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Zhao M, Luo Y, Guo Z, Mu L, Lu J. The Efficacy of Tranexamic Acid in Craniomaxillofacial Surgery: A Systematic Review of Randomized Controlled Trials. J Craniofac Surg 2023; 34:2437-2441. [PMID: 37702525 DOI: 10.1097/scs.0000000000009724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/04/2023] [Indexed: 09/14/2023] Open
Abstract
This study aimed to evaluate the use of tranexamic acid in craniomaxillofacial surgery by meta-analysis. A comprehensive search was performed for randomized controlled trials (RCTs) mainly in 3 electronic databases (PubMed, EMBASE, and Cochrane Library) before August 2022. We collected and managed data for weighted mean difference of intraoperative blood loss, transfusion requirement, and operation time for the study. A total of 13 randomized controlled trials were included in the analysis. Compared with the control group, the tranexamic acid group showed a reduction in intraoperative blood loss of 198.67 ml (95% CI: -258.84 to -138.50 ml, P <0.00001), with blood transfusion requirement decreased by 7.77 ml/kg (95% CI: -10.80 to -4.73, P <0.0001) and less operation time (weighted mean difference= -10.39 min; 95% CI: -16.49 to -4.30 min, P =0.0008).
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Affiliation(s)
- Minghao Zhao
- Department of Cranio-maxillo-facial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yuna Luo
- Department of Cranio-maxillo-facial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ziying Guo
- Department of Cranio-maxillo-facial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lin Mu
- Department of Burns and Plastic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Jianjian Lu
- Department of Cranio-maxillo-facial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Lin PS, Yao YT, Tian LJ, Jiang JJ, Zhang Y, He LX, Yu YP, Ma J. The efficacy and safety of intravenous administration of tranexamic acid in patients undergoing cardiac surgery: Evidence from a single cardiovascular center. Medicine (Baltimore) 2023; 102:e33819. [PMID: 37335691 DOI: 10.1097/md.0000000000033819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND The current study was performed to systemically review the efficacy and safety of tranexamic acid (TXA) in patients undergoing cardiac surgery at a single large-volume cardiovascular center. METHODS A computerized search of electronic databases was performed to identify all relevant studies using search terms till December 31st, 2021. The primary outcomes were postoperative blood loss and the composite incidence of mortality and morbidities during hospitalization. Secondary outcomes included postoperative massive bleeding and transfusion, postoperative recovery profiles, coagulation functions, inflammatory variables, and biomarkers of vital organ injury. RESULTS Database search yielded 23 qualified studies including 27,729 patients in total. Among them, 14,136 were allocated into TXA group and 13,593 into Control group. The current study indicated that intravenous TXA significantly reduced total volume of postoperative bleeding in both adult and pediatric patients, and that medium- and high-dose TXA were more effective than low-dose TXA in adult patients (P < .05). The current study also demonstrated that intravenous TXA, as compared to Control, remarkably reduced postoperative transfusion incidences and volume of red blood cell and fresh frozen plasma, and reduced postoperative transfusion incidence of platelet concentrates (PC) (P < .05) without obvious dose-effects (P > .05), but TXA did not reduce PC transfusion volume postoperatively in adult patients (P > .05). For pediatrics, TXA did not significantly reduce postoperative transfusion incidence and volume of allogenic red blood cell, fresh frozen plasma and PC (P > .05). Additionally, the current study demonstrated that intravenous TXA did not influence the composite incidence of postoperative mortality and morbidities in either adults or pediatrics during hospitalization (P > .05), and that there was no obvious dose-effect of TXA in adult patients (P > .05). CONCLUSIONS This current study suggested that intravenous TXA significantly reduced total volume of postoperative bleeding in both adult and pediatric patients undergoing cardiac surgery at the single cardiovascular center without increasing the composite incidence of mortality and morbidities.
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Affiliation(s)
- Pei-Shuang Lin
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Cardiovascular surgery, Fujian Medical University Affiliated First Quanzhou Hospital, Fujian, China
| | - Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Li-Juan Tian
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Juan-Juan Jiang
- Key Laboratory of Clinical Research for Cardiovascular Medications, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Zhang
- Department of Laboratory Medicine, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Li-Xian He
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Kunming, China
| | - Yi-Ping Yu
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jie Ma
- Department of Pharmacy, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Tan H, Pan S, Wei C, Chen Z, Chen T. Comparative efficacy and safety of different hemostatic medications during spinal surgery: A network meta-analysis. Medicine (Baltimore) 2023; 102:e32923. [PMID: 36862901 PMCID: PMC9981439 DOI: 10.1097/md.0000000000032923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Significant blood loss is still one of the most frequent issues in spinal surgery. There were different hemostatic methods to prevent blood loss during spinal surgery. However, the optimal hemostatic therapy for spinal surgery is controversial. The purpose of this study was to assess the efficacy and safety of different hemostatic therapies in spinal surgery. METHODS Two independent reviewers conducted electronic literature searches in 3 electronic databases (PubMed, Embase, and Cochrane library database) as well as a manual search to identify eligible clinical studies from inception to Nov 2022. Studies that including different hemostatic therapy (tranexamic acid [TXA], epsilon-acetyl aminocaproic acid [EACA], and aprotinin [AP]) for spinal surgery were included. The Bayesian network meta-analysis was performed with a random effects model. The surface under the cumulative ranking curve (SUCRA) analysis was performed to determine the ranking order. All analyses were performed by R software and Stata software. P value less than .05 was identified as statistically significant. RESULTS Finally, a total of 34 randomized controlled trials met the inclusion criteria and finally included in this network meta-analysis. The SUCRA shows that TXA ranked first (SUCRA, 88.4%), AP ranked second (SUCRA, 71.6%), EACA ranked third (SUCRA, 39.9%), and placebo ranked the last (SUCRA, 0.3%) as for total blood loss. The SUCRA shows that TXA ranked first (SUCRA, 97.7%), AP ranked second (SUCRA, 55.8%), EACA ranked third (SUCRA, 46.2%), and placebo ranked the last (SUCRA, 0.2%) for need for transfusion. CONCLUSIONS TXA appears optimal in the reduction of perioperative bleeding and blood transfusion during spinal surgery. However, considering the limitations in this study, more large-scale, well-designed randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Haitao Tan
- Department of Spinal Surgery, The First Affiliated Hospital of Hainan Medical University (Hainan Province Clinical Medical Center), Haikou, China
| | - Songli Pan
- Department of Spinal Surgery, The First Affiliated Hospital of Hainan Medical University (Hainan Province Clinical Medical Center), Haikou, China
| | - Chuanchun Wei
- Department of Anesthesia and Operation, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Zhilin Chen
- Department of Breast surgery, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Tao Chen
- Department of Spinal Surgery, The First Affiliated Hospital of Hainan Medical University (Hainan Province Clinical Medical Center), Haikou, China
- *Correspondence: Tao Chen, Department of Spinal Surgery, The First Affiliated Hospital of Hainan Medical University (Hainan Province Clinical Medical Center), No. 31, Longhua Road, Longhua District, Haikou, Hainan 570102, China (e-mail: )
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The effect of tranexamic acid on myocardial injury in cardiac surgical patients: a systematic review and meta-analysis. Blood Coagul Fibrinolysis 2022; 33:429-437. [PMID: 35946446 DOI: 10.1097/mbc.0000000000001158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Tranexamic acid (TXA) is one of the most commonly used antifibrinolytic agents for surgical patients. However, the effect of TXA on myocardial injury remains controversial. We systemically reviewed literature regarding the effectiveness of TXA on myocardial injury in patients who have undergone a cardiac surgery. We included all randomized controlled trials (RCTs) comparing TXA and control (saline) in cardiac surgical patients. Relevant studies were identified by a comprehensive electronic literature search from database inception to 15 August 2021. A standardized data extraction form was used to collect methodological and outcome variables from each eligible study. We conducted a meta-analysis to estimate the pooled effect size of TXA administration on myocardial injury. In total, eight RCTs were identified, with 292 patients in the TXA group, and 241 patients in saline or control group. The meta-analysis demonstrated that patients in the TXA group had lower levels of CK-MB and cTnI within 24 h postoperatively (CK-MB: P = 0.005; cTnI: P = 0.01), compared with the saline group. No significant difference was found with respect to AST level ( P = 0.71) between TXA and saline groups within 24 h postoperatively. TXA administration was found to be associated with less myocardial injury among patients who have undergone cardiac surgery. High-quality randomized controlled trials are warranted to further examine the cardioprotective effects of TXA.
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Prophylactic Use of Antifibrinolytics During Pediatric Cardiac Surgery With Cardiopulmonary Bypass on Postoperative Bleeding and Transfusion: A Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2022; 23:e517-e529. [PMID: 35997516 DOI: 10.1097/pcc.0000000000003049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To determine the effect of intraoperative antifibrinolytics, including tranexamic acid (TXA), aminocaproic acid (EACA), or aprotinin, on bleeding in children undergoing cardiac surgery with cardiopulmonary bypass (CPB). DATA SOURCES Relevant articles were systematically searched from Ovid MEDLINE, Ovid EMBASE, CINAHL, Cochrane Library, and Web of Science to November 15, 2021. STUDY SELECTION Abstracts were screened, and full texts were reviewed using predetermined inclusion and exclusion criteria using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. DATA EXTRACTION A standardized data extraction tool was used. DATA SYNTHESIS Sixty-eight studies including 28,735 patients were analyzed. TXA compared with placebo resulted in a mean decrease in chest tube output of 9.1 mL/kg (95% CI, 6.0-12.3 mL/kg), I2 equals to 65.2%, p value of less than 0.001, platelet requirement of 2.9 mL/kg (95% CI, 0.1-5.8 mL/kg), I2 =72.5%, p value less than 0.001 and plasma requirement of 4.0 mL/kg (95% CI, 0.6-7.2 mL/kg), I2 equals to 94.5%, p value less than0.001. Aprotinin compared with placebo resulted in a mean decrease in chest tube output of 4.3 mL/kg (2.4-6.2 mL/kg), I2 equals to 66.3%, p value of less than 0.001, platelet transfusion of 4.6 mL/kg (95% CI, 0.6-8.6 mL/kg), I2 equals to 93.6%, p value of less than 0.001, and plasma transfusion of 7.7 mL/kg (95% CI, 2.1-13.2 mL/kg), I2 equals to 95.3%, p value of less than 0.001. EACA compared with placebo resulted in a mean decrease in chest tube output of 9.2 mL/kg (2.3-21.0 mL/kg), I2 equals to 96.4%, p value of less than 0.001, RBC transfusion of 7.2 mL/kg (95% CI, 2.4-12.1 mL/kg), I2 equals to 94.5%, p value equals to 0.002, and platelet transfusion of 10.7 mL/kg (95% CI, 2.9-18.5 mL/kg), I2 equals to 0%, p value of less than 0.001. No statistical difference was observed in chest tube output when TXA was compared with aprotinin. Subgroup analysis of cyanotic patients showed a significant decrease in chest tube output, platelet requirement, and plasma requirement for patients receiving aprotinin. Overall, the quality of evidence was moderate. CONCLUSIONS Antifibrinolytics are effective at decreasing blood loss and blood product requirement in children undergoing cardiac surgery with CPB although the quality of evidence is only moderate.
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Nishijima DK, VanBuren JM, Linakis SW, Hewes HA, Myers SR, Tran NK, Ghetti S, Bobinski M, Adelson PD, Roberts I, Holmes JF, Schalick WO, Dean JM, Casper TC, Kuppermann N. Traumatic injury clinical trial evaluating tranexamic acid in children (TIC-TOC): A pilot randomized trial. Acad Emerg Med 2022; 29:862-873. [PMID: 35266589 PMCID: PMC9463410 DOI: 10.1111/acem.14481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/04/2022] [Accepted: 03/06/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The antifibrinolytic drug tranexamic acid (TXA) improves survival in adults with traumatic hemorrhage; however, the drug has not been evaluated in a trial in injured children. We assessed the feasibility of a large-scale trial evaluating the effects of TXA in children with severe hemorrhagic injuries. METHODS Severely injured children (0 up to 18th birthday) were randomized into a double-blind randomized trial of (1) TXA 15 mg/kg bolus dose, followed by 2 mg/kg/h infusion over 8 h, (2) TXA 30 mg/kg bolus dose, followed by 4 mg/kg/h infusion over 8 h, or (3) normal saline placebo bolus and infusion. The trial was conducted at four pediatric Level I trauma centers in the United States between June 2018 and March 2020. We enrolled patients under federal exception from informed consent (EFIC) procedures when parents were unable to provide informed consent. Feasibility outcomes included the rate of enrollment, adherence to intervention arms, and ability to measure the primary clinical outcome. Clinical outcomes included global functioning (primary), working memory, total amount of blood products transfused, intracranial hemorrhage progression, and adverse events. The target enrollment rate was at least 1.25 patients per site per month. RESULTS A total of 31 patients were randomized with a mean age of 10.7 years (standard deviation [SD] 5.0 years) and 22 (71%) patients were male. The mean time from injury to randomization was 2.4 h (SD 0.6 h). Sixteen (52%) patients had isolated brain injuries and 15 (48%) patients had isolated torso injuries. The enrollment rate using EFIC was 1.34 patients per site per month. All eligible enrolled patients received study intervention (nine patients TXA 15 mg/kg bolus dose, 10 patients TXA 30 mg/kg bolus dose, and 12 patients placebo) and had the primary outcome measured. No statistically significant differences in any of the clinical outcomes were identified. CONCLUSION Based on enrollment rate, protocol adherence, and measurement of the primary outcome in this pilot trial, we confirmed the feasibility of conducting a large-scale, randomized trial evaluating the efficacy of TXA in severely injured children with hemorrhagic brain and/or torso injuries using EFIC.
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Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California, USA
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Seth W Linakis
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Ohio State University School of Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Hilary A Hewes
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Sage R Myers
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, California, USA
| | - Simona Ghetti
- Department of Psychology, University of California, Davis, Davis, California, USA
| | - Matthew Bobinski
- Department of Radiology, UC Davis School of Medicine, Sacramento, California, USA
| | - P David Adelson
- Department of Pediatric Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - James F Holmes
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California, USA
| | - Walton O Schalick
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, UC Davis School of Medicine, Sacramento, California, USA
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Brown NJ, Wilson B, Ong V, Gendreau JL, Yang CY, Himstead AS, Shahrestani S, Shlobin NA, Reardon T, Choi EH, Birkenbeuel J, Cohn SJ, Sahyouni R, Yang I. Use of Tranexamic Acid for Elective Resection of Intracranial Neoplasms: A Systematic Review. World Neurosurg 2022; 160:e209-e219. [PMID: 34995825 DOI: 10.1016/j.wneu.2021.12.117] [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: 11/27/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND As an established antifibrinolytic agent, tranexamic acid (TXA) has garnered widespread use during surgery to limit intraoperative blood loss. In the field of neurosurgery, TXA is often introduced in cases of traumatic brain injury or elective spine surgeries; however, its role during elective cranial surgeries is not well established. We report a systematic review of the use of TXA in elective surgical resection of intracranial neoplasms. METHODS We performed this systematic review following PRISMA guidelines to identify studies investigating the use of TXA in elective neurosurgical resection of intracranial neoplasms. Variables extracted included patient demographics, surgical indications, type of surgery performed, TXA dose and route of administration, operative duration, blood loss, transfusion rate, postoperative hemoglobin level, and complications. RESULTS After careful screening, 4 articles (consisting of 682 patients) met our inclusion/exclusion criteria. The studies included 2 prospective cohort studies, 1 retrospective cohort study, and 1 case series. A χ2 test of pooled data demonstrated that patients administered TXA had a significantly decreased need for blood transfusions during surgery (odds ratio, 0.6273; 95% confidence interval, 0.4254-0.9251; P = 0.018). Mean total blood loss was 821.9 mL in the TXA group and 1099.0 mL in the control group across the studies. There was no significant difference in postoperative hemoglobin levels, with a mean of 11.4 g/dL in both the TXA and control groups. CONCLUSIONS These results support the use of intraoperative TXA in tumor resection. However, its role in tumor resection has been less well investigated compared with its use in other areas of neurosurgery.
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Affiliation(s)
- Nolan J Brown
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Bayard Wilson
- Department of Neurological Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Vera Ong
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Julian L Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA.
| | - Chen Yi Yang
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Alexander S Himstead
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Shane Shahrestani
- Keck School of Medicine of USC, Los Angeles, California, USA; Medical Scientist Training Program, California Institute of Technology, Pasadena, California, USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Taylor Reardon
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, Kentucky, USA
| | - Elliot H Choi
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Jack Birkenbeuel
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Sebastian J Cohn
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ronald Sahyouni
- Department of Neurological Surgery, University of California San Diego, La Jolla, California, USA
| | - Isaac Yang
- Department of Neurological Surgery, University of California Los Angeles, Los Angeles, California, USA
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Kornelsen E, Kuppermann N, Nishijima D, Ren LY, Rumantir M, Gill PJ, Finkelstein Y. Effectiveness and safety of tranexamic acid in pediatric trauma: A systematic review and meta-analysis. Am J Emerg Med 2022; 55:103-110. [DOI: 10.1016/j.ajem.2022.01.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/25/2022] [Accepted: 01/31/2022] [Indexed: 12/27/2022] Open
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Huber JL, Berger S, Löllgen RM. Balanced Electrolyte Solutions or Normal Saline? Resuscitative Fluid Administration Practice in Swiss Pediatric Acute Care: A Cross-Sectional Study. Pediatr Emerg Care 2021; 37:e812-e816. [PMID: 31045958 DOI: 10.1097/pec.0000000000001813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The ideal asanguineous intravenous fluid for volume resuscitation in children is controversially debated and clinical practice guidelines are scarce. Administration of large amounts of normal saline has been associated with complications including hyperchloremic acidosis, dysnatremia, neurologic damage, and fatality. AIM We examined the current practice of intravenous fluid and blood product administration in acutely ill and injured children among pediatric acute care physicians in Switzerland. METHODS For this descriptive, cross-sectional study, pediatric emergency departments, pediatric and neonatal intensive care units were surveyed by means of an online questionnaire. RESULTS Sixty of 66 departments and 47 of 87 participants returned the survey. Normal saline (NS) was most commonly administered (n = 42/46, 91.3%) and twice as many times as balanced electrolyte solutions (n = 20/46, 43.5%). The mean fluid volumes ranged from 7.9 to 19.1 mL/kg. Hypertonic saline/NS were selected most often for shock with severe head injury. Half of participants administered colloids (48.9%). Packed red blood cells (97.7%) and fresh frozen plasma (88.4%) were most frequently given blood products. CONCLUSION There is a distinct practice variation in intravenous fluid and blood product administration in children in Switzerland. Although NS is most frequently given, we observed a trend toward the use of balanced electrolyte solutions. Prospective studies are warranted to compare NS with balanced electrolyte solution (BES) in the pediatric acute care setting. We suggest that pediatric fluid administration guidelines and mass transfusion protocols are implemented to standardize this frequent intervention and minimize complications.
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Affiliation(s)
| | | | - Ruth M Löllgen
- Pediatric Emergency Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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11
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Siemens K, Sangaran DP, Hunt BJ, Murdoch IA, Tibby SM. Antifibrinolytic Drugs for the Prevention of Bleeding in Pediatric Cardiac Surgery on Cardiopulmonary Bypass: A Systematic Review and Meta-analysis. Anesth Analg 2021; 134:987-1001. [PMID: 34633994 DOI: 10.1213/ane.0000000000005760] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Bleeding is one of the commonest complications affecting children undergoing cardiac surgery on cardiopulmonary bypass. Antifibrinolytic drugs are part of a multifaceted approach aimed at reducing bleeding, though sufficiently sized pediatric studies are sparse, and dosing algorithms are heterogeneous. Our objective was to evaluate the efficacy and safety of antifibrinolytic agents as well as the effectiveness of different dosing regimens in pediatric cardiac surgery using cardiopulmonary bypass. METHODS We performed a systematic review and meta-analysis evaluating randomized controlled trials published between 1980 and 2019, identified by searching the databases MEDLINE, EMBASE, PubMed, and CENTRAL. All studies investigating patients <18 years of age without underlying hematological disorders were included. The primary outcome was postoperative bleeding; secondary end points included blood product transfusion, mortality, and safety (thromboses, anaphylaxis, renal or neurological dysfunction, and seizures). Different dosing regimens were compared. Studies were dual appraised, outcomes were reported descriptively and, if appropriate, quantitatively using the Review Manager 5 (REVMAN 5) software (The Cochrane Collaboration). RESULTS Thirty of 209 articles were included, evaluating the following drugs versus control: aprotinin n = 14, tranexamic acid (TXA) n = 12, and epsilon-aminocaproic acid (EACA) n = 4. The number of participants per intervention group ranged from 11 to 100 (median, 25; interquartile range [IQR], 20.5) with a wide age span (mean, 13 days to 5.8 years) and weight range (mean, 3.1-26.3 kg). Methodological quality was low to moderate.All agents reduced mean 24-hour blood loss compared to control: aprotinin by 6.0 mL/kg (95% confidence interval [CI], -9.1 to -3.0; P = .0001), TXA by 9.0 mL/kg (95% CI, -11.3 to -6.8; P < .00001), and EACA by 10.5 mL/kg (95% CI, -21.1 to 0.0; P = .05). Heterogeneity was low for TXA (I2 = 29%; P = .19), moderate for aprotinin (I2 = 41%; P = .11), and high for EACA (I2 = 95%; P = <.00001). All agents also reduced 24-hour blood product transfusion. There was no clear dose-response effect for TXA nor aprotinin. Studies were underpowered to detect significant differences in mortality, thromboses, anaphylaxis, and renal or neurological dysfunction. CONCLUSIONS The available data demonstrate efficacy for all 3 antifibrinolytic drugs. Therefore, the agent with the most favorable safety profile should be used. As sufficient data are lacking, large comparative trials are warranted to assess the relative safety and appropriate dosing regimens in pediatrics.
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Affiliation(s)
- Kristina Siemens
- From the Pediatric Intensive Care, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - Dilanee P Sangaran
- From the Pediatric Intensive Care, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - Beverley J Hunt
- Department of Hematology, St Thomas' Hospital, London, United Kingdom
| | - Ian A Murdoch
- From the Pediatric Intensive Care, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - Shane M Tibby
- From the Pediatric Intensive Care, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
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12
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Velik‐Salchner C, Tauber H, Rastner V, Pajk W, Mittermayr M, Wally D, Kilo J, Vondrys D, Fries D, Fritz J, Streif W. Administration of fibrinogen concentrate combined with prothrombin complex maintains hemostasis in children undergoing congenital heart repair (a long-term propensity score-matched study). Acta Anaesthesiol Scand 2021; 65:1178-1186. [PMID: 34152599 PMCID: PMC8518112 DOI: 10.1111/aas.13945] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/05/2021] [Accepted: 05/26/2021] [Indexed: 12/28/2022]
Abstract
Background Bleeding is a common problem in children with congenital heart disease undergoing major cardiac surgery requiring cardiopulmonary bypass (CPB). Little is known about optimal management with blood products. Objective To investigate clinical outcome and hemostatic effects of fibrinogen concentrate (FC) in combination with prothrombin complex concentrate (PCC) versus standard treatment with fresh frozen plasma (FFP) in children undergoing cardiac surgery. Methods For this single‐institution cohort study, data on 525 children were analyzed. Propensity score matching in 210 children was applied to reduce the impact of various baseline characteristics. Results Three children treated with FC/PCC developed surgical site bleeding requiring surgical revision. One child developed central venous line‐related thrombosis. Blood loss through chest tube drainage was independent of FC/PCC. Coagulation abnormalities were not present in any of these children. Time to extubation and ICU stay did not differ. In the FC/PCC group, children received (median, Q1, Q3) 52 mg/kg (32, 83) FC and 28IU/kg (13, 44) PCC. Fibrinogen concentration was comparable at baseline. On admission to the ICU, fibrinogen was higher in children receiving FC/PCC, namely, 232 mg/dL (196, 280), than in children receiving FFP (186 mg/dL, 149, 224; P < .001). On discharge from the ICU, values did not differ ((FC/PCC 416 mg/dL (288, 501)), non‐FC/PCC 418 mg/dL (272, 585; P = 1.000)). Conclusion FC/PCC was well tolerated and permitted hemostasis to be maintained, even in the very young. We were not able to detect a signal for inferiority of this treatment. We conclude that FC/PCC can safely replace FFP.
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Affiliation(s)
- Corinna Velik‐Salchner
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Helmuth Tauber
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Verena Rastner
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Werner Pajk
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Markus Mittermayr
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Dieter Wally
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Juliane Kilo
- Department of Cardiac Surgery Medical University of Innsbruck Innsbruck Austria
| | - David Vondrys
- Department of Cardiac Surgery Medical University of Innsbruck Innsbruck Austria
| | - Dietmar Fries
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Josef Fritz
- Department of Medical Statistics Informatics and Health Economics Medical University of Innsbruck Innsbruck Austria
| | - Werner Streif
- Department of Paediatrics Medical University of Innsbruck Innsbruck Austria
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13
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Gómez Ochoa P, Alférez MD, de Blas I, Fernendes T, Sánchez Salguero X, Balañá B, Meléndez Lazo A, Barbero Fernandez A, Caivano D, Corda F, Corda A. Ultrasound-Guided Radiofrequency Ablation of Chemodectomas in Five Dogs. Animals (Basel) 2021; 11:2790. [PMID: 34679812 PMCID: PMC8532905 DOI: 10.3390/ani11102790] [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: 07/01/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 11/17/2022] Open
Abstract
Chemodectomas are low prevalence tumors with complex clinical management. Many present as an incidental finding however, in other dogs, they produce pericardial effusion and/or compression, leading to the appearance of severe clinical signs. There are currently several approaches: surgery, radiotherapy, stent placement and chemotherapy. This is the first description of percutaneous echo-guided radiofrequency ablation of aortic body tumors. This minimally invasive treatment is based on high frequency alternating electrical currents from an electrode that produces ionic agitation and generates frictional heat, causing coagulation necrosis. Five dogs with an echocardiographic and cytological diagnosis of chemodectoma underwent percutaneous echo-guided radiofrequency ablation. At the time of presentation, all the dogs showed clinical signs, such as ascites and/or collapse. There were no complications either during the procedure or in the following 24 hours. Rapid clinical improvement associated with a reduction in size and change in sonographic appearance of the mass were achieved with no complications. Six months follow-up was carried out in all dogs. A second percutaneous echo-guided RFA was performed eight months after the first procedure in one dog. Based on our experience, radiofrequency ablation seems to be a feasible and safe technique, making it a potential alternative therapeutic approach in the clinical management of aortic body tumors leading to severe clinical compromise.
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Affiliation(s)
- Pablo Gómez Ochoa
- VetCorner, 50012 Zaragoza, Spain;
- Department of Animal Pathology, University of Zaragoza, 50013 Zaragoza, Spain;
| | | | - Ignacio de Blas
- Department of Animal Pathology, University of Zaragoza, 50013 Zaragoza, Spain;
| | - Telmo Fernendes
- Imaginologia Veterinaria do Porto, 4490-479 Porto, Portugal;
| | - Xavier Sánchez Salguero
- Department of Animal Science, School of Agriculture, Food Science and Veterinary Medicine (ETSEA), University of Lleida, 25198 Lleida, Spain;
| | - Beatriz Balañá
- Hospital Aralar Veterinarios, Cuarte de Huerva, 50410 Zaragoza, Spain;
| | | | - Alicia Barbero Fernandez
- Department of Veterinary Medicine, University Alfonso X el Sabio, Villanueva de la Cañada, 28691 Madrid, Spain;
| | - Domenico Caivano
- Department of Veterinary Medicine, University of Perugia, 06126 Perugia, Italy
| | - Francesca Corda
- Department of Veterinary Medicine, University of Sassari, 07100 Sassari, Italy; (F.C.); (A.C.)
| | - Andrea Corda
- Department of Veterinary Medicine, University of Sassari, 07100 Sassari, Italy; (F.C.); (A.C.)
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14
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Zhang XC, Sun MJ, Pan S, Rui M, Zhao FC, Zha GC, Pang Y, Zheng X, Guo KJ. Intravenous administration of tranexamic acid in total hip arthroplasty does not change the blood coagulopathy: a prospective thrombelastography analysis. J Orthop Surg (Hong Kong) 2021; 28:2309499020959516. [PMID: 32985369 DOI: 10.1177/2309499020959516] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Despite the wide use of tranexamic acid (TXA) in the perioperative period of total hip arthroplasty (THA), whether the hemostatic state changes after the application of intravenous (IV)-TXA are still unknown. The aim of this study was to investigate whether IV administration of TXA changes the blood coagulation following primary THA via thrombelastography (TEG) analysis and conventional laboratory tests. METHODS A total of 174 patients who underwent primary THA from September 2016 to July 2018 were selected. They were randomly divided into two groups, 86 patients with IV administration of 15 mg/kg TXA and 88 controls without TXA usage. Demographic data, TEG paremeters, d-dimer levels, fibrin degradation products, hemoglobin, hematocrit concentration, platelet, transfusion rates, perioperative blood loss, and the occurrence of deep vein thrombosis were collected. TEG and conventional laboratory tests were performed the day before operation, the first day after operation, and seventh day after operation. RESULTS There were no differences with regard to TEG or conventional laboratory tests between the two groups (p > 0.05). The total blood loss and drain blood loss in the TXA group were significantly lower than those in the control group (p < 0.05). The transfusion rates and the volume of blood transfusion of the control group were higher than those of the TXA group (p < 0.05). CONCLUSION The administration of IV-TXA resulted in a significant reduction in total blood loss, transfusion volumes, and transfusion rates without the increase of thromboembolic complications. Moreover, it was confirmed that TXA would not change the coagulation via the TEG analysis.
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Affiliation(s)
- Xing-Chen Zhang
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Ma-Ji Sun
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Sheng Pan
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Min Rui
- Department of Orthopaedics, Jiangsu Jiangyin People's Hospital, Jiangyin, China
| | - Feng-Chao Zhao
- Department of Orthopaedics, 71069The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Guo-Chun Zha
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yong Pang
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xin Zheng
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Kai-Jin Guo
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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15
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Long E, Williams A, Babl FE, Kinmonth A, Tse WC, Palmer CS, Crighton G, Savoia H, Teague WJ, Nystrup KB. Changes in emergency department blood product use for major paediatric trauma following the implementation of a major haemorrhage protocol. Emerg Med Australas 2021; 33:966-974. [PMID: 33811442 DOI: 10.1111/1742-6723.13773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/12/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Fixed ratio blood product administration may improve outcomes in trauma patients with massive blood loss. The present study aimed to describe the impact of a major haemorrhage protocol (MHP) on the ratio of blood products administered for paediatric major trauma. METHODS Retrospective observational study in a state-designated paediatric major trauma centre in Melbourne, Australia. Children with major trauma who received blood products in the ED were identified from a hospital trauma registry. Blood product ratios before, during and after implementation of a hospital MHP were compared in consecutive 2 year blocks. RESULTS Over a 6 year period, 767 major trauma patients were identified, of whom 47 received blood products in the ED and were included in the analysis; 14 pre-MHP implementation, 24 during-MHP implementation and nine post-MHP implementation. No patients received blood products at a ratio of 1:1:1 for red blood cells:fresh frozen plasma:platelets, respectively, during any time period. In this cohort of predominantly blunt trauma, blood products were infrequently administered in the ED because of the low prevalence of massive blood loss. Coagulopathy and hypofibrinogenaemia were commonly observed, nearly half of included patients were managed operatively and one quarter did not survive their injuries. CONCLUSION The implementation of a MHP did not change the ratio of blood product administration in this cohort of patients because of the infrequency of massive blood loss. Future studies may focus on the impact of treating coagulopathy and hypofibrinogenaemia on patient-centred outcomes.
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Department of Medicine and Radiology, Melbourne Medical School, Melbourne, Victoria, Australia
| | - Amanda Williams
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Department of Medicine and Radiology, Melbourne Medical School, Melbourne, Victoria, Australia
| | - Anne Kinmonth
- Department of Haematology, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Wai Chung Tse
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Cameron S Palmer
- Trauma Service, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Gemma Crighton
- Department of Haematology, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Helen Savoia
- Department of Haematology, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Warwick J Teague
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Trauma Service, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Kristin Brønnum Nystrup
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
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16
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Nellis ME, Vasovic LV, Goel R, Karam O. Epidemiology of the Use of Hemostatic Agents in Children Supported by Extracorporeal Membrane Oxygenation: A Pediatric Health Information System Database Study. Front Pediatr 2021; 9:673613. [PMID: 34041211 PMCID: PMC8141845 DOI: 10.3389/fped.2021.673613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/13/2021] [Indexed: 11/24/2022] Open
Abstract
Objectives: Children supported by extracorporeal membrane oxygenation (ECMO) are at high risk of bleeding. Though practitioners often prescribe blood components and/or medications to prevent or treat bleeding, the utilization of these hemostatic measures in children is not well-understood. We sought to evaluate the use of hemostatic blood products (platelet, plasma and cryoprecipitate transfusions) and medications [aminocaproic acid, tranexamic acid (TXA) and Factor VIIa] in children supported by ECMO. Design: Retrospective observational study using the Pediatric Health Information System (PHIS) database from 2011-2017. Setting: Fifty-one U.S. children's hospitals. Patients: Children (aged 0-18 years) supported by ECMO. Interventions: None. Measurements and Main Results: ECMO was employed in the care of 7,910 children for a total of 56,079 ECMO days. Fifty-five percent of the patients were male with a median (IQR) age of 0 (0-2) years. The median (IQR) length of ECMO was 5 (2-9) days with a hospital mortality rate of 34%. Platelets were transfused on 49% of ECMO days, plasma on 33% of ECMO days and cryoprecipitate on 17% of ECMO days. Twenty-two percent of children received TXA with the majority receiving it on the first day of ECMO and the use of TXA increased during the 6-year period studied (p < 0.001). Seven percent of children received aminocaproic acid and 3% received Factor VIIa. Conclusions: Children supported by ECMO are exposed to a significant number of hemostatic blood products. Antifibrinolytics, in particular TXA, are being used more frequently. Given the known morbidity and mortality associated with hemostatic blood products, studies are warranted to evaluate the effectiveness of hemostatic strategies.
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Affiliation(s)
- Marianne E Nellis
- Department of Pediatrics, New York Presbyterian Hospital - Weill Cornell Medicine, New York, NY, United States
| | - Ljiljana V Vasovic
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Ruchika Goel
- Division of Hematology, Oncology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States.,Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD, United States
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, United States
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17
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Siemens K, Hunt BJ, Harris J, Nyman AG, Parmar K, Tibby SM. Individualized, Intraoperative Dosing of Fibrinogen Concentrate for the Prevention of Bleeding in Neonatal and Infant Cardiac Surgery Using Cardiopulmonary Bypass (FIBCON): A Phase 1b/2a Randomized Controlled Trial. Circ Cardiovasc Interv 2020; 13:e009465. [PMID: 33213194 DOI: 10.1161/circinterventions.120.009465] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mediastinal bleeding is common following pediatric cardiopulmonary bypass surgery for congenital heart disease. Fibrinogen concentrate (FC) represents a potential therapy for preventing bleeding. METHODS We performed a single-center, phase 1b/2a, randomized controlled trial on infants 2.5 to 12 kg undergoing cardiopulmonary bypass surgery, aimed at (1) demonstrating the feasibility of an intraoperative point-of-care test, rotational thromboelastometry, to screen out patients at low risk of postoperative bleeding and then guide individualized FC dosing in high-risk patients and (2) determining the dose, safety, and efficacy of intraoperative FC supplementation. Screening occurred intraoperatively 1-hour before bypass separation using the rotational thromboelastometry variable fibrinogen thromboelastometry maximum clot firmness (FibTEM-MCF; fibrinogen contribution to clot firmness). If FibTEM-MCF ≥7 mm, patients entered the monitoring cohort. If FibTEM-MCF ≤6 mm, patients were randomized to receive FC/placebo (2:1 ratio). Individualized FC dose calculation included weight, bypass circuit volume, hematocrit, and intraoperative measured and desired FibTEM-MCF. The coprimary outcomes, measured 5 minutes post-FC administration were FibTEM-MCF (desired range, 8-13 mm) and fibrinogen levels (desired range, 1.5-2.5 g/L). Secondary outcomes were thrombosis and thrombosis-related major complications and postoperative 24-hour mediastinal blood loss. RESULTS We enrolled 111 patients (cohort, n=21; FC, n=60; placebo, n=30); mean (SD) age, 6.4 months (5.8); weight, 5.9 kg (2.0). Intraoperative rotational thromboelastometry screening effectively excluded low-risk patients, in that none in the cohort arm (FibTEM-MCF, ≥7 mm) demonstrated clinically significant early postoperative bleeding (>10 mL/kg per 4 hours). Among randomized patients, the median (range) FC administered dose was 114 mg/kg (51-218). Fibrinogen levels increased from a mean (SD) of 0.91 (0.22) to 1.7 g/L (0.41). The postdose fibrinogen range was 1.2 to 3.3 g/L (72% within the desired range). The corresponding FibTEM-MCF values were as follows: pre-dose, 5.3 mm (1.9); post-dose, 13 mm (3.2). Ten patients (8 FC and 2 placebo) exhibited 12 possible thromboses; none were clearly related to FC. There was an overall difference in mean (SD) 24-hour mediastinal drain loss: cohort, 12.6 mL/kg (6.4); FC, 11.6 mL/kg (5.2); placebo, 17.1 mL/kg (14.3; ANOVA P=0.02). CONCLUSIONS Intraoperative, individualized dosing of FC appears feasible. The need for individualized dosing is supported by the finding that a 4-fold variation in FC dose is required to achieve therapeutic fibrinogen levels. Registration: URL: https://eudract.ema.europa.eu/; Unique identifier: 2013-003532-68. URL: https://www.isrctn.com/; Unique identifier: 50553029.
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Affiliation(s)
- Kristina Siemens
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, United Kingdom (K.S., J.H., A.G.N., S.M.T.)
| | - Beverley J Hunt
- Department of Haematology, St Thomas' Hospital, London, United Kingdom (B.J.H., K.P.)
| | - Julia Harris
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, United Kingdom (K.S., J.H., A.G.N., S.M.T.)
| | - Andrew G Nyman
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, United Kingdom (K.S., J.H., A.G.N., S.M.T.)
| | - Kiran Parmar
- Department of Haematology, St Thomas' Hospital, London, United Kingdom (B.J.H., K.P.)
| | - Shane M Tibby
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, United Kingdom (K.S., J.H., A.G.N., S.M.T.)
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18
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Eisler LD, Lenke LG, Sun LS, Li G, Kim M. Do Antifibrinolytic Agents Reduce the Risk of Blood Transfusion in Children Undergoing Spinal Fusion?: A Propensity Score-matched Comparison Using a National Database. Spine (Phila Pa 1976) 2020; 45:1055-1061. [PMID: 32675611 PMCID: PMC8120993 DOI: 10.1097/brs.0000000000003455] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To evaluate the effectiveness and safety of antifibrinolytic (AF) agents in reducing perioperative blood transfusion in pediatric patients undergoing spinal fusion. SUMMARY OF BACKGROUND DATA The potential for AF to decrease bleeding and reduce exposure to allogenic transfusions has led to widespread off-label use in a number of major pediatric surgical procedures. Recent reviews call for improving the body of evidence for their effectiveness and safety in pediatric spinal fusion. METHODS Children undergoing spinal fusion were identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) 2016 and 2017 databases. Univariate analyses of patient and perioperative characteristics informed the creation of a propensity score model predicting treatment with AF, followed by 1:1 matching to allow comparison of allogenic red blood cell transfusion rates and secondary outcomes between treated and untreated patients. RESULTS Of 6626 total patients, 5434 (81%) received AF and 1533 (23%) received a blood transfusion. Analysis of data for 1192 propensity score-matched pairs revealed that treatment with AF was associated with a statistically nonsignificant 16% reduction in perioperative transfusion (OR 0.84, 95% confidence interval 0.68-1.05, P = 0.119) and a statistically significant 43% reduction in postoperative transfusion (OR 0.57, 95% confidence interval 0.39-0.81, P = 0.002). No differences in the incidences of postoperative seizure or thrombosis were observed, with overall rates of 7.5 and 22.5 events per 10,000 patients, respectively. CONCLUSION AF agents appear to reduce postoperative allogenic transfusion in children undergoing spinal fusion surgery. Adverse drug effects such as thromboembolic complications and seizure were extremely rare and warrant continued monitoring, though this is the largest study to date providing evidence for the safety profile of these drugs. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Lisa D. Eisler
- Anesthesiology, Columbia University Medical Center, New York, NY, USA
| | | | - Lena S. Sun
- Anesthesiology, Columbia University Medical Center, New York, NY, USA
- Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Guohua Li
- Anesthesiology, Columbia University Medical Center, New York, NY, USA
- Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - Minjae Kim
- Anesthesiology, Columbia University Medical Center, New York, NY, USA
- Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
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19
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Switzer T, Faraoni D. Blood Conservation in Pediatric Surgical Patients. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00399-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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20
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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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21
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Schroeder RJ, Langsdon PR. Effect of Local Tranexamic Acid on Hemostasis in Rhytidectomy. Facial Plast Surg Aesthet Med 2020; 22:195-199. [PMID: 32228311 DOI: 10.1089/fpsam.2020.0061] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Importance: Hematoma is the most common complication in rhytidectomy. Tranexamic acid (TXA) is an antifibrinolytic that may be a useful tool to reduce intraoperative bleeding and postoperative hematoma risk. Objective: To determine whether local TXA reduces intraoperative bleeding and postoperative drain output in rhytidectomy. Design, Setting, and Participants: Retrospective cohort study of patients undergoing deep plane rhytidectomy with platysmaplasty. Beginning January 1, 2019, we began adding 1 cc (100 mg) of TXA to every 10 cc of local anesthetic and tumescent solution. Patients were, therefore, separated into two cohorts: control and TXA. Primary outcomes include postoperative day 1 (POD1) drain output, days to drain removal, percentage drains removed POD1, and percentage POD1 drain output <25 cc. Secondary outcomes include minor hematoma, major hematoma, Nitro-bid use, intraoperative estimated blood loss (EBL), and thromboembolic events. Results: POD1 drain output reduced from 50.4 cc in control group versus 14.8 cc with TXA (p < 0.001). Average day of drain removal reduced from 1.8 days in control group versus 1.2 days with TXA (p = 0.001). Percentage of drains removed on POD1 was increased from 34.4% in control group to 77.3% with TXA (p < 0.001). Percentage of POD1 drain output <25 cc was increased from 21.9% in control group to 95.5% with TXA (p < 0.001). Intraoperative EBL <50 cc increased from 25% in control group to 75% with TXA (p < 0.001). No statistically significant difference was observed between control and TXA in rates of minor hematoma, major hematoma, Nitro-bid use, or thromboembolic events. Conclusions and Relevance: Local TXA used in rhytidectomy significantly reduces intraoperative blood loss, postoperative drain output, and time to drain removal. No significant difference was observed in postoperative complication rates.
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Affiliation(s)
- Ronald J Schroeder
- Department of Otolaryngology, Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Phillip R Langsdon
- Department of Otolaryngology, Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,The Langsdon Clinic, Germantown, Tennessee, USA
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Inhaled Tranexamic Acid As a Novel Treatment for Pulmonary Hemorrhage in Critically Ill Pediatric Patients: An Observational Study. Crit Care Explor 2020; 2:e0075. [PMID: 32166295 PMCID: PMC7063899 DOI: 10.1097/cce.0000000000000075] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objectives: To describe the use of inhaled or endotracheally instilled tranexamic acid in critically ill pediatric patients for the treatment of pulmonary hemorrhage, which can be severe, life-threatening, and include potentially high-risk management procedures. Design: Retrospective observational study from 2011-2018 with patients followed until hospital discharge. Setting: Free-standing children’s hospital with an annual ICU volume of more than 3,500 yearly admissions. Patients: Pediatric patients, ages 0 to 18 years, admitted to an ICU and who received at least one dose of inhaled or endotracheally instilled tranexamic acid were included. Interventions: Inhaled or endotracheally instilled tranexamic acid. Measurements and Main Results: This study described the efficacy and adverse effects of patients who received inhaled or endotracheally instilled tranexamic acid. A total of 19 patients met inclusion criteria; median age was 72 months (11–187 mo), most patients were female (11, 58%), and almost half our patients (8, 42%) had congenital heart disease. Nine of 19 encounters (47%) had diffuse alveolar hemorrhage, four (21%) had pulmonary hemorrhage related to major aortopulmonary collateral arteries, two (11%) had mucosal airway bleeding, two (11%) were iatrogenic, one had a pulmonary embolism, and one patient did not have their etiology of pulmonary hemorrhage determined. Cessation of pulmonary hemorrhage was achieved in 18 of 19 patients (95%) with inhaled tranexamic acid with no major adverse events recorded. Conclusions and Relevance: We demonstrate that inhaled tranexamic acid may be safely used to treat pulmonary hemorrhage from varied etiologies in critically ill pediatric patients. Prospective studies are required in this vulnerable population to determine optimal dosing and delivery strategies, as well as to define any differential effect according to etiology.
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23
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Faraoni D, Meier J, New HV, Van der Linden PJ, Hunt BJ. Patient Blood Management for Neonates and Children Undergoing Cardiac Surgery: 2019 NATA Guidelines. J Cardiothorac Vasc Anesth 2019; 33:3249-3263. [DOI: 10.1053/j.jvca.2019.03.036] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 12/22/2022]
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Zhang Y, Jia Y, Shi J, Yuan S, Wang R, Zhang Z, Wang X, Liu J, Ran J, Zhao Y, Hua Z, Yan J, Li S, Zheng Z, Hu S, Wang Y, Yan F. Safety and efficacy of tranexamic acid in paediatric cardiac surgery: study protocol for a double-blind randomised controlled trial. BMJ Open 2019; 9:e032642. [PMID: 31772102 PMCID: PMC6887001 DOI: 10.1136/bmjopen-2019-032642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION An initial retrospective study suggested that tranexamic acid (TXA) administration increased the incidence of seizures in paediatric patients undergoing cardiac surgery. However, the efficacy of TXA in paediatric cardiac surgery remains unclear owing to the small sample sizes of the studies. Therefore, this study will investigate the efficacy and safety of TXA in paediatric patients undergoing cardiac surgery. We hypothesised that TXA may increase the incidence of postoperative seizures with no effect on postoperative allogeneic transfusion in paediatric patients undergoing cardiac surgery. The pragmatic study will provide important implications for paediatric cardiac surgery. METHODS AND ANALYSIS This will be a single-centre prospective, double-blind randomised controlled trial. The plan is to enrol in the study 2090 paediatric patients aged 31 days to 7 years who will be undergoing cardiac surgery with cardiopulmonary bypass (CPB). All eligible participants will be randomly assigned to either the TXA or placebo group by using a Web-based randomisation service in a 1:1 ratio. The primary safety end point will be postoperative seizures until hospital discharge, and the primary efficacy end point will be the volume of allogeneic red blood cell transfusion after termination of CPB. All patients will be followed up for 1 year postdischarge. All data will be analysed in accordance with the intention-to-treat principle. ETHICS AND DISSEMINATION This study was approved by the institutional review board of Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (No 20191195). Written informed consent will be obtained from the parents/legal guardian of each patient because all participants will be <18 years of age. The results of the trial will be published in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Register (ChiCTR1900024131).
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Affiliation(s)
- Yu Zhang
- Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Jia
- Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Shi
- Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Su Yuan
- Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rong Wang
- Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhe Zhang
- Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu Wang
- Paediatric Intensive Care Unit, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinping Liu
- Cardiopulmonary Bypass, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Ran
- Cardiovascular Surgery, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuchen Zhao
- Cardiovascular Surgery, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhongdong Hua
- Cardiovascular Surgery, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Yan
- Cardiovascular Surgery, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shoujun Li
- Cardiovascular Surgery, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhe Zheng
- Cardiovascular Surgery, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- Cardiovascular Surgery, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Wang
- Medical Research and Biometrics Centre, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fuxia Yan
- Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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25
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Tranexamic acid and perioperative bleeding in children: what do we still need to know? Curr Opin Anaesthesiol 2019; 32:343-352. [PMID: 30893114 DOI: 10.1097/aco.0000000000000728] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Perioperative bleeding and blood product transfusion are associated with significant morbidity and mortality. Prevention and optimal management of bleeding decreases risk and lowers costs. Tranexamic acid (TXA) is an antifibrinolytic agent that reduces bleeding and transfusion in a broad number of adult and pediatric surgeries, as well as in trauma and obstetrics. This review highlights the current pediatric indications and contraindications of TXA. The efficacy and safety profile, given current and evolving research, will be covered. RECENT FINDINGS Based on the published evidence, prophylactic or therapeutic TXA administration is a well-tolerated and effective strategy to reduce bleeding, decrease allogeneic blood product transfusion, and improve pediatric patients' outcomes. TXA is now recommended in recent guidelines as an important part of pediatric blood management protocols. SUMMARY Based on TXA pharmacokinetics, the authors recommend a dosing regimen of between 10 to 30 mg/kg loading dose followed by 5 to 10 mg/kg/h maintenance infusion rate for pediatric trauma and surgery. Maximal efficacy and minimal side-effects with this dosage regime will have to be determined in larger prospective trials including high-risk groups. Furthermore, future research should focus on determining the ideal TXA plasma therapeutic concentration for maximum efficacy and minimal side-effects.
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26
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Cholette JM, Faraoni D, Goobie SM, Ferraris V, Hassan N. Patient Blood Management in Pediatric Cardiac Surgery: A Review. Anesth Analg 2019; 127:1002-1016. [PMID: 28991109 DOI: 10.1213/ane.0000000000002504] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.
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Affiliation(s)
- Jill M Cholette
- From the Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston, Massachusetts.,Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Ferraris
- Department of Surgery, University of Kentucky Chandler Medical Center & Lexington Veterans Affairs Medical Center, Lexington, Kentucky
| | - Nabil Hassan
- Division of Pediatric Critical Care, Children's Hospital of Illinois At OSF St Frances, University of Illinois at Peoria, Peoria, Illinois
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27
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Sentilhes L, Madar H, Mattuizzi A, Froeliger A, Merlot B, Elleboode B, Deneux-Tharaux C. Tranexamic acid for childbirth: why, when, and for whom. Expert Rev Hematol 2019; 12:753-761. [DOI: 10.1080/17474086.2019.1642744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Hugo Madar
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Aurélien Mattuizzi
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Alizée Froeliger
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Benjamin Merlot
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Benoit Elleboode
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Catherine Deneux-Tharaux
- INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Statistics Sorbonne Paris Cité, Paris Descartes University, Paris, France
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28
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Nishijima DK, Kuppermann N, Roberts I, VanBuren JM, Tancredi DJ. The Effect of Tranexamic Acid on Functional Outcomes: An Exploratory Analysis of the CRASH-2 Randomized Controlled Trial. Ann Emerg Med 2019; 74:79-87. [DOI: 10.1016/j.annemergmed.2018.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/02/2018] [Accepted: 11/13/2018] [Indexed: 11/30/2022]
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Faraoni D, Rahe C, Cybulski KA. Use of antifibrinolytics in pediatric cardiac surgery: Where are we now? Paediatr Anaesth 2019; 29:435-440. [PMID: 30365221 DOI: 10.1111/pan.13533] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/18/2018] [Accepted: 10/20/2018] [Indexed: 01/24/2023]
Abstract
Fibrinolytic activation is a major and preventable source of bleeding in neonates and children undergoing cardiac surgery with cardiopulmonary bypass. Based on the existing literature (adult and pediatric; cardiac and noncardiac), prophylactic administration of antifibrinolytic agents can help reduce fibrinolytic activation, and consequently reduces perioperative bleeding and the requirement for blood product transfusion. Due to the increased risk of renal failure and mortality reported in adults undergoing cardiac surgery, aprotinin should not be considered as a safe option in neonates and children. Further well-designed studies would be required before the prophylactic administration of aprotinin could be considered in pediatric cardiac surgery. The lysine analogs, tranexamic acid and ϵ-aminocaproic acid,, should be considered as safe and effective antifibrinolytic agents. Although no major side effects have been reported following the administration of lysine analogs in children undergoing cardiac surgery, high-dose tranexamic acid should not be recommended in order to avoid the increased risk of clinical seizures. Despite the recent advances made in our understanding of the pharmacokinetics of tranexamic acid and ϵ-aminocaproic acid,, the optimal plasmatic concentration to be targeted remains unknown. Further studies are therefore urgently needed to better define the optimal dose regimen to be used in neonates and children. In the meantime, the dose regimen published in the most recent pharmacokinetic studies can be used. Although no studies have assessed the effect of massive bleeding and transfusion on the plasmatic concentrations of the lysine analogs, additional boluses might be considered in the presence of bleeding and/or when signs of fibrinolytic activations are observed on viscoelastic hemostatic assays.
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Affiliation(s)
- David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cornelius Rahe
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Karen A Cybulski
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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30
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Structural studies of plasmin inhibition. Biochem Soc Trans 2019; 47:541-557. [DOI: 10.1042/bst20180211] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/28/2019] [Accepted: 01/31/2019] [Indexed: 12/24/2022]
Abstract
Abstract
Plasminogen (Plg) is the zymogen form of the serine protease plasmin (Plm), and it plays a crucial role in fibrinolysis as well as wound healing, immunity, tissue remodeling and inflammation. Binding to the targets via the lysine-binding sites allows for Plg activation by plasminogen activators (PAs) present on the same target. Cellular uptake of fibrin degradation products leads to apoptosis, which represents one of the pathways for cross-talk between fibrinolysis and tissue remodeling. Therapeutic manipulation of Plm activity plays a vital role in the treatments of a range of diseases, whereas Plm inhibitors are used in trauma and surgeries as antifibrinolytic agents. Plm inhibitors are also used in conditions such as angioedema, menorrhagia and melasma. Here, we review the rationale for the further development of new Plm inhibitors, with a particular focus on the structural studies of the active site inhibitors of Plm. We compare the binding mode of different classes of inhibitors and comment on how it relates to their efficacy, as well as possible future developments.
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31
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Zhang Y, Zhang X, Wang Y, Shi J, Yuan S, Duan F, Wang Y, Zhang Z, Jia Y, Gong J, Li L, Yan F. Efficacy and Safety of Tranexamic Acid in Pediatric Patients Undergoing Cardiac Surgery: A Single-Center Experience. Front Pediatr 2019; 7:181. [PMID: 31134172 PMCID: PMC6514189 DOI: 10.3389/fped.2019.00181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/18/2019] [Indexed: 12/15/2022] Open
Abstract
Aims: This study evaluated the efficacy and safety of tranexamic acid (TXA) undergoing cardiac surgery. Methods: Using a retrospective cohort study design, 2,026 consecutive pediatric patients who underwent surgical repair of atrial or ventricular septal defect or complete repair of Tetralogy of Fallot were included, and divided into a control group and a TXA group. Results: Compared with that in the control group, there were statistically significant reduction of both the 12-h and total postoperative blood loss in the TXA group [6.573 ± 0.144 vs. 5.499 ± 0.133 ml kg-1, mean difference (MD) 1.074 ml kg-1, p < 0.001; 12.183 ± 0.298 vs. 9.973 ± 0.276 ml kg-1, MD, 2.210 ml kg-1, p < 0.001]. There was a statistically significant reduction of the MD of 12-h postoperative blood loss due to TXA in patients aged < 1 year compared with that in patients aged ≥1 year (MD, 1.544 vs. 0.681 ml kg-1, P = 0.007). There were statistically significant reduction of the MD of both the 12-h and total postoperative blood loss due to TXA in patients weighing < 10 kg compared with that in patients weighing ≥10 kg (MD, 1.542 vs. 0.456 ml kg-1, P < 0.001, and MD, 2.195 vs. 0.929 ml kg-1, P = 0.036, respectively). There was a statistically significant reduction of the MD of total postoperative blood loss due to TXA in cyanotic patients compared with that in acyanotic patients (MD, 3.381 vs. 1.038 ml kg-1, P = 0.002). There was no significant difference in the postoperative volume or exposure of allogeneic transfusion, in-hospital morbidity or mortality between the groups. Conclusions: TXA took effects in reduction of postoperative blood loss but not the allogeneic transfusion requirement in pediatric patients undergoing cardiac surgery, particularly in infants weighing < 10 kg and cyanotic children. Moreover, the study suggested the use of TXA was safe in pediatric cardiac surgery.
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Affiliation(s)
- Yu Zhang
- Department of Anesthesiology, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xue Zhang
- Department of Information Center, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Wang
- Department of Medical Research & Biometrics Center, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Shi
- Department of Anesthesiology, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fujian Duan
- Department of Anesthesiology, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuefu Wang
- Department of Anesthesiology, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhe Zhang
- Department of Anesthesiology, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Jia
- Department of Anesthesiology, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junsong Gong
- Department of Anesthesiology, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihuan Li
- Department of Anesthesiology, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fuxia Yan
- Department of Anesthesiology, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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32
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Nishijima DK, VanBuren J, Hewes HA, Myers SR, Stanley RM, Adelson PD, Barnhard SE, Bobinski M, Ghetti S, Holmes JF, Roberts I, Schalick WO, Tran NK, Tzimenatos LS, Michael Dean J, Kuppermann N. Traumatic injury clinical trial evaluating tranexamic acid in children (TIC-TOC): study protocol for a pilot randomized controlled trial. Trials 2018; 19:593. [PMID: 30376893 PMCID: PMC6208101 DOI: 10.1186/s13063-018-2974-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 10/10/2018] [Indexed: 01/29/2023] Open
Abstract
Background Trauma is the leading cause of morbidity and mortality in children in the United States. The antifibrinolytic drug tranexamic acid (TXA) improves survival in adults with traumatic hemorrhage, however, the drug has not been evaluated in a clinical trial in severely injured children. We designed the Traumatic Injury Clinical Trial Evaluating Tranexamic Acid in Children (TIC-TOC) trial to evaluate the feasibility of conducting a confirmatory clinical trial that evaluates the effects of TXA in children with severe trauma and hemorrhagic injuries. Methods Children with severe trauma and evidence of hemorrhagic torso or brain injuries will be randomized to one of three arms: (1) TXA dose A (15 mg/kg bolus dose over 20 min, followed by 2 mg/kg/hr infusion over 8 h), (2) TXA dose B (30 mg/kg bolus dose over 20 min, followed by 4 mg/kg/hr infusion over 8 h), or (3) placebo. We will use permuted-block randomization by injury type: hemorrhagic brain injury, hemorrhagic torso injury, and combined hemorrhagic brain and torso injury. The trial will be conducted at four pediatric Level I trauma centers. We will collect the following outcome measures: global functioning as measured by the Pediatric Quality of Life (PedsQL) and Pediatric Glasgow Outcome Scale Extended (GOS-E Peds), working memory (digit span test), total amount of blood products transfused in the initial 48 h, intracranial hemorrhage progression at 24 h, coagulation biomarkers, and adverse events (specifically thromboembolic events and seizures). Discussion This multicenter trial will provide important preliminary data and assess the feasibility of conducting a confirmatory clinical trial that evaluates the benefits of TXA in children with severe trauma and hemorrhagic injuries to the torso and/or brain. Trial registration ClinicalTrials.gov registration number: NCT02840097. Registered on 14 July 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2974-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, UC Davis School of Medicine, 4150 V. Street, PSSB 2100, Sacramento, CA, 95817, USA.
| | - John VanBuren
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Hilary A Hewes
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah School of Medicine, Primary Children's Hospital, 100 N. Mario Capecchi Dr., Salt Lake City, UT, 84113, USA
| | - Sage R Myers
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Rachel M Stanley
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Ohio State University School of Medicine, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205, USA
| | - P David Adelson
- Department of Pediatric Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Rd, Phoenix, AZ, 85016, USA
| | - Sarah E Barnhard
- Department of Pathology and Laboratory Medicine, UC Davis School of Medicine, 2315 Stockton Blvd., Sacramento, CA, 95817, USA
| | - Matthew Bobinski
- Department of Radiology, UC Davis School of Medicine, 2315 Stockton Blvd., Sacramento, CA, 95817, USA
| | - Simona Ghetti
- Department of Psychology, University of California, Davis, 102K Young Hall, 1 Shields Ave., Davis, CA, 95616, USA
| | - James F Holmes
- Department of Emergency Medicine, UC Davis School of Medicine, 4150 V. Street, PSSB 2100, Sacramento, CA, 95817, USA
| | - Ian Roberts
- Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Walton O Schalick
- Department of Orthopedics and Rehabilitation, University of Wisconsin, 317 Knutson Drive, Madison, WI, 53704, USA
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California, Davis, 3422 Tupper Hall, Davis, CA, 95616, USA
| | - Leah S Tzimenatos
- Department of Emergency Medicine, UC Davis School of Medicine, 4150 V. Street, PSSB 2100, Sacramento, CA, 95817, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, UC Davis School of Medicine, 4150 V. Street, PSSB 2100, Sacramento, CA, 95817, USA
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Ghadimi K, Levy JH, Welsby IJ. Perioperative management of the bleeding patient. Br J Anaesth 2018; 117:iii18-iii30. [PMID: 27940453 DOI: 10.1093/bja/aew358] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Perioperative bleeding remains a major complication during and after surgery, resulting in increased morbidity and mortality. The principal causes of non-vascular sources of haemostatic perioperative bleeding are a preexisting undetected bleeding disorder, the nature of the operation itself, or acquired coagulation abnormalities secondary to haemorrhage, haemodilution, or haemostatic factor consumption. In the bleeding patient, standard therapeutic approaches include allogeneic blood product administration, concomitant pharmacologic agents, and increasing application of purified and recombinant haemostatic factors. Multiple haemostatic changes occur perioperatively after trauma and complex surgical procedures including cardiac surgery and liver transplantation. Novel strategies for both prophylaxis and therapy of perioperative bleeding include tranexamic acid, desmopressin, fibrinogen and prothrombin complex concentrates. Point-of-care patient testing using thromboelastography, rotational thromboelastometry, and platelet function assays has allowed for more detailed assessment of specific targeted therapy for haemostasis. Strategic multimodal management is needed to improve management, reduce allogeneic blood product administration, and minimize associated risks related to transfusion.
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Affiliation(s)
- K Ghadimi
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - J H Levy
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - I J Welsby
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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Liao L, Chen Y, Tang Q, Chen YY, Wang WC. Tranexamic acid plus drain-clamping can reduce blood loss in total knee arthroplasty: A systematic review and meta-analysis. Int J Surg 2018; 52:334-341. [PMID: 29408472 DOI: 10.1016/j.ijsu.2018.01.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 01/08/2018] [Accepted: 01/29/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND The efficacy of tranexamic acid (TXA) plus drain-clamping in reducing blood loss after total knee arthroplasty (TKA) is controversial. This meta-analysis aimed to identify whether combined tranexamic acid and drain-clamping was superior to TXA alone, drain clamping alone and control treatments. METHODS We searched the PubMed, EMBASE, Web of Science and Google databases and the Cochrane Database of Systematic Reviews. Patients prepared for primary TKA and who underwent TXA plus drain-clamping for blood loss were included in this meta-analysis. Outcomes included the need for transfusion, total blood loss, blood loss in drainage, a decrease in hemoglobin and the occurrence of deep venous thrombosis (DVT). Stata 12.0 was used for meta-analysis. RESULTS Finally, 7 clinical studies with 839 patients were included in this meta-analysis. Compared with the control group, TXA group and drain clamping group treatments, TXA plus drain-clamping could reduce the need for transfusion, total blood loss, blood loss in drainage and the decrease in hemoglobin with statistically significance. CONCLUSIONS TXA plus drain-clamping is an efficient method for controlling blood loss after TKA, and more studies should focus on the optimal clamping duration.
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MESH Headings
- Administration, Intravenous
- Aged
- Antifibrinolytic Agents/adverse effects
- Antifibrinolytic Agents/therapeutic use
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Blood Loss, Surgical/prevention & control
- Blood Loss, Surgical/statistics & numerical data
- Blood Transfusion/statistics & numerical data
- Constriction
- Databases, Factual
- Drainage/methods
- Hemoglobins/analysis
- Hemostasis, Surgical/adverse effects
- Hemostasis, Surgical/methods
- Humans
- Middle Aged
- Tranexamic Acid/adverse effects
- Tranexamic Acid/therapeutic use
- Venous Thrombosis/epidemiology
- Venous Thrombosis/etiology
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Affiliation(s)
- Lele Liao
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - You Chen
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Qi Tang
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Yi-Yue Chen
- Department of Rheumatology and Immunology, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Wan-Chun Wang
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China.
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Alam A, Bopardikar A, Au S, Barrett J, Callum J, Kiss A, Choi S. Protocol for a pilot, randomised, double-blinded, placebo-controlled trial of prophylactic use of tranexamic acid for preventing postpartum haemorrhage (TAPPH-1). BMJ Open 2017; 7:e018586. [PMID: 29025850 PMCID: PMC5652619 DOI: 10.1136/bmjopen-2017-018586] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Postpartum haemorrhage (PPH) is the leading cause of maternal morbidity and mortality worldwide. Despite the availability of multiple uterotonic agents, the incidence of PPH continues to rise. Tranexamic acid (TXA) has been shown to be a safe, effective and inexpensive therapeutic option for the treatment of PPH, however, its use prophylactically in mitigating the risk of PPH is unknown. This pragmatic randomised prospective trial assesses the feasibility and safety of administering TXA at the time of delivery for the prevention of PPH. METHODS AND ANALYSIS A pilot pragmatic randomised double-blinded placebo-controlled trial will be performed. 58 singleton parturients at term >32 weeks, undergoing either spontaneous vaginal delivery, or caesarean section will be randomised to receive 1 g of TXA or placebo (0.9% saline) intravenously. The primary outcome assessed will be the feasibility of administrating TXA, along with collecting data regarding safety of drug administration. The groups will also be analysed on efficacy of mitigating the onset of PPH and clinically relevant variables. Demographic, feasibility, safety and clinical endpoints will be summarised and the appropriate measures of central tendency and dispersion will be presented. ETHICS AND DISSEMINATION This protocol was approved by the Sunnybrook Health Sciences Centre Research Ethics Board (number: 418-2016). The results will be disseminated in a peer-reviewed journal and at scientific meetings. TRIAL REGISTRATION NUMBER NCT03069859; Pre-results.
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Affiliation(s)
- Asim Alam
- Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Trauma, Emergency and Critical Care Research Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ameya Bopardikar
- Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shelly Au
- Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jon Barrett
- Departmentof Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Univesity of Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Departmentof Clinical Pathology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alex Kiss
- Evaluative Clinical Sciences, Hurvitz Brain Science Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Stephen Choi
- Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Abnormalities in fibrinolysis at the time of admission are associated with deep vein thrombosis, mortality, and disability in a pediatric trauma population. J Trauma Acute Care Surg 2017; 82:27-34. [PMID: 27779597 DOI: 10.1097/ta.0000000000001308] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Abnormalities in fibrinolysis are common and associated with increased mortality in injured adults. While hyperfibrinolysis (HF) and fibrinolysis shutdown (SD) are potential prognostic indicators and treatment targets in adults, these derangements are not well described in a pediatric trauma cohort. METHODS This was a prospective analysis of highest level trauma activations in subjects aged 0 to 18 years presenting to our academic center between June 1, 2015, and July 31, 2016, with admission rapid thrombelastograph. Shutdown was defined as LY30 (lysis 30 minutes after the maximum amplitude has been reached) of 0.8% or less and HF defined as LY30 of 3.0% or greater. Variables of interest included demographics, admission vital signs and laboratory values, injuries, incidence of venous thromboembolism under our screening protocol, death, and functional disability (discharge to facility or dependence in functional independence measure category). Youden index determined optimal definition of SD, then Wilcoxon rank-sum, Kruskal-Wallis, and Fisher exact tests were performed. RESULTS One hundred thirty-three patients are included with median age of 10 years (interquartile range [IQR], 5-13 years); male sex, 5.4%; median Injury Severity Score, 17 (IQR, 10-26); blunt mechanism, 68.4%. Youden analysis defined SD as LY30 of 0.8 or less. In total, 38.3% (n = 51) had SD on admission; 19.6% (n = 26) had HF, and 42.1% (n = 56) were normal. Mortality rate was 9.0% (n = 12), and deep vein thrombosis incidence was 10.7% (n = 13/121 surviving). Shutdown and HF were both associated with mortality (p = 0.014 and p = 0.021) and blood transfusion (p = 0.001 and p < 0.001); SD was also associated with disability (p < 0.001) and deep vein thrombosis (p = 0.002). Blunt mechanism was associated with SD, and penetrating mechanism was associated with HF (p = 0.011). Both SD (p = 0.001) and HF (p = 0.036) were associated with elevated international normalized ratio. LY30 did not differ significantly across age groups. CONCLUSIONS Children demonstrate high rates of inhibition (SD) and overactivation (HF) of fibrinolysis after injury. Shutdown and HF are both associated with poor outcomes. Shutdown is a particularly poor prognostic indicator, accounting for the greatest percentage of death, disability, and patients requiring transfusion, as well as later development of hypercoagulable state. The addition of thrombelastograph to pediatric trauma care protocols should be considered as it contributes important prognostic and clinical information. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Abstract
Following results from the CRASH-2 trial, tranexamic acid (TXA) gained considerable interest for the treatment of hemorrhage in trauma patients. Although TXA is effective at reducing mortality in patients presenting within 3 hours of injury, optimal dosing, timing of administration, mechanism, and pharmacokinetics require further elucidation. The concept of fibrinolysis shutdown in hemorrhagic trauma patients has prompted discussion of real-time viscoelastic testing and its potential role for appropriate patient selection. The results of ongoing clinical trials will help establish high-quality evidence for optimal incorporation of TXA in mature trauma networks in the United States and abroad.
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Affiliation(s)
- Ricardo J Ramirez
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Philip C Spinella
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Grant V Bochicchio
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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Li C, Gong Y, Dong L, Xie B, Dai Z. Is prophylactic tranexamic acid administration effective and safe for postpartum hemorrhage prevention?: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e5653. [PMID: 28072700 PMCID: PMC5228660 DOI: 10.1097/md.0000000000005653] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To assess the efficacy and safety of tranexamic acid (TA) in reducing blood loss and lowering transfusion needs for patients undergoing caesarean section (CS) or vaginal delivery (VD). METHODS An electronic literature search of PubMed, EMBASE, OVID, Cochrane library, Scopus, Central, and Clinical trials.gov was performed to identify studies that evaluating the usage of TA in CS or VD. The methodological quality of included trials was assessed and data extraction was performed. RESULTS Finally, 25 articles with 4747 participants were included. Our findings indicated TA resulted in a reduced intra-, postoperative, and total blood loss by a mean volume of 141.25 mL (95% confidence interval [CI] -186.72 to -95.79, P < 0.00001), 36.42 mL (95% CI -46.50 to -26.34, P < 0.00001), and 154.25 mL (95% CI -182.04 to -126.47, P < 0.00001) in CS. TA administration in VD was associated with a reduced intra-, postoperative, and total blood loss by a mean volume of 22.88 mL (95% CI -50.54 to 4.77, P = 0.10), 41.24 mL (95% CI -55.50 to -26.98, P < 0.00001), and 84.79 mL (95% CI -109.93 to -59.65, P < 0.00001). In addition, TA could lower the occurrence rate of postpartum hemorrhage (PPH) and severe PPH, and reduce the risk of blood transfusions. No increased risk of deep vein thrombosis (DVT) after CS or VD was associated with TA usage, while the minor side effects were more common. CONCLUSIONS Our findings indicated that intravenous TA for patients undergoing CS was effective and safe. Although prophylactic TA administration is associated with reduced PPH, current existing data are insufficient to draw definitive recommendations about its clinical significance due to the poor to moderate quality of the included literatures. Thus, high-quality randomized controlled trials with larger samples are needed to validate our findings.
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Affiliation(s)
- Chunbo Li
- Department of Obstetrics and Gynaecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine
| | - Yuping Gong
- Department of Nursing, Zhongshan Hospital of Fudan University
| | - Lingling Dong
- Department of Obstetrics and Gynaecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine
| | - Bingying Xie
- Department of Gynaecology and Obstetrics, Gynaecology and Obstetrics Hospital of Fudan University, Shanghai, China
| | - Zhiyuan Dai
- Department of Obstetrics and Gynaecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine
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40
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New HV, Berryman J, Bolton-Maggs PHB, Cantwell C, Chalmers EA, Davies T, Gottstein R, Kelleher A, Kumar S, Morley SL, Stanworth SJ. Guidelines on transfusion for fetuses, neonates and older children. Br J Haematol 2016; 175:784-828. [DOI: 10.1111/bjh.14233] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Helen V. New
- NHS Blood and Transplant; London UK
- Imperial College Healthcare NHS Trust; London UK
| | | | | | | | | | | | - Ruth Gottstein
- St. Mary's Hospital; Manchester/University of Manchester; Manchester UK
| | | | - Sailesh Kumar
- Mater Research Institute; University of Queensland; Brisbane Australia
| | - Sarah L. Morley
- Addenbrookes Hospital/NHS Blood and Transplant; Cambridge UK
| | - Simon J. Stanworth
- Oxford University Hospitals NHS Trust/NHS Blood and Transplant; Oxford UK
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Urban D, Dehaeck R, Lorenzetti D, Guilfoyle J, Poon MC, Steele M, Lardner D, Ma IWY, Brindle ME. Safety and efficacy of tranexamic acid in bleeding paediatric trauma patients: a systematic review protocol. BMJ Open 2016; 6:e012947. [PMID: 27660323 PMCID: PMC5051427 DOI: 10.1136/bmjopen-2016-012947] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Trauma is the leading cause of death among children aged 1-18. Studies indicate that better control of bleeding could potentially prevent 10-20% of trauma-related deaths. The antifibrinolytic agent tranexamic acid (TxA) has shown promise in haemorrhage control in adult trauma patients. However, information on the potential benefits of TxA in children remains sparse. This review proposes to evaluate the current uses, benefits and adverse effects of TxA in the bleeding paediatric trauma population. METHODS AND ANALYSIS A structured search of bibliographic databases (eg, MEDLINE, EMBASE, PubMed, CINAHL, Cochrane CENTRAL) has been undertaken to retrieve randomised controlled trials and cohort studies that describe the use of TxA in paediatric trauma patients. To ensure that all relevant data were captured, the search did not contain any restrictions on language or publication time. After deduplication, citations will be screened independently by 2 authors, and selected for inclusion based on prespecified criteria. Data extraction and risk of bias assessment will be performed independently and in duplicate. Meta-analytic methods will be employed wherever appropriate. ETHICS AND DISSEMINATION This study will not involve primary data collection, and formal ethical approval will therefore not be required. The findings of this study will be disseminated through a peer-reviewed publication and at relevant conference meetings. TRIAL REGISTRATION NUMBER CRD42016038023.
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Affiliation(s)
- Denisa Urban
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ruben Dehaeck
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Diane Lorenzetti
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Jonathan Guilfoyle
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Man-Chiu Poon
- Division of Hematology/Hematologic Malignancies, Department of Medicine,Cumming School of Medicine, Calgary, Alberta, Canada
- Division of Hematology/Hematologic Malignancies, Department of Pediatrics, Cumming School of Medicine, Calgary, Alberta, Canada
- Division of Hematology/Hematologic Malignancies, Department of Oncology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - MacGregor Steele
- Section of Pediatric Hematology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David Lardner
- Division of Pediatric Anesthesia, Department of Anesthesia, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Irene Wai Yan Ma
- Division of General Internal Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mary Elizabeth Brindle
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Intraoperative Red Blood Cell Transfusion in Infant Heart Transplant Patients Is Not Associated with Worsened Outcomes. Anesth Analg 2016; 122:1567-77. [DOI: 10.1213/ane.0000000000001241] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Nishijima DK, Monuteaux MC, Faraoni D, Goobie SM, Lee L, Galante J, Holmes JF, Kuppermann N. Tranexamic Acid Use in United States Children's Hospitals. J Emerg Med 2016; 50:868-874.e1. [PMID: 27017532 DOI: 10.1016/j.jemermed.2016.02.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/13/2016] [Accepted: 02/04/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The prevalence of tranexamic acid (TXA) use for trauma and other conditions in children is unknown. OBJECTIVES The objective of this study was to describe the use of TXA in United States (US) children's hospitals for children in general, and specifically for trauma. METHODS We conducted a secondary analysis of a large, administrative database of 36 US children's hospitals. We included children <18 years of age who received TXA (based on pharmacy charge codes) between 2009 and 2013. Patients were grouped into the following diagnostic categories: trauma, congenital heart surgery, scoliosis surgery, craniosynostosis/craniofacial surgery, and other, based on the International Classification of Diseases, Ninth Revision principal procedure and diagnostic codes. TXA administration and dosage, in-hospital clinical variables, and diagnostic and procedure codes were documented. RESULTS A total of 35,478 pediatric encounters with a TXA charge were included in the study cohort. The proportions of children who received TXA were similar across the years 2009 to 2013. Only 110 encounters (0.31%) were for traumatic conditions. Congenital heart surgery accounted for more than one-half of the encounters (22,863; 64%). Overall, the median estimated weight-based dose of TXA was 22.4 mg/kg (interquartile range, 7.3-84.9 mg/kg). CONCLUSIONS We identified a wide frequency of use and range of doses of TXA for several diagnostic conditions in children. The use of TXA among injured children, however, appears to be rare despite its common use and efficacy among injured adults. Additional work is needed to identify appropriate indications for TXA and provide dosage guidelines among children with a variety of conditions, including trauma.
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Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Michael C Monuteaux
- Division of Pediatric Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - David Faraoni
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lois Lee
- Division of Pediatric Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph Galante
- Division of Trauma and Emergency Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, California
| | - James F Holmes
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California; Department of Pediatrics, University of California Davis School of Medicine, Sacramento, California
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Effective tranexamic acid concentration for 95% inhibition of tissue-type plasminogen activator induced hyperfibrinolysis in children with congenital heart disease. Eur J Anaesthesiol 2015; 32:844-50. [DOI: 10.1097/eja.0000000000000316] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Abstract
Abstract
Antifibrinolytic therapy reduces bleeding and chest tube drainage output in cardiac surgical patients but is associated with potential side effects. Two phase-II studies with new compounds were terminated prematurely. There is increasing evidence of adverse side effects with tranexamic acid.
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46
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Experimental model of hyperfibrinolysis designed for rotational thromboelastometry in children with congenital heart disease. Blood Coagul Fibrinolysis 2015; 26:290-7. [DOI: 10.1097/mbc.0000000000000238] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Transfusion therapy in paediatric trauma patients: a review of the literature. Scand J Trauma Resusc Emerg Med 2015; 23:21. [PMID: 25888054 PMCID: PMC4336766 DOI: 10.1186/s13049-015-0097-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Accepted: 01/20/2015] [Indexed: 01/12/2023] Open
Abstract
Haemorrhage is a leading cause of death in paediatric trauma patients. Predefined massive transfusion protocols (MTP) have the potential to significantly reduce mortality by treating haemorrhagic shock and coagulopathy, in adhering to the principles of haemostatic resuscitation with rapid administration of balanced ratios of packed red blood cells (RBC), fresh frozen plasma (FFP) and platelets (PLT). Because of their substantial physiological reserve, initial vital signs may not be good predictors of early haemorrhage in paediatric patients. Determining the triggers for MTP activation in paediatric trauma patients is challenging, and the optimal blood product ratio that will increase survival in massively bleeding paediatric trauma patients has yet to be determined. To date, only a few small descriptive studies and case reports have investigated the use of predefined MTP in paediatric trauma patients. MTP with increased FFP or PLT to RBC ratios combined with viscoelastic haemostatic assay (VHA) guided haemostatic resuscitation have not yet been tested in paediatric populations but based on results from adult trauma patients, this therapeutic approach seems promising. Considering the high prevalence of early coagulopathy in paediatric trauma patients, immediate identification and implementation of VHA-directed treatment of traumatic coagulopathy could ensure faster haemostasis and thereby, potentially, reduce bleeding as well as the total transfusion requirements and further improve outcome in paediatric trauma patients. Prospective randomized trials investigating this therapeutic approach in paediatric trauma patients are highly warranted.
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Continuous or discontinuous tranexamic acid effectively inhibits fibrinolysis in children undergoing cardiac surgery with cardiopulmonary bypass. Blood Coagul Fibrinolysis 2015; 25:259-65. [PMID: 24418941 DOI: 10.1097/mbc.0000000000000051] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Tranexamic acid is given continuously or discontinuously as an anti-fibrinolytic therapy during cardiac surgery, but the effects on fibrinolysis parameters remain poorly investigated. We sought to assess the effects of continuous and discontinuous tranexamic acid on fibrinolysis parameters in children undergoing cardiac surgery with cardiopulmonary bypass (CPB). Children requiring cardiac surgery or repeat surgery by sternotomy with CPB for congenital heart disease were randomized to receive either continuous or discontinuous tranexamic acid. Blood tranexamic acid, D-dimers, tissue plasminogen activator (tPA), tPA-plasminogen activator inhibitor 1 (tPA-PAI1) complexes, fibrinogen and fibrin monomers were measured and compared to values obtained from children who did not receive tranexamic acid. Tranexamic acid inhibited the CPB-induced increase in D-dimers, with a similar potency between continuous and discontinuous regimens. Time courses for tPA, fibrin monomers, and fibrinogen were also similar for both regimen, and there was a significant difference in tPA-PAI1 complex concentrations at the end of surgery, which may be related to a significantly higher tranexamic acid concentration. Continuous and discontinuous regimen are suitable for an effective inhibition of fibrinolysis in children undergoing cardiac surgery with CPB, but the continuous regimen was previously shown to be more effective to maintain stable tranexamic acid concentrations.
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Vel R, Udupi BP, Satya Prakash MVS, Adinarayanan S, Mishra S, Babu L. Effect of low dose tranexamic acid on intra-operative blood loss in neurosurgical patients. Saudi J Anaesth 2015; 9:42-8. [PMID: 25558198 PMCID: PMC4279349 DOI: 10.4103/1658-354x.146304] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Blood loss is often a major complication in neurosurgery that requires transfusion of multiple units of blood. The purpose of this study was to assess the effect of tranexamic acid (TXA) on intraoperative blood loss and the need for blood transfusion in patients undergoing craniotomy for tumor excision. Materials and Methods: A total of 100 patients aged 18-60 years, with American Society of Anesthesiologists physical Status 1 and 2 scheduled to undergo elective craniotomy for tumor excision were enrolled. Patients received 10 mg/kg bolus about 20 min before skin incision followed by 1 mg/kg/h infusion of either TXA or saline. Hemodynamic variables, intravenous fluid transfused, amount of blood loss and blood given were measured every 2 h. Laboratory parameters such as serum electrolytes and fibrinogen values were measured every 3 h. On the 5th postoperative day hemoglobin (POD Hb5), Hb estimation was done and the estimated blood loss (EBL) calculated. Patients were also monitored for any complications. Results: The Mean heart rate in TXA group was significantly lower compared with the saline group. Mean arterial pressure and fibrinogen levels were higher in TXA group. The mean total blood loss in the TXA group was less than in the saline group. Blood transfusion requirements were comparable in two groups. The EBL and POD5 Hb were comparable in two groups. Conclusion: Even though, there is a significant reduction in the total amount of blood loss in TXA group. However, there was no reduction in intraoperative transfusion requirement.
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Affiliation(s)
- Ramya Vel
- Department of Anesthesiology and Critical Care, JIPMER, Puducherry, India
| | | | | | | | - Sandeep Mishra
- Department of Anesthesiology and Critical Care, JIPMER, Puducherry, India
| | - Lenin Babu
- Department of Anesthesiology and Critical Care, JIPMER, Puducherry, India
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Faraoni D, Goobie SM. The efficacy of antifibrinolytic drugs in children undergoing noncardiac surgery: a systematic review of the literature. Anesth Analg 2014; 118:628-36. [PMID: 24557107 DOI: 10.1213/ane.0000000000000080] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Children undergoing major surgery are frequently exposed to a high risk of blood loss often requiring transfusion. Although the risks associated with blood product transfusion have considerably decreased over the last decade, transfusion is still associated with significant morbidity and mortality. Thus, rigorous efforts should be made to decrease surgical bleeding and the need for blood product transfusion. Antifibrinolytic drugs have been shown to be effective when used in both adult and pediatric surgical patients. While there are data in adults to support safety, data remain limited for pediatric patients. Since the restriction of aprotinin use in 2008, the most commonly used antifibrinolytic drugs have been the lysine analogs, tranexamic acid (TXA), and ε-aminocaproic acid, which inhibit the conversion of plasminogen to plasmin and decrease the degree of fibrinolysis. We performed a systematic review of the literature pertaining to the efficacy of antifibrinolytic drugs in children undergoing noncardiac surgery. During spine surgery, both TXA and ε-aminocaproic acid decrease blood loss and transfusion requirements; however, this information comes from small, mainly retrospective trials. Two prospective, randomized, controlled trials have tested the efficacy of TXA in children undergoing craniofacial surgery and have reported that TXA decreases transfusion requirements. Two pharmacokinetic trials were also recently published and are summarized in this review. No data have been published regarding the efficacy of TXA administration in the pediatric trauma population. Further data are still needed in this field of study, and we discuss some perspectives for future research.
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Affiliation(s)
- David Faraoni
- From the *Department of Pediatric Anesthesiology, Queen Fabiola Children's University Hospital, Free University of Brussels, Brussels, Belgium; and †Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
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