood loss (WMD -276.6, 95% CI -327.8 to -225.4; P < 0.0001). When compared to the intravenous administration, there was no difference between the two groups in terms of transfusion requirements (pooled OR 1.03, 95% CI 0.72 to 1.46; P=0.88) or blood loss (WMD -21.95, 95% CI -66.61 to 27.71; P=0.34). There was no difference in the odds of developing a venous thromboembolic complication between the topical TXA and control groups (pooled OR=0.78, 95% CI 0.47 to 1.29; P=0.33) or the topical and intravenous groups (pooled OR=0.75, 95% CI 0.39 to 1.46; P=0.40). The topical application of TXA effectively reduces both transfusion risk and blood loss compared to placebo, without increasing thromboembolic risks. There were no major differences between topical and intravenous tranexamic acid with respect to safety and efficacy, and both were superior to placebo with regards to blood loss and transfusion requirements. Further study of the topical application is required outside of the field of orthopedics.
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Affiliation(s)
- Joshua Montroy
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; University of Ottawa, School of Epidemiology, Community Medicine and Preventive Medicine, Ottawa, ON, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; University of Ottawa, School of Epidemiology, Community Medicine and Preventive Medicine, Ottawa, ON, Canada
| | - Preveshen Moodley
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Nicholas A Fergusson
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alan Tinmouth
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Luke T Lavallée
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; University of Ottawa, School of Epidemiology, Community Medicine and Preventive Medicine, Ottawa, ON, Canada; Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Rodney H Breau
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.
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Montroy J, Fergusson NA, Hutton B, Lavallée LT, Morash C, Cagiannos I, Cnossen S, Fergusson DA, Breau RH. The Safety and Efficacy of Lysine Analogues in Cancer Patients: A Systematic Review and Meta-Analysis. Transfus Med Rev 2017; 31:141-148. [DOI: 10.1016/j.tmrv.2017.03.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
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Management of the Jehovah's Witness in Obstetrics and Gynecology: A Comprehensive Medical, Ethical, and Legal Approach. Obstet Gynecol Surv 2017; 71:488-500. [PMID: 27526872 DOI: 10.1097/ogx.0000000000000343] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Obstetricians and gynecologists frequently deal with hemorrhage so they should be familiar with management of patients who refuse blood transfusion. Although there are some reports in the literature about management of Jehovah's Witness patients in obstetrics and gynecology, most of them are case reports, and a comprehensive review about these patients including ethicolegal perspective is lacking. OBJECTIVE This review outlines the medical, ethical, and legal implications of management of Jehovah's Witness patients in obstetrical and gynecological settings. EVIDENCE ACQUISITION A search of published literature using PubMed, Ovid Medline, EMBASE, and Cochrane databases was conducted about physiology of oxygen delivery and response to tissue hypoxia, mortality rates at certain hemoglobin levels, medical management options for anemic patients who refuse blood transfusion, and ethical/legal considerations in Jehovah's Witness patients. RESULTS Early diagnosis of anemia and immediate initiation of therapy are essential in patients who refuse blood transfusion. Medical management options include iron supplementation and erythropoietin. There are also some promising therapies that are in development such as antihepcidin antibodies and hemoglobin-based oxygen carriers. Options to decrease blood loss include antifibrinolytics, desmopressin, recombinant factor VII, and factor concentrates. When surgery is the only option, every effort should be made to pursue minimally invasive approaches. CONCLUSION AND RELEVANCE All obstetricians and gynecologists should be familiar with alternatives and "less invasive" options for patients who refuse blood transfusions.
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