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Mergoum AM, Mergoum AS, Larson NJ, Dries DJ, Cook A, Blondeau B, Rogers FB. Tranexamic Acid Use in the Surgical Arena: A Narrative Review. J Surg Res 2024; 302:208-221. [PMID: 39106732 DOI: 10.1016/j.jss.2024.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/02/2024] [Accepted: 07/07/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION Tranexamic acid (TXA) is a potent antifibrinolytic drug that inhibits the activation of plasmin by plasminogen. While not a new medication, TXA has quickly gained traction across a variety of surgical subspecialties to prevent and treat bleeding. Knowledge on the use of this drug is essential for the modern surgeon to continue to provide excellent care to their patients. METHODS A comprehensive review of the PubMed database was conducted of articles published within the last 10 y (2014-2024) relating to TXA and its use in various surgical subspecialties. Seminal studies regarding the use of TXA older than 10 y were included from the author's archives. RESULTS Indications for TXA are not limited to trauma alone, and TXA is utilized across a variety of surgical subspecialties from neurosurgery to hepatic surgery to control hemorrhage. Overall, TXA is well tolerated with common dose-dependent adverse effects, including headache, nasal symptoms, dizziness, nausea, diarrhea, and fatigue. More severe adverse events are rare and easily mitigated by not exceeding a dose of 50 mg/kg. CONCLUSIONS The administration of TXA as an adjunct to treat trauma saves lives. The ability of TXA to induce seizures is dose dependent with identifiable risk factors, making this serious adverse effect predictable. As for the potential for TXA to cause thrombotic events, uncertainty remains. If this association is proven to be real, the risk will likely be small, since the use of TXA is still advantageous in most situations because of its efficacy for a more common concern, bleeding.
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Affiliation(s)
| | - Adel S Mergoum
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | - Alan Cook
- Department of Surgery, University of Texas at Tyler School of Medicine, Tyler, Texas
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
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Kim DJ, Cho SY, Jung KT. Tranexamic acid - a promising hemostatic agent with limitations: a narrative review. Korean J Anesthesiol 2024; 77:411-422. [PMID: 37599607 PMCID: PMC11294883 DOI: 10.4097/kja.23530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/21/2023] [Indexed: 08/22/2023] Open
Abstract
Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that has been used for several decades to reduce blood loss during surgery and after trauma. TXA was traditionally used to reduce bleeding in various clinical settings such as menorrhagia, hemophilia, or other bleeding disorder. Numerous studies have demonstrated the efficacy of TXA in reducing blood loss and the need for transfusions. Interest in the potential applications of TXA beyond its traditional use has been growing recently, with studies investigating the use of TXA in postpartum hemorrhage, cardiac surgery, trauma, neurosurgery, and orthopedic surgery. Despite its widespread use and expanding indications, data regarding the safe and appropriate use of TXA is lacking. Recent clinical trials have found various potential risks and limitations in the long-term benefits of TXA. This narrative review summarizes the clinical applications and limitations of TXA.
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Affiliation(s)
- Dong Joon Kim
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Chosun University College of Medicine and Medical School, Gwangju, Korea
| | - Su Yeon Cho
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Chosun University College of Medicine and Medical School, Gwangju, Korea
| | - Ki Tae Jung
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Chosun University College of Medicine and Medical School, Gwangju, Korea
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Koster A, Hulde N, Deutsch MA, Gummert JF, von Dossow V, Zittermann A. The Efficacy and Safety of a Low-Dose Tranexamic Acid Bolus-Only Protocol Compared with the Moderate-Dose Protocol in Valvular Heart Surgery. Thorac Cardiovasc Surg 2024; 72:55-58. [PMID: 36657457 DOI: 10.1055/s-0042-1760205] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
In 873 propensity score-matched pairs of patients undergoing valvular heart surgery, we compared a "moderate dose" of tranexamic acid (TXA) protocol (group 1; median TXA dose: 24 mg/kg body weight) with a 1.5-g "bolus-only" protocol (group 2; median TXA dose: 19 mg/kg body weight). The number of transfused patients was higher in group 2 than in group 1 (74.5 vs 66.0%, p < 0.001), as was the number of transfused red blood cell concentrates (p = 0.001). The risks of re-exploration and convulsive seizures were similar between groups (p > 0.50). Data indicate an impaired efficacy following the "bolus-only" protocol, without a significant safety improvement.
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Affiliation(s)
- Andreas Koster
- Institute for Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Nikolai Hulde
- Institute for Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Marcus-Andre Deutsch
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Jan F Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Vera von Dossow
- Institute for Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Armin Zittermann
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
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Foster D, Sebro R, Garner H, Stanborough R, Spaulding AC, Goulding K, Houdek M, Wilke B. Intravenous tranexamic acid is associated with an increased risk of pulmonary embolism following sarcoma resection. J Surg Oncol 2023; 128:869-876. [PMID: 37428014 DOI: 10.1002/jso.27391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/12/2023] [Accepted: 06/16/2023] [Indexed: 07/11/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) is an antifibrinolytic drug that has been shown to reduce blood loss following surgery. The use of TXA during orthopedic procedures has gained widespread acceptance, with multiple clinical studies demonstrating no increase in thrombotic complications. While TXA has been shown to be safe and effective for several orthopedic procedures, its use in orthopedic sarcoma surgery is not well established. Cancer-associated thrombosis remains a significant cause of morbidity and mortality in patients with sarcoma. It is unknown if intraoperative TXA use will increase the risk of developing a postoperative thrombotic complication in this population. This study aimed to compare the risk of postoperative thrombotic complications in patients who received TXA during sarcoma resection to patients who did not receive TXA. METHODS A retrospective review was performed of 1099 patients who underwent resection of a soft tissue or bone sarcoma at our institution between 2010 and 2021. Baseline demographics and postoperative outcomes were compared between patients who did and did not receive intraoperative TXA. We evaluated 90-day complication rates, including: deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), cerebrovascular accident (CVA), and mortality. RESULTS TXA was used more commonly for bone tumors (p < 0.001), tumors located in the pelvis (p = 0.004), and larger tumors (p < 0.001). Patients who received intraoperative TXA were associated with a significant increase in developing a postoperative DVT (odds ratio [OR]: 2.22, p = 0.036) and PE (OR: 4.62, p < 0.001), but had no increase in CVA, MI, or mortality (all p > 0.05) within 90 days of surgery, following univariate analysis. Multivariable analysis confirmed that TXA was independently associated with developing a postoperative PE (OR: 10.64, 95% confidence interval: 2.23-50.86, p = 0.003). We found no association with DVT, MI, CVA, or mortality within 90 days postoperatively, following intraoperative TXA use. CONCLUSION Our results demonstrate a higher associated risk of PE following TXA use in sarcoma surgery and caution is warranted with TXA use in this patient population.
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Affiliation(s)
- Devon Foster
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Ronnie Sebro
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Hillary Garner
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Aaron C Spaulding
- Department of Biostatistics, Mayo Clinic, Jacksonville, Florida, USA
| | - Krista Goulding
- Department of Orthopedic Surgery, Mayo Clinic Scottsdale, Scottsdale, Arizona, USA
| | - Matthew Houdek
- Department of Orthopedic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Benjamin Wilke
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Lam T, Medcalf RL, Cloud GC, Myles PS, Keragala CB. Tranexamic acid for haemostasis and beyond: does dose matter? Thromb J 2023; 21:94. [PMID: 37700271 PMCID: PMC10496216 DOI: 10.1186/s12959-023-00540-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023] Open
Abstract
Tranexamic acid (TXA) is a widely used antifibrinolytic agent that has been used since the 1960's to reduce blood loss in various conditions. TXA is a lysine analogue that competes for the lysine binding sites in plasminogen and tissue-type plasminogen activator impairing its interaction with the exposed lysine residues on the fibrin surface. The presence of TXA therefore, impairs the plasminogen and tPA engagement and subsequent plasmin generation on the fibrin surface, protecting fibrin clot from proteolytic degradation. However, critical lysine binding sites for plasmin(ogen) also exist on other proteins and on various cell-surface receptors allowing plasmin to exert potent effects on other targets that are unrelated to classical fibrinolysis, notably in relation to immunity and inflammation. Indeed, TXA was reported to significantly reduce post-surgical infection rates in patients after cardiac surgery unrelated to its haemostatic effects. This has provided an impetus to consider TXA in other indications beyond inhibition of fibrinolysis. While there is extensive literature on the optimal dosage of TXA to reduce bleeding rates and transfusion needs, it remains to be determined if these dosages also apply to blocking the non-canonical effects of plasmin.
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Affiliation(s)
- Tammy Lam
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia
| | - Geoffrey C Cloud
- Department of Clinical Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne VIC, Australia
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne VIC, Australia
| | - Charithani B Keragala
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia.
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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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Wang E, Wang Y, Li Y, Hu S, Yuan S. Tranexamic acid is associated with improved hemostasis in elderly patients undergoing coronary-artery surgeries in a retrospective cohort study. Front Surg 2023; 10:1117974. [PMID: 36896258 PMCID: PMC9989169 DOI: 10.3389/fsurg.2023.1117974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/03/2023] [Indexed: 02/23/2023] Open
Abstract
Background More elderly patients undergo coronary artery bypass surgery (CABG) than younger patients. Whether tranexamic acid (TA) is still effective and safe in elderly patients undergoing CABG surgeries is still unclear. Methods In this study, a cohort of 7,224 patients ≥70 years undergoing CABG surgery were included. Patients were categorized into the no TA group, TA group, high-dose group, and low-dose group according whether TA was administered and the dose administered. The primary endpoint was blood loss and blood transfusion after CABG. The secondary endpoints were thromboembolic events and in-hospital death. Results The blood loss at 24 and 48 h and the total blood loss after surgery in patients in the TA group were 90, 90, and 190 ml less than those in the no-TA group, respectively (p < 0.0001). The total blood transfusion was reduced 0.38-fold with TA administration compared to that without TA (OR = 0.62, 95% CI 0.56-0.68, p < 0.0001). Blood component transfusion was also reduced. High-dose TA administration reduced the blood loss by 20 ml 24 h after surgery (p = 0.032) but had no relationship with the blood transfusion. TA increased the risk of perioperative myocardial infarction (PMI) by 1.62-fold [p = 0.003, OR = 1.62, 95% CI (1.18-2.22)] but reduced the hospital stay time in patients who were administered TA compared to that of patients who did not receive TA (p = 0.026). Conclusion We revealed that elderly patients undergoing CABG surgeries had better hemostasis after TA administration but increased the risk of PMI. High-dose TA was effective and safe compared with low-dose TA administration in elderly patients undergoing CABG surgery.
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Affiliation(s)
- Enshi Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yang Wang
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Yuan Li
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Jakowenko ND, Kopp BJ, Erstad BL. Appraising the use of tranexamic acid in traumatic and non-traumatic intracranial hemorrhage: A narrative review. J Am Coll Emerg Physicians Open 2022; 3:e12777. [PMID: 35859856 PMCID: PMC9286528 DOI: 10.1002/emp2.12777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/06/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022] Open
Abstract
Recently there has been increasing interest and debate on the use of tranexamic acid (TXA), an antifibrinolytic drug, in both traumatic and non-traumatic intracranial hemorrhage. In this review we aim to discuss recent investigations looking at TXA in traumatic brain injury (TBI) and different categories of spontaneous intracranial hemorrhage. We also discuss differences between setting (hospital vs pre-hospital), dosing and timing strategies, and other logistical challenges surrounding optimal use of TXA for isolated intracranial hemorrhage. Last, we hope to provide guidance for clinicians when considering the use of TXA in a patient with traumatic or non-traumatic intracranial hemorrhage based on appraisal of the available literature as well as some potential ideas for future research in this area.
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Affiliation(s)
| | - Brian J. Kopp
- Department of PharmacyBanner University Medical Center–TucsonTucsonArizonaUSA
| | - Brian L. Erstad
- Department of Pharmacy Practice and ScienceUniversity of Arizona College of PharmacyTucsonArizonaUSA
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Letter to the editor: Is it the time to rethink how to use tranexamic acids in managing gastrointestinal bleeding? Am J Emerg Med 2022; 59:162-164. [DOI: 10.1016/j.ajem.2022.06.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022] Open
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Wang E, Yuan X, Wang Y, Chen W, Zhou X, Hu S, Yuan S. Blood conservation outcomes and safety of tranexamic acid in coronary artery bypass graft surgery. Int J Cardiol 2021; 348:50-56. [PMID: 34920046 DOI: 10.1016/j.ijcard.2021.12.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/13/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The safety and blood management effects of Tranexamic acid (TXA) and its dose effects in coronary artery bypass graft (CABG) were still ambiguous. This study aimed to analyze these TXA effects. METHODS Overall, 42,010 patients undergoing CABG were enrolled in this retrospective cohort study. Patients were assigned to the TXA group (n = 29,536) and the no-TXA group (n = 12,474). Furthermore, the TXA group was divided into the high-dose (≥50 mg/kg) (16,488) and the low-dose (<50 mg/kg) (13,048) subgroup. Propensity score matching was performed in both groups respectively. The primary endpoint after CABG was composed of hospital death, perioperative myocardial infarction (PMI), stroke, acute kidney injury (AKI), and pulmonary embolism. The secondary endpoint included blood loss and blood transfusion after surgery. RESULTS TXA led to a 1.40-fold risk of PMI (p < 0.001). Patients in the TXA group had fewer re-operations for bleeding or tamponade [Odd ratio (OR) = 0.82, p = 0.044], less blood loss after surgery (p < 0.001), and a lower risk for blood transfusion exposure (OR = 0.45, p < 0.001) than those in the no-TXA group. The high-dose TXA reduced blood loss after cardiac surgery compared to the low-dose TXA (p < 0.001) with no associations with blood exposure or adverse events. CONCLUSIONS The use of TXA during CABG increased the risk of PMI despite better blood control after surgery. The high dose of TXA acquired better bleeding management. Meanwhile, it did not increase the risk of primary endpoint.
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Affiliation(s)
- Enshi Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing 100037, China
| | - Xin Yuan
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing 100037, China
| | - Yang Wang
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Xicheng District, Beijing 100037, China
| | - Weinan Chen
- Information Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing 100037, China
| | - Xingtong Zhou
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing 100037, China
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing 100037, China.
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing 100037, China.
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Ockerman A, Vanassche T, Garip M, Vandenbriele C, Engelen MM, Martens J, Politis C, Jacobs R, Verhamme P. Tranexamic acid for the prevention and treatment of bleeding in surgery, trauma and bleeding disorders: a narrative review. Thromb J 2021; 19:54. [PMID: 34380507 PMCID: PMC8356407 DOI: 10.1186/s12959-021-00303-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We review the evidence for tranexamic acid (TXA) for the treatment and prevention of bleeding caused by surgery, trauma and bleeding disorders. We highlight therapeutic areas where evidence is lacking and discuss safety issues, particularly the concern regarding thrombotic complications. METHODS An electronic search was performed in PubMed and the Cochrane Library to identify clinical trials, safety reports and review articles. FINDINGS TXA reduces bleeding in patients with menorrhagia, and in patients undergoing caesarian section, myomectomy, hysterectomy, orthopedic surgery, cardiac surgery, orthognathic surgery, rhinoplasty, and prostate surgery. For dental extractions in patients with bleeding disorders or taking antithrombotic drugs, as well as in cases of idiopathic epistaxis, tonsillectomy, liver transplantation and resection, nephrolithotomy, skin cancer surgery, burn wounds and skin grafting, there is moderate evidence that TXA is effective for reducing bleeding. TXA was not effective in reducing bleeding in traumatic brain injury and upper and lower gastrointestinal bleeding. TXA reduces mortality in patients suffering from trauma and postpartum hemorrhage. For many of these indications, there is no consensus about the optimal TXA dose. With certain dosages and with certain indications TXA can cause harm, such as an increased risk of seizures after high TXA doses with brain injury and cardiac surgery, and an increased mortality after delayed administration of TXA for trauma events or postpartum hemorrhage. Whereas most trials did not signal an increased risk for thrombotic events, some trials reported an increased rate of thrombotic complications with the use of TXA for gastro-intestinal bleeding and trauma. CONCLUSIONS TXA has well-documented beneficial effects in many clinical indications. Identifying these indications and the optimal dose and timing to minimize risk of seizures or thromboembolic events is work in progress.
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Affiliation(s)
- Anna Ockerman
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium.
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Melisa Garip
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Jeroen Martens
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peter Verhamme
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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SORAN TÜRKCAN B, ÜNAL EU, KİRİŞ E, AYTEKİN B, AKKAYA B, DEMİR Z, AYKUT A, AKSÖYEK A, BIRINCIOĞLU L. Heparin titration protocol with tranexamic acid in cardiac surgery: a pilot study. ACTA MEDICA ALANYA 2021. [DOI: 10.30565/medalanya.956769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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13
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Efficacy and Safety of Antifibrinolytic Drugs in Pediatric Surgery: A Systematic Review. Semin Thromb Hemost 2021; 47:538-568. [PMID: 34192794 DOI: 10.1055/s-0040-1721736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Antifibrinolytic drugs are used to reduce blood loss and subsequent transfusions during surgery and following trauma, but the optimal dosing regimen in the pediatric population is still unresolved. The aim of this systematic review was to evaluate efficacy and safety of antifibrinolytic drugs in pediatric surgery and trauma to determine the optimal dosing regimen. A literature search was performed in PubMed, Embase, Cochrane, and Web of Science on May 3, 2020. We included randomized controlled studies investigating the effect of tranexamic acid (TXA), aprotinin, and epsilon-aminocaproic acid, in terms of reducing blood loss, blood transfusions, reoperations, and rebleeds in pediatric patients aged 0 to 18 years undergoing cardiac surgery, noncardiac surgery, or trauma. Fifty randomized controlled trials (RCTs) were included; 28 RCTs investigated cardiac surgery and 22 investigated noncardiac surgery. No RCTs regarding trauma met the inclusion criteria. All antifibrinolytic drugs reduced postoperative blood loss and transfusions when used in pediatric surgery. The dosing regimen varied between studies, but similar effect sizes were found in terms of reduced blood loss regardless of the cumulative dose used. Few studies found adverse events, and no difference in incidence or type of adverse events was seen between the antifibrinolytic and the placebo group. In conclusion, use of antifibrinolytics is efficient and safe in children undergoing surgery. We propose TXA as the drug of choice based on its level of evidence and safety profile; we recommend a dosing regimen composed of a loading dose of 10 to 15 mg/kg prior to surgery followed by 1 to 5 mg/kg/h as continuous infusion throughout surgery.
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Ravi GK, Panda N, Ahluwalia J, Chauhan R, Singla N, Mahajan S. Effect of tranexamic acid on blood loss, coagulation profile, and quality of surgical field in intracranial meningioma resection: A prospective randomized, double-blind, placebo-controlled study. Surg Neurol Int 2021; 12:272. [PMID: 34221603 PMCID: PMC8247710 DOI: 10.25259/sni_296_2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 04/22/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Resection of intracranial meningioma has been associated with significant blood loss. Providing a clear surgical field and maintaining hemodynamic stability are the major goals of anesthesia during meningioma surgery. Tranexamic acid has been used to reduce blood loss in various neurosurgical settings with limited evidence in literature. A randomized, double-blind, and placebo-controlled trial was conducted to evaluate the efficacy of tranexamic acid on blood loss, coagulation profile, and quality of surgical field during resection of intracranial meningioma. Methods: Thirty patients aged 18–65 years undergoing elective meningioma resection surgery were given either tranexamic acid or placebo (0.9% saline), tranexamic acid at a loading dose of 20 mg/kg, and infusion of 1 mg/kg/h during surgery. The intraoperative blood loss, coagulation profile, and the surgical field using Likert scale were assessed. Results: The patients in tranexamic group had significantly decreased intraoperative blood loss compared to the placebo group (616.42 ± 393.42 ml vs. 1150.02 ± 416.1 ml) (P = 0.02). The quality of the surgical field was better in the tranexamic group (median score 4 vs. 2 on Likert Scale) (P < 0.001). Patients in tranexamic group had an improved coagulation profile and decreased blood transfusion requirement (p=0.016). The blood collected in closed suction drain in 24 h postsurgery was less in the tranexamic acid group compared to placebo group (84.7 ± 50.4 ml vs. 127.6 ± 62.2 ml) (P = 0.047). Conclusion: Tranexamic acid bolus followed by infusion reduces perioperative blood loss by 46.43% and blood transfusion requirement with improved surgical field and coagulation profile in patients undergoing intracranial meningioma resection surgery.
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Affiliation(s)
- Gopala K Ravi
- Department of Intensive Care Medicine, Manipal Hospital Bengaluru, Bengaluru, Karnataka, India
| | - Nidhi Panda
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jasmina Ahluwalia
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajeev Chauhan
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Navneet Singla
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shalvi Mahajan
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Samir M, Saafan AM, Afifi RM, Tawfick A. Can high-dose tranexamic acid have a role during transurethral resection of the prostate in large prostates? A randomised controlled trial. Arab J Urol 2021; 20:24-29. [PMID: 35223106 PMCID: PMC8881071 DOI: 10.1080/2090598x.2021.1932125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/16/2021] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES To assess the efficacy and safety of high-dose tranexamic acid (TXA) during bipolar transurethral resection of the prostate (B-TURP) in patients with large prostates compared to placebo. PATIENTS AND METHODS From February 2018 to May 2020, 204 patients with enlarged prostates of 80-130 g and in need of surgical intervention were randomised into two groups. Patients in Group A underwent B-TURP and received TXA as an intravenous loading dose of 50 mg/kg over 20 min before induction of anaesthesia followed by a maintenance infusion of 5 mg/kg/h until resection was completed. The patients in Group B (placebo) received a saline infusion of a similar volume. RESULTS There was highly significant drop in haemoglobin in the placebo group at 4- and 24-h postoperatively compared with the TXA group (P < 0.001). However, there was no significant difference in the blood transfusion rate between the two groups with five patients (5.5%) in the placebo group and four (4.2%) in the TXA group requiring a transfusion (P = 0.74). The procedural time was significantly less in the TXA group vs the control group, at a mean (SD) of 79.93 (22.18) vs 90.91 (21.4) min (P = 0.001). Also, the intraoperative irrigation fluid volume and postoperative irrigation duration were significantly less in the TXA group vs the control group, at a mean (SD) of 19.21 (3.13) vs 23.05 (3.8) L and 14.75 (5.15) vs 18.33 (5.96) h, respectively (P = 0.001). Catheterisation and hospital stay durations were comparable between both groups (P = 0.384 and P = 0.388, respectively). No complications were recorded with use of high-dose TXA. CONCLUSION High-dose TXA was effective in controlling blood loss during B-TURP in patients with large prostates, with no adverse drug reactions.
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Affiliation(s)
- Mohamed Samir
- Department of Urology, Ain Shams University, Cairo, Egypt
| | | | - Rania M. Afifi
- Department of Urology, Ain Shams University, Cairo, Egypt
| | - Ahmed Tawfick
- Department of Urology, Ain Shams University, Cairo, Egypt
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Franz ND, Machado-Aranda D, Miller JT, Farina N. Impact of Obesity on Tranexamic Acid Efficacy in Adult Patients With Major Bleeding. Ann Pharmacother 2021; 55:1076-1083. [PMID: 33384016 DOI: 10.1177/1060028020983323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic used for prophylaxis and treatment of acute bleeding. Although fixed dosing is often used in practice, weight-based dosing is sometimes used in the operating room (OR). The efficacy and safety of fixed-dose TXA is not well established in patients with above average weight or body mass index. OBJECTIVE To characterize the efficacy and safety of intravenous TXA in obese patients with major bleeding. METHODS This was a retrospective review of 165 patients receiving fixed-dose TXA for acute bleeding outside the OR. Blood product administration (BPA) before and after TXA was collected, along with demographic and bleed-related information. Thrombotic events were the major safety end point. A prespecified subgroup analysis was conducted in patients weighing at least 100 kg compared with a lower weight. Logistic regression was performed to determine whether an association exists between body weight and blood product requirement after TXA administration. RESULTS In the 24 hours after TXA, patients received an average of 4.17 units of blood product. Patients weighing at least 100 kg averaged 4.04 total units, compared with 4.19 units in the lower weight group (P = 0.603). Administration of individual blood products did not differ between groups, and thrombotic events were similar. Regression analysis did not associate weight with total BPA. CONCLUSION AND RELEVANCE In patients receiving fixed-dose TXA, weight does not appear to alter blood product requirements or rates of adverse thrombotic events. These data support continued use of fixed-dose TXA for treatment of acute major bleeding in obese patients.
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Affiliation(s)
| | | | - James T Miller
- University of Michigan Health System, Ann Arbor, MI, USA
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Chen DS, Zhu JW, Wang TF, Zhu B, Feng CH. Tranexamic Acid Is Beneficial to Patients Undergoing Open-Wedge High Tibial Osteotomy. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2514207. [PMID: 33204689 PMCID: PMC7661119 DOI: 10.1155/2020/2514207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/23/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to investigate the efficacy of tranexamic acid (TXA) in patients undergoing open-wedge high tibial osteotomy (OWHTO). Patients from August 2018 to May 2020 were retrospectively studied. Clinical data were obtained including gender, age, height, weight, body mass index (BMI), smoking, alcohol consumption, hypertension, diabetes, history of aspirin, prepostoperative hematocrit (Hct) and hemoglobin (Hb), thrombotic events, blood transfusion requirement, hospital length of stay, size of osteotomy gap, and wound complications such as wound hematoma and infection. 52 patients were enrolled in the tranexamic acid group (TA group), and 48 patients were enrolled in the nontranexamic acid group (NTA group); there were no significant differences between both groups in terms of gender, age, BMI, preoperative Hb, size of osteotomy gap, incidence of smoking, alcohol consumption, hypertension, diabetes, history of aspirin, thrombotic events, blood transfusion requirement, and wound hematoma and infection. The mean hospital length of stay was 9.4 ± 1.0 days in the TA group and 11.0 ± 1.2 days in the NTA group (P < 0.001), the blood loss was 296.0 ± 128.7 ml in the TA group and 383.3 ± 181.3 ml in the NTA group (P < 0.05), and the postoperative Hb level was 120.8 ± 15.0 g/l in the TA group and 109.5 ± 13.8 g/l in the NTA group (P < 0.001). In conclusion, the administration of TXA is beneficial to patients undergoing OWHTO via decreasing hospital length of stay, reducing blood loss, and maintaining higher postoperative Hb levels.
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Affiliation(s)
| | | | | | - Bo Zhu
- Department of Tianjin Hospital, Tianjin, China
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Besser V, Albert A, Sixt SU, Ackerstaff S, Roussel E, Ullrich S, Lichtenberg A, Hoffmann T. Fibrinolysis and the Influence of Tranexamic Acid Dosing in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:2664-2673. [DOI: 10.1053/j.jvca.2020.03.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/14/2020] [Accepted: 03/18/2020] [Indexed: 12/27/2022]
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Hypothesis for a partially non urinary elimination of tranexamic acid in haemorrhagic caesarean section: Traces pilot pharmacokinetic study: Pharmacokinetics of tranexamic acid in obstetrics. Eur J Pharm Sci 2020; 153:105486. [PMID: 32717429 DOI: 10.1016/j.ejps.2020.105486] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 07/19/2020] [Accepted: 07/20/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND In previous studies, the choice of doses of tranexamic acid was empirically defined as no pharmacokinetic study had been conducted in haemorrhagic caesarean section. OBJECTIVE The objective was to build a pharmacokinetic model in patients receiving a single 0.5, 1 or 2 g intravenous bolus. METHOD A preliminary monocentric open study was performed in the Lille centre. Blood samples and one urinary sample were collected in the 6 h following the injection. Nine patients were included. Tranexamic acid concentration was measured using liquid chromatography system coupled with tandem mass spectrometry. We used Monolix 2019R1 for population pharmacokinetic modelling. A structural model was constructed followed by the investigation of potential covariates. RESULTS Data were best described with a two-compartment model with a double first-order elimination from the central compartment. The model was improved when the variable ideal weight per dose was affected as a covariate for the apparent volume of distribution. Assuming a dose of 1 g and a height of 160 cm, the pharmacokinetic parameters were estimated at 10.26 L.h-1 for total clearance, 11.5 L for the volume of the central compartment, 15.8 L for the volume of the second compartment, a diffusional clearance of 30.36 L.h-1 , and a urinary excretion fraction of 25.8%. CONCLUSIONS The population pharmacokinetic model of tranexamic acid in haemorrhagic caesarean section was successfully established in our tiny sample of patients. The results of this preliminary TRACES pharmacokinetic study suggested that elimination of tranexamic acid is partially non urinary in contrast with healthy patients.
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Strauss ER, Dahmane E, Judd M, Guo D, Williams B, Meyer M, Gammie JS, Taylor B, Mazzeffi MA, Gobburu JVS, Tanaka KA. A Pharmacokinetic and Pharmacodynamic Investigation of an ε-Aminocaproic Acid Regimen Designed for Cardiac Surgery With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2020; 35:406-417. [PMID: 32811752 DOI: 10.1053/j.jvca.2020.07.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate the pharmacokinetics and pharmacodynamics of an ε-aminocaproic acid (EACA) regimen designed for cardiac surgery with cardiopulmonary bypass (CPB). DESIGN Prospective observational study requiring blood sampling to measure EACA concentrations and fibrinolysis markers (fibrinogen, D-dimer, α2-antiplasmin, and tissue plasminogen activator-plasminogen activator inhibitor [tPA-PAI-1] complex). SETTING Single-center, tertiary medical center. PARTICIPANTS Patients who underwent cardiac surgery with CPB between 2018 and 2019 for aortic or mitral valve replacement/repair or coronary artery bypass grafting. Previous sternotomy patients were included. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The pharmacokinetics of EACA, during CPB, were described by a 3-compartment disposition model. EACA concentrations were greater than 130 mg/L in all patients after CPB and in most patients during CPB. The D-dimer level trended up and reached a peak median level of 1.35 mg/L of fibrinogen equivalence units (FEU) at 15 minutes after protamine administration. The median change in D-dimer (ΔD-dimer) from baseline to 15 minutes after protamine was 0.34 (-0.48 to 3.81) mg/L FEU. ΔD-dimer did not correlate with EACA concentration intraoperatively, urine output, body weight, glomerular filtration rate, cell salvage volume, and ultrafiltration volume. The median 24-hour chest tube output was 445 (180-1,011) mL. CONCLUSION This regimen provided maximum EACA concentrations near the time of protamine administration, with a total perioperative dose of 15 g. Most patients had EACA concentrations greater than the target during CPB. ΔD-dimer did not correlate with EACA concentration. The median 24-hour chest tube output compared well to similar studies that used higher doses of EACA.
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Affiliation(s)
- Erik R Strauss
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
| | - Elyes Dahmane
- Department of Pharmacy Practice and Science, Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD
| | - Miranda Judd
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Dong Guo
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, MD
| | - Brittney Williams
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | | | - James S Gammie
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Bradley Taylor
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Michael A Mazzeffi
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Jogarao V S Gobburu
- Department of Pharmacy Practice and Science, Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD
| | - Kenichi A Tanaka
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
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Aggarwal NK, Subramanian A. Antifibrinolytics and cardiac surgery: The past, the present, and the future. Ann Card Anaesth 2020; 23:193-199. [PMID: 32275035 PMCID: PMC7336973 DOI: 10.4103/aca.aca_205_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/05/2019] [Accepted: 03/09/2019] [Indexed: 12/02/2022] Open
Abstract
Cardiac surgery is usually associated with significant blood loss, which often necessitates blood transfusion. In order to decrease the risks associated with the latter, pharmacological as well as nonpharmacological strategies have been used to reduce blood loss. Among the pharmacological approaches, antifibrinolytic drugs are the mainstay. Aprotinin, which was the first ubiquitously used drug, fell into disrepute only to re-emerge after much debate. The decline of aprotinin paved the way for the lysine analogs. However, we must be aware with the side effects of these drugs as well as the dose modification required in special situations. Nonsaccharide glycosaminoglycans have been under investigation to overcome the drawbacks of the lysine analogs. It remains to be seen whether these drugs can replace the traditional antifibrinolytics.
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Affiliation(s)
- Naresh K Aggarwal
- Department of Cardiac Anesthesia, Manipal Hospitals, New Delhi, India
| | - Arun Subramanian
- Department of Cardiac Anesthesia, Manipal Hospitals, New Delhi, India
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Taam J, Yang QJ, Pang KS, Karanicolas P, Choi S, Wasowicz M, Jerath A. Current Evidence and Future Directions of Tranexamic Acid Use, Efficacy, and Dosing for Major Surgical Procedures. J Cardiothorac Vasc Anesth 2020; 34:782-790. [DOI: 10.1053/j.jvca.2019.06.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/21/2019] [Accepted: 06/27/2019] [Indexed: 12/26/2022]
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Hoxha A, Shehu S, Deveja R, Qirjazi T. Impact of Clopidogrel Loading for Coronarography on Bleeding After Urgent First Time CABG. Med Arch 2018; 72:319-324. [PMID: 30524161 PMCID: PMC6282917 DOI: 10.5455/medarh.2018.72.319-324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/25/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Excessive bleeding impairs outcome after coronary artery bypass grafting (CABG). Clopidogrel in combination with aspirin, given before percutaneous coronary intervention, have become the standard for stent thrombosis prevention. Some premedicated patients, however, are found to need surgical treatment, thus platelet inhibition caused by clopidogrel becomes a concern for post operation major bleeding. AIMS This study was designed to evaluate the impact of preoperative clopidogrel on bleeding and outcomes after coronary artery bypass graft surgery (CABG). METHODS The study represent a observational retrospective analysis of collected data. The follow up of 223 treated with clopidogrel and aspirin and 77 patients not receiving treatment with platelet antagonist 7 days before CABG are analyzed. RESULTS The groups were comparable in age, gender, body surface area, preoperative hematocrit, preoperative prothrombin time and prior myocardial infarction. The clopidogrel group had higher12h and 24h mean chest tube output (at 12h mean 519.7ml vs 353.1 ml, p < 0.05, at 24h mean 756.6 ml vs 563.5 ml, p<0.05). Moreover, reoperation for bleeding was 4.5-fold higher in the clopidogrel group (5.9% vs. 1.3%, p <0.01), and more transfusions of red blood cells (3.23U vs 2.6 U, p<0.05), platelets (1.53U vs 1.23U, p<0.01) and fresh frozen plasma (0.84U vs 0.36 U, p<0.01). The clopidogrel group also showed a longer mechanical ventilation time (16.9h vs 12.9 h p = 0.03) and trend towards more prolonged stay in ICU (2.08 days vs 1.7 days p= 0.048). CONCLUSIONS Clopidogrel in combination with aspirin before CABG is associated with higher postoperative bleeding, exposure to blood products and morbidity. These findings raise concern regarding the routine administration of clopidogrel before anticipated but undecided coronary stent implantation.
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Affiliation(s)
- Aleksander Hoxha
- Department of Anesthesia and Critical Care, Medical University of Tirana, Albania
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Gerstein NS, Brierley JK, Windsor J, Panikkath PV, Ram H, Gelfenbeyn KM, Jinkins LJ, Nguyen LC, Gerstein WH. Antifibrinolytic Agents in Cardiac and Noncardiac Surgery: A Comprehensive Overview and Update. J Cardiothorac Vasc Anesth 2017; 31:2183-2205. [DOI: 10.1053/j.jvca.2017.02.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Indexed: 12/19/2022]
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Jansen JA, Lameijer JRC, Snoeker BAM. Combined intravenous, topical and oral tranexamic acid administration in total knee replacement: Evaluation of safety in patients with previous thromboembolism and effect on hemoglobin level and transfusion rate. Knee 2017; 24:1206-1212. [PMID: 28765007 DOI: 10.1016/j.knee.2017.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 06/02/2017] [Accepted: 07/05/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aims of this study were to investigate the safety of combined intravenous, oral and topical tranexamic acid (TXA) in primary total knee replacement. We assessed dose-related efficacy on hemoglobin level, transfusion, length of stay and thromboembolic complications. In addition, TXA safety in patients with previous history of thromboembolism >12months ago was monitored specifically. METHODS From January 2013 until January 2016, 922 patients were included who received TXA after primary total knee replacement. Patients without TXA administration or with thromboembolic events <12months ago were excluded. TXA dosage groups were divided into ≤10mg/kg, >10-25mg/kg and >25-50mg/kg. RESULTS Between the three TXA groups no significant difference was found in thromboembolic complications (deep venous thrombosis (DVT) and pulmonary embolism (PE)), wound leakage and transfusion rate. For patients with DVT or PE in their history >12months ago specifically, no more complications were noted in higher-TXA-dosage groups compared to the low-dosage group. Length of stay was shorter in the highest-TXA-dosage group compared with lower-dosage groups (median two vs three days). With high TXA dose a smaller difference between pre- and postoperative Hb was found: the >25-50mg/kg TXA group had a 0.419mmol/l smaller decrease in postoperative hemoglobin compared to the lowest-dosage group (P<0.05). CONCLUSION Combined intravenous, oral and topical TXA is effective in knee replacement and can safely be given to patients with a thromboembolic history >12months ago. High dosage (>25-50mg/kg) TXA resulted in the smallest decrease in postoperative hemoglobin.
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Affiliation(s)
- Joris A Jansen
- Department of Orthopedics, Alrijne Hospital Leiden, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands.
| | - Joost R C Lameijer
- Department of Orthopedics, Alrijne Hospital Leiden, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
| | - Barbara A M Snoeker
- Department of Orthopedics, Alrijne Hospital Leiden, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
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Morrison RJM, Tsang B, Fishley W, Harper I, Joseph JC, Reed MR. Dose optimisation of intravenous tranexamic acid for elective hip and knee arthroplasty: The effectiveness of a single pre-operative dose. Bone Joint Res 2017; 6:499-505. [PMID: 28851694 PMCID: PMC5579309 DOI: 10.1302/2046-3758.68.bjr-2017-0005.r1] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 05/10/2017] [Indexed: 11/26/2022] Open
Abstract
Objectives We have increased the dose of tranexamic acid (TXA) in our enhanced total joint recovery protocol at our institution from 15 mg/kg to 30 mg/kg (maximum 2.5 g) as a single, intravenous (IV) dose. We report the clinical effect of this dosage change. Methods We retrospectively compared two cohorts of consecutive patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery in our unit between 2008 and 2013. One group received IV TXA 15 mg/kg, maximum 1.2 g, and the other 30 mg/kg, maximum 2.5 g as a single pre-operative dose. The primary outcome for this study was the requirement for blood transfusion within 30 days of surgery. Secondary measures included length of hospital stay, critical care requirements, re-admission rate, medical complications and mortality rates. Results A total of 1914 THA and 2537 TKA procedures were evaluated. In THA, the higher dose of TXA was associated with a significant reduction in transfusion (p = 0.02, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.58 to 0.96) and rate of re-admission (p < 0.001, RR 0.50, 95% CI 0.35 to 0.71). There were reductions in the requirement for critical care (p = 0.06, RR 0.55, 95% CI 0.31 to 1.00), and in the length of stay from 4.7 to 4.3 days (p = 0.02). In TKA, transfusion requirements (p = 0.049, RR 0.64, 95% CI 0.41 to 0.99), re-admission rate (p = 0.001, RR 0.56, 95% CI 0.39 to 0.80) and critical care requirements (p < 0.003, RR 0.34, 95% CI 0.16 to 0.72) were reduced with the higher dose. Mean length of stay reduced from 4.6 days to 3.6 days (p < 0.01). There was no difference in the incidence of deep vein thrombosis, pulmonary embolism, gastrointestinal bleed, myocardial infarction, stroke or death in THA and TKA between cohorts. Conclusion We suggest that a single pre-operative dose of TXA, 30 mg/kg, maximum 2.5g, results in a lower transfusion requirement compared with a lower dose in patients undergoing elective primary hip and knee arthroplasty. However, these findings should be interpreted in the context of the retrospective non-randomised study design. Cite this article: R. J. M. Morrison, B. Tsang, W. Fishley, I. Harper, J. C. Joseph, M. R. Reed. Dose optimisation of intravenous tranexamic acid for elective hip and knee arthroplasty: The effectiveness of a single pre-operative dose. Bone Joint Res 2017;6:499–505. DOI: 10.1302/2046-3758.68.BJR-2017-0005.R1.
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Affiliation(s)
- R J M Morrison
- Trauma & Orthopaedics Department, Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, Northumberland NE63 9JJ, UK
| | - B Tsang
- Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, Northumberland NE63 9JJ, UK
| | - W Fishley
- Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, Northumberland NE63 9JJ, UK
| | - I Harper
- Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, Northumberland NE63 9JJ, UK
| | - J C Joseph
- Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, Northumberland NE63 9JJ, UK
| | - M R Reed
- Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, Northumberland NE63 9JJ, UK
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Gerstein NS, Brierley JK, Culling MD. Left ventricle thrombus after tranexamic acid for spine surgery in an HIV-positive patient. Spine J 2016; 16:e77-82. [PMID: 26523960 DOI: 10.1016/j.spinee.2015.10.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/02/2015] [Accepted: 10/22/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Our case highlights the underappreciated thrombotic risks of tranexamic acid (TXA) use in non-cardiac surgery and emphasizes the need to elucidate these risks with appropriate clinical trials. PURPOSE The use of TXA in non-cardiac surgery has significantly expanded in the past 5 years, especially after the 2010 publication of the CRASH-2 Trial. We submit a case with the intent to highlight the thrombotic risk of TXA use during non-cardiac surgery and discuss the need for careful risk stratification before the use of TXA in this context. STUDY DESIGN A 66-year-old man with long-standing HIV infection, hypertension, and no history of coronary artery disease (CAD) presented for revision spinal fusion surgery with the use of TXA is presented. METHODS To limit perioperative blood loss, the case patient received TXA intraoperatively. His operative course was uneventful. RESULTS During the first 12 hours postoperatively the patient was noted to have persistent tachycardia and ST-elevation on electrocardiogram. Echocardiography showed a new apical wall motion abnormality and a left ventricle thrombus; cardiac catheterization confirmed two-vessel CAD, treated with a bare-metal stent and anticoagulation. CONCLUSIONS The thrombotic risks of TXA use in non-cardiac surgery have yet to be adequately studied in clinical trials. Hence, TXA use in this context is still an area of uncertainty, and its thrombogenic risks have yet to be studied as a primary outcome in any large prospective trial to date. Patients with any hypercoagulable risk factors, including HIV infection or any prior thrombotic history in which TXA use is being considered, should prompt a discussion among the perioperative physicians involved.
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Affiliation(s)
- Neal Stuart Gerstein
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, MSC 10 6000, 2211 Lomas Blvd NE, Albuquerque, New Mexico 87106, USA.
| | - Janet Kathryn Brierley
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, MSC 10 6000, 2211 Lomas Blvd NE, Albuquerque, New Mexico 87106, USA
| | - Matthew Douglas Culling
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, MSC 10 6000, 2211 Lomas Blvd NE, Albuquerque, New Mexico 87106, USA
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Theusinger OM, Spahn DR. Perioperative blood conservation strategies for major spine surgery. Best Pract Res Clin Anaesthesiol 2015; 30:41-52. [PMID: 27036602 DOI: 10.1016/j.bpa.2015.11.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 11/12/2015] [Accepted: 11/20/2015] [Indexed: 01/25/2023]
Abstract
BACKGROUND Orthopedic surgery, especially spine and spinal deformity surgery, may be associated with high perioperative blood loss. In order to reduce the risk of excessive blood loss and unnecessary blood transfusions, strategies such as Patient Blood Management including goal-directed coagulation management have been developed. RECENT FINDINGS Adverse effects of allogeneic blood transfusions have been shown for most surgical fields including orthopedic surgery. Several efforts have been made to increase the preoperative red blood cell (RBC) mass, to reduce the intraoperative blood loss, and to use restrictive transfusion triggers in order to minimize or avoid RBC transfusions. Measures to reduce intraoperative blood loss include new surgical techniques, use of cell salvage where possible, bedside coagulation management with point-of-care devices, substitution of coagulation factors, antifibrinolytic agents, and desmopressin, induced hypotension, and avoidance of hypothermia. SUMMARY Blood conservation in spinal surgery is a multidisciplinary approach and the efficacy of most single measures has been shown. Cost-effectiveness and the benefits of long-term patient outcomes are the subjects of current and future research.
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Affiliation(s)
- Oliver M Theusinger
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland.
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
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