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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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Fiameni R, Lucchelli M, Novelli C, Salice V, Orsenigo F, Gomarasca M, MoroSalihovic B, Mondin F, Mistraletti G, Beverina I. Impact of introduction of a goal directed transfusion strategy in a patient blood management program: A single cardiac surgery centre experience. Transfus Med 2024; 34:257-267. [PMID: 38945994 DOI: 10.1111/tme.13063] [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: 10/24/2023] [Revised: 05/16/2024] [Accepted: 06/18/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND The aim of this retrospective and observational study was to analyse the impact of the introduction of a goal directed transfusion (GDT) strategy based on a viscoelastic test (ROTEM®) and specific procoagulant products in a patient blood management (PBM) Program on blood product use and perioperative bleeding in a single cardiac surgery centre. STUDY DESIGN AND METHODS Patient population underwent cardiac surgery from 2011 to 2021 was divided in two groups based on PBM protocol used (G#11-14, years 2011-2014, G#15-21, years 2015-2021) and compared for the following variables: intraoperative and postoperative transfusions of packed red blood cell and any procoagulant products, postoperative drain blood loss volume and rate of re-exploration surgery. The second program was defined after the introduction of a GDT protocol based on viscoelastic tests and specific procoagulant products. RESULTS After the introduction of a GDT protocol, about 80% less amongst patients were transfused with fresh frozen plasma and any procoagulant product (p < 0.001 for both phases). Moreover, similar results were obtained with PRBC transfusions (p < 0.001) and drain blood loss volume (p = 0.006) in the postoperative phase. The main factors affecting the use of any procoagulant and PBRC transfusion in the multivariate logistic regression analysis was Group (2 versus 1, OR 0.207, p < 0.001) and preoperative haemoglobin (OR 0.728, p < 0.001), respectively. DISCUSSION In our experience, a GDT strategy for the diagnosis and treatment of the coagulopathy in patients undergone cardiac surgery led to a significant reduction in bleeding and transfusion.
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Affiliation(s)
- Riccardo Fiameni
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Matteo Lucchelli
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Chiara Novelli
- S.C. Immunoematologia e Centro Trasfusionale, ASST Ovest Milanese, Legnano, Italy
| | - Valentina Salice
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Francesca Orsenigo
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Mattia Gomarasca
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | | | - Federico Mondin
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Giovanni Mistraletti
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Italy
| | - Ivo Beverina
- S.C. Immunoematologia e Centro Trasfusionale, ASST Ovest Milanese, Legnano, Italy
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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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Banasiewicz T, Machała W, Borejsza Wysocki M, Lesiak M, Krych S, Lange M, Hogendorf P, Durczyński A, Cwaliński J, Bartkowiak T, Dziki A, Kielan W, Kłęk S, Krokowicz Ł, Kusza K, Myśliwiec P, Pędziwiatr M, Richter P, Sobocki J, Szczepkowski M, Tarnowski W, Zegarski W, Zembala M, Zieniewicz K, Wallner G. Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects. POLISH JOURNAL OF SURGERY 2023; 95:14-39. [PMID: 38084044 DOI: 10.5604/01.3001.0053.8966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.
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Affiliation(s)
- Tomasz Banasiewicz
- Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej, Instytut Chirurgii, Uniwersytet Medyczny im K. Marcinkowskiego w Poznaniu
| | - Waldemar Machała
- Klinika Anestezjologii i Intensywnej Terapii - Uniwersytecki Szpital Kliniczny im. Wojskowej Akademii Medycznej - Centralny Szpital Weteranów, Łódź
| | - Maciej Borejsza Wysocki
- Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej, Instytut Chirurgii, Uniwersytet Medyczny im K. Marcinkowskiego w Poznaniu
| | - Maciej Lesiak
- Katedra i Klinika Kardiologii Uniwersytetu Medycznego im. K. Marcinkowskiego w Poznaniu
| | - Sebastian Krych
- Katedra i Klinika Kardiochirurgii, Transplantologii, Chirurgii Naczyniowej i Endowaskularnej SUM. Studenckie Koło Naukowe Kardiochirurgii Dorosłych. Śląski Uniwersytet Medyczny w Katowicach
| | - Małgorzata Lange
- Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej, Instytut Chirurgii, Uniwersytet Medyczny im K. Marcinkowskiego w Poznaniu
| | - Piotr Hogendorf
- Klinika Chirurgii Ogólnej i Transplantacyjnej, Uniwersytet Medyczny w Łodzi
| | - Adam Durczyński
- Klinika Chirurgii Ogólnej i Transplantacyjnej, Uniwersytet Medyczny w Łodzi
| | - Jarosław Cwaliński
- Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej, Instytut Chirurgii, Uniwersytet Medyczny im K. Marcinkowskiego w Poznaniu
| | - Tomasz Bartkowiak
- Oddział Kliniczny Anestezjologii, Intensywnej Terapii i Leczenia Bólu, Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu
| | - Adam Dziki
- Klinika Chirurgii Ogólnej i Kolorektalnej Uniwersytetu Medycznego w Łodzi
| | - Wojciech Kielan
- II Katedra i Klinika Chirurgii Ogólnej i Chirurgii Onkologicznej, Uniwersytet Medyczny we Wrocławiu
| | - Stanisław Kłęk
- Klinika Chirurgii Onkologicznej, Narodowy Instytut Onkologii - Państwowy Instytut Badawczy im. Marii Skłodowskiej-Curie, Oddział w Krakowie, Kraków
| | - Łukasz Krokowicz
- Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej, Instytut Chirurgii, Uniwersytet Medyczny im K. Marcinkowskiego w Poznaniu
| | - Krzysztof Kusza
- Katedra i Klinika Anestezjologii i Intensywnej Terapii, Uniwersytet Medyczny im K. Marcinkowskiego w Poznaniu
| | - Piotr Myśliwiec
- I Klinika Chirurgii Ogólnej i Endokrynologicznej, Uniwersytet Medyczny w Białymstoku
| | - Michał Pędziwiatr
- Katedra Chirurgii Ogólnej, Wydział Lekarski, Uniwersytet Jagielloński - Collegium Medicum, Kraków
| | - Piotr Richter
- Oddział Kliniczny Chirurgii Ogólnej, Onkologicznej i Gastroenterologicznej Szpital Uniwersytecki w Krakowie
| | - Jacek Sobocki
- Katedra i Klinika Chirurgii Ogólnej i Żywienia Klinicznego, Centrum Medyczne Kształcenia Podyplomowego, Warszawski Uniwersytet Medyczny, Warszawa
| | - Marek Szczepkowski
- Klinika Chirurgii Kolorektalnej, Ogólnej i Onkologicznej, Centrum Medyczne Kształcenia Podyplomowego, Szpital Bielański, Warszawa
| | - Wiesław Tarnowski
- Klinika Chirurgii Ogólnej, Onkologicznej i Bariatrycznej CMKP, Szpital im. Prof. W. Orłowskiego, Warszawa
| | | | - Michał Zembala
- Wydział Medyczny, Katolicki Uniwersytet Lubelski Jana Pawła II w Lublinie
| | - Krzysztof Zieniewicz
- Katedra i Klinika Chirurgii Ogólnej, Transplantacyjnej i Wątroby, Warszawski Uniwersytet Medyczny, Warszawa
| | - Grzegorz Wallner
- II Katedra i Klinika Chirurgii Ogólnej, Gastroenterologicznej i Nowotworów Układu Pokarmowego, Uniwersytet Medyczny w Lublinie
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Colson P, Fellahi JL, Gaudard P, Provenchère S, Rozec B. Cost Analysis of Aprotinin Reintroduction in French Cardiac Surgery Centres: A Real-World Data-Based Analysis. Adv Ther 2023; 40:1803-1817. [PMID: 36867329 PMCID: PMC10070296 DOI: 10.1007/s12325-023-02464-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/14/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION The European Medicines Agency restored aprotinin (APR) use for preventing blood loss in patients undergoing isolated coronary artery bypass graft (iCABG) in 2016 but requested the collection of patient and surgery data in a registry (NAPaR). The aim of this analysis was to evaluate the impact of APR reintroduction in France on the main hospital costs (operating room, transfusion and intensive unit stay) compared to the current use of tranexamic acid (TXA), which was the only antifibrinolytic available before APR reinstatement. METHODS A multicenter before-after post-hoc analysis to compare APR and TXA was carried out in four French university hospitals. APR use followed the ARCOTHOVA (French Association of Cardiothoracic and Vascular Anesthetists) protocol, which had framed three main indications in 2018. Data from 236 APR patients were retrieved from the NAPaR (N = 874); 223 TXA patients were retrospectively retrieved from each center database and matched to APR patients upon indication classes. Budget impact was evaluated using both direct costs associated with antifibrinolytics and transfusion products (within the first 48 h) and other costs such as surgery duration and ICU stay. RESULTS The 459 collected patients were distributed as: 17% on-label; 83% off-label. Mean cost per patient until ICU discharge tended to be lower in the APR group versus the TXA group, which resulted in an estimated gross saving of €3136 per patient. These savings concerned operating room and transfusion costs but were mainly driven by reduced ICU stays. When extrapolated to the whole French NAPaR population, the total savings of the therapeutic switch was estimated at around €3 million. CONCLUSION The budget impact projected that using APR according to ARCOTHOVA protocol resulted in decreased requirement for transfusion and complications related to surgery. Both were associated with substantial cost savings from the hospital's perspective compared with exclusive use of TXA.
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Affiliation(s)
- Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, 371 avenue du doyen Gaston Giraud, 34295, Montpellier, France.
- Montpellier University, INSERM, CNRS, Institut de Génomique Fonctionnelle, Montpellier, France.
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care Medicine, Louis Pradel Hospital, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France
- Laboratoire CarMeN, Inserm U1060, Université Claude Bernard Lyon 1, Lyon, France
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, 371 avenue du doyen Gaston Giraud, 34295, Montpellier, France
- University of Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Sophie Provenchère
- Department of Anesthesiology and Critical Care Medecine, AP-HP, Bichat-Claude-Bernard Hospital, Paris, France
- INSERM Clinical Investigation Center 007, Paris, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes, France
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Nantes, 44093, Nantes, France
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Abstract
Acute aortic dissection is a highly morbid condition with high mortality that requires emergent surgical evaluation and repair. The intraoperative management of acute aortic dissection requires the anesthesiologist to do far more than administer anesthesia and begins before the patient arrives at the operative theater. High-fidelity communication with the surgeon, knowledge of the surgical plan, knowledge of the anatomy of the dissection, and a nuanced understanding of aortic dissection pathophysiology are all critical aspects of anesthetic management.
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Affiliation(s)
- D Keegan Stombaugh
- Department of Anesthesiology, Division of Cardiovascular Anesthesia, University of Virginia, School of Medicine, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908, USA; Department of Anesthesiology, Division of Critical Care Medicine, University of Virginia, School of Medicine, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908, USA
| | - Venkat Reddy Mangunta
- Department of Anesthesiology, Division of Cardiovascular Anesthesia, University of Virginia, School of Medicine, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908, USA; Department of Anesthesiology, Division of Critical Care Medicine, University of Virginia, School of Medicine, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908, USA.
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Patel PA, Wyrobek JA, Butwick AJ, Pivalizza EG, Hare GMT, Mazer CD, Goobie SM. Update on Applications and Limitations of Perioperative Tranexamic Acid. Anesth Analg 2022; 135:460-473. [PMID: 35977357 DOI: 10.1213/ane.0000000000006039] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tranexamic acid (TXA) is a potent antifibrinolytic with documented efficacy in reducing blood loss and allogeneic red blood cell transfusion in several clinical settings. With a growing emphasis on patient blood management, TXA has become an integral aspect of perioperative blood conservation strategies. While clinical applications of TXA in the perioperative period are expanding, routine use in select clinical scenarios should be supported by evidence for efficacy. Furthermore, questions regarding optimal dosing without increased risk of adverse events such as thrombosis or seizures should be answered. Therefore, ongoing investigations into TXA utilization in cardiac surgery, obstetrics, acute trauma, orthopedic surgery, neurosurgery, pediatric surgery, and other perioperative settings continue. The aim of this review is to provide an update on the current applications and limitations of TXA use in the perioperative period.
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Affiliation(s)
- Prakash A Patel
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Julie A Wyrobek
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Evan G Pivalizza
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center, Houston, Texas
| | - Gregory M T Hare
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76:1151-1184. [PMID: 35300861 DOI: 10.1016/j.jhep.2021.09.003] [Citation(s) in RCA: 122] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022]
Abstract
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
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Zou ZY, He LX, Yao YT. Tranexamic acid reduces postoperative blood loss in Chinese pediatric patients undergoing cardiac surgery: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e28966. [PMID: 35244062 PMCID: PMC8896488 DOI: 10.1097/md.0000000000028966] [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] [Received: 10/23/2021] [Revised: 02/06/2022] [Accepted: 02/07/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Tranexamic acid has been increasingly used for blood conservation in cardiac surgery. However, the evidence supporting the routine use of tranexamic acid in Chinese pediatric patients undergoing cardiac surgery remains weak. This meta-analysis aimed to systematically review the efficacy of tranexamic acid when applying to Chinese pediatric patients undergoing cardiac surgery. PARTICIPANTS Chinese pediatric patients undergoing cardiac surgery. INTERVENTIONS Tranexamic acid or control drugs (saline/blank). METHODS PUBMED, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Wanfang Data, and VIP Data till May 4, 2021, database search was updated on August 1. Primary outcomes of interest included postoperative bleeding, allogeneic transfusion, and reoperation for bleeding. Secondary outcomes of interest included postoperative recovery. For continuous/dichotomous variables, treatment effects were calculated as weighted mean difference (WMD)/odds ratio and 95% confidence interval. RESULTS A database search yielded 15 randomized controlled trials including 1641 patients, where 8 studies were allocated into non-cyanotic congenital group, 5 were allocated into cyanotic congenital group, and the other 2 were allocated into combined cyanotic/non-cyanotic group. This meta-analysis demonstrate that tranexamic acid administration can reduce the postoperative 24 hours blood loss in non-cyanotic, cyanotic, and combined cyanotic/non-cyanotic patients, the red blood cell transfusion in non-cyanotic and cyanotic patients, and the fresh frozen plasma transfusion in non-cyanotic and combined cyanotic/non-cyanotic patients. CONCLUSION This meta-analysis demonstrates that tranexamic acid is highly effective in reducing the blood loss in Chinese pediatric cardiac surgery, but it behaves poorly when it comes to the transfusion requirement. To further confirm this, more well-designed and adequately-powered randomized trials are needed.
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Affiliation(s)
- Zhi-yao Zou
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Yunnan Province, Kunming, China
| | - Li-xian He
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Yunnan Province, Kunming, China
| | - Yun-tai Yao
- Anesthesia Center, Fuwai Hospital, NCCD, PUMC&CAMS, Beijing, China
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Preservation of Renal Function. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00017-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Peña Borras JJ, Pajares Moncho A, Puig J, Mateo Rodríguez E, López Forte C, Peña Pérez L, Moreno Pachón J, Gabaldón Conejos T, Pérez Artacho J, Ferrer Gómez C, Férez Martí A, López Cantero M, de Andrés Ibáñez J. Tranexamic acid in cardiac surgery: Are low doses enough? REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:576-583. [PMID: 34857506 DOI: 10.1016/j.redare.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 02/09/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Tranexamic acid is used to prevent hyperfibrinolysis and reduce postoperative bleeding and blood transfusions in on-pump cardiac surgery. We evaluate the efficacy of low or high dose tranexamic acid in a prospective cohort study conducted in Valencia. MATERIALS AND METHODS A total of 427 patients were recruited between January 2019 and January 2020, 207 in the Hospital General Universitario (low dose [LD]) and 220 in the Hospital Universitario y Politécnico La Fe (high dose [HD] and intermediate dose [ID]). We recorded the presence of hyperfibrinolysis on rotational thromboelastometry, intra- and postoperative administration of blood products, chest tube output within the first 12 h, and incidence of convulsions. Univariate and multivariate comparisons were performed. Univariate analysis of all categories was performed after propensity score matching between LD and HD and between LD and ID. RESULTS There were no statistically significant differences in: appearance of hyperfibrinolysis, administration of blood products, postoperative chest tube output within the first 12 h, or occurrence of convulsions. Group LD received less fibrinogen than group HD (P = .014) and ID (P = .040) but more fresh frozen plasma than group ID (P = .0002). CONCLUSIONS Administration of low-dose tranexamic acid is as effective as higher doses in hyperfibrinolysis prophylaxis and the prevention of postoperative bleeding in cardiac surgery.
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Affiliation(s)
- J J Peña Borras
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - A Pajares Moncho
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - J Puig
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain; Departamento de Cirugía, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, Spain.
| | - E Mateo Rodríguez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - C López Forte
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - L Peña Pérez
- Centre for Haematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - J Moreno Pachón
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - T Gabaldón Conejos
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - J Pérez Artacho
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - C Ferrer Gómez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - A Férez Martí
- Servicio de Análisis Clínicos, Hospital General Universitario de Valencia, Valencia, Spain
| | - M López Cantero
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - J de Andrés Ibáñez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain; Departamento de Cirugía, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, Spain
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12
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Abstract
Fibrinogen plays a fundamental role in coagulation through its support for platelet aggregation and its conversion to fibrin. Fibrin stabilizes clots and serves as a scaffold and immune effector before being broken down by the fibrinolytic system. Given its importance, abnormalities in fibrin(ogen) and fibrinolysis result in a variety of disorders with hemorrhagic and thrombotic manifestations. This review summarizes (i) the basic elements of fibrin(ogen) and its role in coagulation and the fibrinolytic system; (ii) the laboratory evaluation for fibrin(ogen) disorders, including the use of global fibrinolysis assays; and (iii) the management of congenital and acquired disorders of fibrinogen and fibrinolysis.
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Affiliation(s)
- Jori E May
- Division of Hematology/Oncology, University of Alabama at Birmingham, 1720 2nd Avenue South, NP 2503, Birmingham, AL 35294, USA
| | - Alisa S Wolberg
- UNC Department of Pathology and Laboratory Medicine, UNC Blood Research Center, 8018A Mary Ellen Jones Building, CB7035, Chapel Hill, NC 27599-7035, USA
| | - Ming Yeong Lim
- Department of Internal Medicine, Division of Hematology and Hematologic Malignancies, University of Utah, 2000 Circle Hope Drive, Room 4126, Salt Lake City, UT 84112, USA.
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13
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Colomina MJ, Contreras L, Guilabert P, Koo M, Méndez E, Sabate A. Clinical use of tranexamic acid: evidences and controversies. Braz J Anesthesiol 2021; 72:795-812. [PMID: 34626756 DOI: 10.1016/j.bjane.2021.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/03/2021] [Accepted: 08/08/2021] [Indexed: 11/26/2022] Open
Abstract
Tranexamic acid (TXA) significantly reduces blood loss in a wide range of surgical procedures and improves survival rates in obstetric and trauma patients with severe bleeding. Although it mainly acts as a fibrinolysis inhibitor, it also has an anti-inflammatory effect, and may help attenuate the systemic inflammatory response syndrome found in some cardiac surgery patients. However, the administration of high doses of TXA has been associated with seizures and other adverse effects that increase the cost of care, and the administration of TXA to reduce perioperative bleeding needs to be standardized. Tranexamic acid is generally well tolerated, and most adverse reactions are considered mild or moderate. Severe events are rare in clinical trials, and literature reviews have shown tranexamic acid to be safe in several different surgical procedures. However, after many years of experience with TXA in various fields, such as orthopedic surgery, clinicians are now querying whether the dosage, route and interval of administration currently used and the methods used to control and analyze the antifibrinolytic mechanism of TXA are really optimal. These issues need to be evaluated and reviewed using the latest evidence to improve the safety and effectiveness of TXA in treating intracranial hemorrhage and bleeding in procedures such as liver transplantation, and cardiac, trauma and obstetric surgery.
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Affiliation(s)
- Maria J Colomina
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain.
| | - Laura Contreras
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Patricia Guilabert
- Universitat Autònoma de Barcelona, Vall d'Hebron University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Maylin Koo
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain
| | - Esther Méndez
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Antoni Sabate
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain
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14
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Peña Borras JJ, Pajares Moncho A, Puig J, Mateo Rodríguez E, López Forte C, Peña Pérez L, Moreno Pachón J, Gabaldón Conejos T, Pérez Artacho J, Ferrer Gómez C, Férez Martí A, López Cantero M, de Andrés Ibáñez J. Tranexamic acid in cardiac surgery: Are low doses enough? REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:S0034-9356(21)00105-5. [PMID: 34538453 DOI: 10.1016/j.redar.2021.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/04/2020] [Accepted: 02/09/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Tranexamic acid is used to prevent hyperfibrinolysis and reduce postoperative bleeding and blood transfusions in on-pump cardiac surgery. We evaluate the efficacy of low or high dose tranexamic acid in a prospective cohort study conducted in Valencia. MATERIALS AND METHODS A total of 427 patients were recruited between January 2019 and January 2020, 207 in the Hospital General Universitario (low dose [LD]) and 220 in the Hospital Universitario y Politécnico La Fe (high dose [HD] and intermediate dose [ID]). We recorded the presence of hyperfibrinolysis on rotational thromboelastometry, intra- and postoperative administration of blood products, chest tube output within the first 12h, and incidence of convulsions. Univariate and multivariate comparisons were performed. Univariate analysis of all categories was performed after propensity score matching between LD and HD and between LD and ID. RESULTS There were no statistically significant differences in: appearance of hyperfibrinolysis, administration of blood products, postoperative chest tube output within the first 12h, or occurrence of convulsions. Group LD received less fibrinogen than group HD (P=.014) and ID (P=.040) but more fresh frozen plasma than group ID (P=.0002). CONCLUSIONS Administration of low-dose tranexamic acid is as effective as higher doses in hyperfibrinolysis prophylaxis and the prevention of postoperative bleeding in cardiac surgery.
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Affiliation(s)
- J J Peña Borras
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - A Pajares Moncho
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - J Puig
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España; Departamento de Cirugía, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, España.
| | - E Mateo Rodríguez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - C López Forte
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - L Peña Pérez
- Centre for Haematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Suecia
| | - J Moreno Pachón
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón Conejos
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - J Pérez Artacho
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - C Ferrer Gómez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - A Férez Martí
- Servicio de Análisis Clínicos, Hospital General Universitario de Valencia, Valencia, España
| | - M López Cantero
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - J de Andrés Ibáñez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España; Departamento de Cirugía, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, España
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15
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Coleman M, Davis J, Maher KO, Deshpande SR. Clinical and Hematological Outcomes of Aminocaproic Acid Use During Pediatric Cardiac ECMO. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:40-45. [PMID: 33814604 PMCID: PMC7995624 DOI: 10.1182/ject-2000032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 01/06/2021] [Indexed: 11/20/2022]
Abstract
Bleeding and thrombosis-related complications are common in pediatric cardiac patients supported by extracorporeal membrane oxygenation (ECMO) and are associated with morbidity and mortality. The purpose of this study was to evaluate the utility of aminocaproic acid (ACA), an antifibrinolytic agent, as it pertains to bleeding in pediatric cardiac patients on ECMO. This included a retrospective cohort study of pediatric cardiac patients receiving ACA while supported on ECMO between 2013 and 2017. For each patient, data were collected in three time intervals: the 24 hours before ACA initiation, and then 0-24 and 24-48 hours following ACA initiation. For each time frame, bleeding, component transfusion, and laboratory data were collected and analyzed. A total of 62 patients were included, representing 42% of our cardiac ECMO patients during the time period. ACA was initiated at 16.3 ± 8.7 hours following initiation of ECMO. The mean bleeding rate before ACA was 10.57 mL/kg/h, which reduced to 7.8 mL/kg/h in the 24-hour period after initiation of ACA and a further decrease to 3.65 mL/kg/h during the 24- to 48-hour time period following ACA initiation. ACA administration was associated with reduction in bleeding (p < .001) and packed red blood cell transfusions (p = .02), administration of fresh frozen plasma (p < .001), platelets (p = .017), cryoprecipitate (p = .05), factor VII (p = .002), and Cell Saver (p = .005). Hemoglobin and platelet count were stable, whereas prothrombin time (PT), partial thromboplastin time, and international normalized ratio (INR) showed significant reduction over the time course. ACA administration was not associated with specific adverse effects. A clinically significant reduction in bleeding amount, red blood cell transfusions, and other hematologic interventions occurred following ACA administration for pediatric patients on ECMO. Wider consideration for ACA use as a part of a multipronged strategy to manage bleeding during ECMO should be considered.
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Affiliation(s)
- Madison Coleman
- Children’s Healthcare of Atlanta, Atlanta, Georgia; Medical College of Georgia, Augusta, Georgia; and Sibley Heart Center Cardiology, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Joel Davis
- Children’s Healthcare of Atlanta, Atlanta, Georgia; Medical College of Georgia, Augusta, Georgia; and Sibley Heart Center Cardiology, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Kevin O. Maher
- Children’s Healthcare of Atlanta, Atlanta, Georgia; Medical College of Georgia, Augusta, Georgia; and Sibley Heart Center Cardiology, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Shriprasad R. Deshpande
- Children’s Healthcare of Atlanta, Atlanta, Georgia; Medical College of Georgia, Augusta, Georgia; and Sibley Heart Center Cardiology, Children’s Healthcare of Atlanta, Atlanta, Georgia
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16
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Bartoszko J, Karkouti K. Managing the coagulopathy associated with cardiopulmonary bypass. J Thromb Haemost 2021; 19:617-632. [PMID: 33251719 DOI: 10.1111/jth.15195] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/29/2022]
Abstract
Cardiopulmonary bypass (CPB) has allowed for significant surgical advancements, but accompanying risks can be significant and must be expertly managed. One of the foremost risks is coagulopathic bleeding. Increasing levels of bleeding in cardiac surgical patients at the time of separation from CPB are associated with poor outcomes and mortality. CPB-associated coagulopathy is typically multifactorial and rarely due to inadequate reversal of systemic heparin alone. The components of the bypass circuit induce systemic inflammation and multiple disturbances of the coagulation and fibrinolytic systems. Anticipating coagulopathy is the first step in managing it, and specific patient and procedural risk factors have been identified as predictors of excessive bleeding. Medication management pre-procedure is critical, as patients undergoing cardiac surgery are commonly on anticoagulants or antiplatelet agents. Important adjuncts to avoid transfusion include antifibrinolytics, and perfusion practices such as red cell salvage, sequestration, and retrograde autologous priming of the bypass circuit have varying degrees of evidence supporting their use. Understanding the patient's coagulation status helps target product replacement and avoid larger volume transfusion. There is increasing recognition of the role of point-of-care viscoelastic and functional platelet testing. Common pitfalls in the management of post-CPB coagulopathy include overdosing protamine for heparin reversal, imperfect laboratory measures of thrombin generation that result in normal or near-normal laboratory results in the presence of continued bleeding, and delayed recognition of surgical bleeding. While challenging, the effective management of CPB-associated coagulopathy can significantly improve patient outcomes.
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Affiliation(s)
- Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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17
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Sussman MS, Urrechaga EM, Cioci AC, Iyengar RS, Herrington TJ, Ryon EL, Namias N, Galbut DL, Salerno TA, Proctor KG. Do all cardiac surgery patients benefit from antifibrinolytic therapy? J Card Surg 2021; 36:1450-1457. [PMID: 33586229 DOI: 10.1111/jocs.15406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/03/2020] [Accepted: 12/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND In trauma patients, the recognition of fibrinolysis phenotypes has led to a re-evaluation of the risks and benefits of antifibrinolytic therapy (AF). Many cardiac patients also receive AF, but the distribution of fibrinolytic phenotypes in that population is unknown. The purpose of this hypothesis-generating study was to fill that gap. METHODS Seventy-eight cardiac surgery patients were retrospectively reviewed. Phenotypes were defined as hypofibrinolytic (LY30 <0.8%), physiologic (0.8%-3.0%), and hyperfibrinolytic (>3%) based on thromboelastogram. RESULTS The population was 65 ± 10-years old, 74% male, average body mass index of 29 ± 5 kg/m2 . Fibrinolytic phenotypes were distributed as physiologic = 45% (35 of 78), hypo = 32% (25 of 78), and hyper = 23% (18 of 78). There was no obvious effect of age, gender, race, or ethnicity on this distribution; 47% received AF. For AF versus no AF, the time with chest tube was longer (4 [1] vs. 3 [1] days, p = .037), and all-cause morbidity was more prevalent (51% vs. 25%, p = .017). However, when these two groups were further stratified by phenotypes, there were within-group differences in the percentage of patients with congestive heart failure (p = .022), valve disease (p = .024), on-pump surgery (p < .0001), estimated blood loss during surgery (p = .015), transfusion requirement (p = .015), and chest tube output (p = .008), which highlight other factors along with AF that might have affected all-cause morbidity. CONCLUSION This is the first description of the prevalence of three different fibrinolytic phenotypes and their potential influence on cardiac surgery patients. The use of AF was associated with increased morbidity, but because of the small sample size and treatment allocation bias, additional confirmatory studies are necessary. We hope these present findings open the dialog on whether it is safe to administer AFs to cardiac surgery patients who are normo- or hypofibrinolytic.
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Affiliation(s)
- Matthew S Sussman
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Eva M Urrechaga
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Alessia C Cioci
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Rahul S Iyengar
- University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Tyler J Herrington
- University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Emily L Ryon
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Nicholas Namias
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - David L Galbut
- Division of Cardiothoracic Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Tomas A Salerno
- University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,Division of Cardiothoracic Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Kenneth G Proctor
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
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18
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Optimal Tranexamic Acid Dosing Regimen in Cardiac Surgery: What Are the Missing Pieces? Anesthesiology 2021; 134:143-146. [PMID: 33433620 DOI: 10.1097/aln.0000000000003637] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Orthotopic Heart and Combined Heart Liver Transplantation: the Ultimate Treatment Option for Failing Fontan Physiology. CURRENT TRANSPLANTATION REPORTS 2021; 8:9-20. [PMID: 33564612 PMCID: PMC7861581 DOI: 10.1007/s40472-021-00315-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 02/07/2023]
Abstract
Purpose of the Review This is a comprehensive update on failing Fontan physiology and the role of heart and combined heart and liver transplantation in the current era. Recent Findings Single ventricle physiology encompasses a series of rare congenital cardiac abnormalities that are characterized by absence of or hypoplasia of one ventricle. This effectively results in a single ventricular pumping chamber. These abnormalities are rarely compatible with long-term survival if left without surgical palliation in the first few years of life. Surgical treatment of single ventricle physiology has evolved over the past 60 years and is characterized by numerous creative innovations. These include the development of arteriopulmonary shunts, the evolution of partial cavopulmonary connections, and the eventual development of the "Fontan" operation. Regardless of the type of Fontan modification, the long-term consequences of the Fontan operation are predominantly related to chronic central venous hypertension and the multi-organ consequences thereof. Atrial arrhythmias can further compromise this circulation.Patients with single ventricle physiology represent a special sub-segment of congenital cardiac transplants and are arguably the most challenging patients considered for transplantation. Summary This review describes in detail the challenges and opportunities of heart and liver transplantation in Fontan patients, as viewed and managed by the experienced team at the Ahmanson/UCLA Adult Congenital Heart Center.
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20
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Epstein D, Vishnepolsky A, Bolotin G, Atweh N, Bonstein L, Lehavi A. Effect of Prolonged Hypothermic Cardiopulmonary Bypass, Heparin, and Protamine on Platelet: A Small-Group Study. Thorac Cardiovasc Surg 2021; 69:719-722. [PMID: 33465799 DOI: 10.1055/s-0040-1721477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Cardiopulmonary bypass (CPB) is associated with platelet dysfunction (PD), an important cause of postoperative bleeding. The etiology of PD is not completely understood. We mapped the platelets' function during CPB to determine the etiology of PD. Platelets activation, measured by procaspase activating compound-1 and P-selectin expression (CD62P), after activation by adenosine diphosphate and thrombin receptor activator peptide, were decreased by protamine. Changes during CPB were insignificant. Platelet-leukocyte aggregation was increased by CPB but not by protamine. Platelet apoptosis marker, annexin V, was increased by protamine. Changes during CPB were insignificant. Our findings demonstrate that protamine given after CPB plays a central role in PD and count decrease.
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Affiliation(s)
- Danny Epstein
- Department of Internal Medicine "B," Rambam Health Care Campus, Haifa, Israel
| | | | - Gil Bolotin
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Nardeen Atweh
- Blood Bank and Platelet Immunology Laboratories, Rambam Health Care Campus, Haifa, Israel
| | - Lilach Bonstein
- Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Blood Bank and Platelet Immunology Laboratories, Rambam Health Care Campus, Haifa, Israel
| | - Amit Lehavi
- Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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21
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Arun-Kumar V, Naresh-Babu J. Is There a Role for Preoperative Local Infiltration of Tranexamic Acid in Elective Spine Surgery? A Prospective Randomized Controlled Trial Analyzing the Efficacy of Intravenous, Local Infiltration, and Topical Administration of Tranexamic Acid. Global Spine J 2021; 11:21-27. [PMID: 32875830 PMCID: PMC7734265 DOI: 10.1177/2192568219888446] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
STUDY DESIGN Randomized control trial. OBJECTIVE The purpose of the study is to evaluate the safety and efficacy of tranexamic acid in reducing blood loss when administered through various routes in instrumented spine surgeries. METHODS A total of 104 patients undergoing instrumented spine surgery were randomly assigned to 4 groups (n = 26 in each group). Groups included (1) ivTXA-intravenous administration of tranexamic acid (TXA) 1 hour prior to surgery, (2) loTXA-local infiltration of TXA bilaterally into the paraspinal musculature prior to incision, (3) tTXA-topical application of TXA just before wound closure, and (4) control group. Outcome measures included intraoperative blood loss, postoperative blood loss, need for blood transfusion, length of hospital stay, and hematological parameters. RESULTS All the 3 different modes of TXA administration were found to be effective in reducing blood loss in the treated groups compared with the control group. Intraoperative blood loss was significantly reduced in ivTXA (223.6 ± 40.1 mL, P < .0001) and loTXA (256.07 ± 119 mL, P = .0039) groups when compared with controls (344 ± 88.5 mL).The postoperative blood loss was least in tTXA followed by ivTXA, loTXA, and controls. There was 67% reduction in need for blood transfusion in tTXA group, 55.5% reduction in ivTXA group, and 33% reduction in loTXA group when compared with the control group. CONCLUSION In instrumented spine surgery, ivTXA and loTXA were found to be equally effective in reducing the intraoperative blood loss. The tTXA has better postoperative blood conserving effects. This is the first study to detail about safety and efficacy on local infiltration of TXA in spine surgery, which is an effective and safe method for reducing intraoperative blood loss.
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Affiliation(s)
- Viswanadha Arun-Kumar
- Mallika Spine Centre, Guntur, Andhra Pradesh, India,Viswanadha Arun-Kumar, Mallika Spine Centre, 12-12-30, Old Club Road, Kothapet, Guntur, Andhra Pradesh, India.
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22
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Therapeutic drug monitoring of tranexamic acid in plasma and urine of renally impaired patients using solid phase microextraction. Talanta 2020; 225:121945. [PMID: 33592700 DOI: 10.1016/j.talanta.2020.121945] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/26/2020] [Accepted: 11/27/2020] [Indexed: 11/24/2022]
Abstract
The purpose of the research was to develop an improved solid phase microextraction (SPME)-based sampling protocol for the therapeutic drug monitoring of tranexamic acid (TXA) from plasma and urine of patients with chronic renal dysfunction (CRD) in order to correct the current dosing schedule to accommodate these patients. A 12-fold improvement in sampling efficiency (25 min for 96 samples -22 s per sample) was achieved with the use of hydrophilic-lipophilic balance (HLB)-coated SPME devices, thereby enabling high throughput profiling of TXA in the plasma and urine of 49 CRD patients undergoing cardiac surgery. A limit of quantification of 10 μg/mL and 25 μg/mL was obtained for plasma and urine respectively while a method accuracy of 103-105% and a precision of less than 8% was achieved. The results from this study were ultimately used by clinicians at the Toronto General Hospital to design a corrective pharmacokinetic dosing schedule for CRD patients. This green method further presents potential application in the clinical field for the fast high throughput monitoring of TXA not only in plasma but also in urine - a biological matrix seldom explored for the analysis of TXA - without the need for solvent-assisted extraction, extensive sample pre-treatment or clean-up, derivatization or excessive pH adjustment to improve amenability for analytical separation.
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23
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Vadivel K, Zaiss AK, Kumar Y, Fabian FM, Ismail AEA, Arbing MA, Buchholz WG, Velander WH, Bajaj SP. Enhanced Antifibrinolytic Efficacy of a Plasmin-Specific Kunitz-Inhibitor (60-Residue Y11T/L17R with C-Terminal IEK) of Human Tissue Factor Pathway Inhibitor Type-2 Domain1. J Clin Med 2020; 9:E3684. [PMID: 33212896 PMCID: PMC7698382 DOI: 10.3390/jcm9113684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 10/21/2020] [Indexed: 12/13/2022] Open
Abstract
Current antifibrinolytic agents reduce blood loss by inhibiting plasmin active sites (e.g., aprotinin) or by preventing plasminogen/tissue plasminogen activator (tPA) binding to fibrin clots (e.g., ε-aminocaproic acid and tranexamic acid); however, they have adverse side effects. Here, we expressed 60-residue (NH2NAE…IEKCOOH) Kunitz domain1 (KD1) mutants of human tissue factor pathway inhibitor type-2 that inhibit plasmin as well as plasminogen activation. A single (KD1-L17R-KCOOH) and a double mutant (KD1-Y11T/L17R- KCOOH) were expressed in Escherichia coli as His-tagged constructs, each with enterokinase cleavage sites. KD1-Y11T/L17R-KCOOH was also expressed in Pichia pastoris. KD1-Y11T/L17R-KCOOH inhibited plasmin comparably to aprotinin and bound to the kringle domains of plasminogen/plasmin and tPA with Kd of ~50 nM and ~35 nM, respectively. Importantly, compared to aprotinin, KD1-L17R-KCOOH and KD1-Y11T/L17R-KCOOH did not inhibit kallikrein. Moreover, the antifibrinolytic potential of KD1-Y11T/L17R-KCOOH was better than that of KD1-L17R-KCOOH and similar to that of aprotinin in plasma clot-lysis assays. In thromboelastography experiments, KD1-Y11T/L17R-KCOOH was shown to inhibit fibrinolysis in a dose dependent manner and was comparable to aprotinin at a higher concentration. Further, KD1-Y11T/L17R-KCOOH did not induce cytotoxicity in primary human endothelial cells or fibroblasts. We conclude that KD1-Y11T/L17R-KCOOH is comparable to aprotinin, the most potent known inhibitor of plasmin and can be produced in large amounts using Pichia.
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Affiliation(s)
- Kanagasabai Vadivel
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (K.V.); (A.K.Z.); (Y.K.)
| | - Anne K. Zaiss
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (K.V.); (A.K.Z.); (Y.K.)
| | - Yogesh Kumar
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (K.V.); (A.K.Z.); (Y.K.)
| | - Frank M. Fabian
- Department of Chemical and Biomolecular Engineering, University of Nebraska, Lincoln, NE 68588, USA; (F.M.F.); (A.E.A.I.); (W.G.B.); (W.H.V.)
- Chemistry Department, Walla Walla University, College Place, WA 99324, USA
| | - Ayman E. A. Ismail
- Department of Chemical and Biomolecular Engineering, University of Nebraska, Lincoln, NE 68588, USA; (F.M.F.); (A.E.A.I.); (W.G.B.); (W.H.V.)
| | - Mark A. Arbing
- Protein Expression Technology Center, UCLA-DOE Institute, University of California, Los Angeles, CA 90095, USA;
| | - Wallace G. Buchholz
- Department of Chemical and Biomolecular Engineering, University of Nebraska, Lincoln, NE 68588, USA; (F.M.F.); (A.E.A.I.); (W.G.B.); (W.H.V.)
| | - William H. Velander
- Department of Chemical and Biomolecular Engineering, University of Nebraska, Lincoln, NE 68588, USA; (F.M.F.); (A.E.A.I.); (W.G.B.); (W.H.V.)
| | - S. Paul Bajaj
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (K.V.); (A.K.Z.); (Y.K.)
- Molecular Biology Institute, University of California, Los Angeles, CA 90095, USA
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Broadwin M, Grant PE, Robich MP, Palmeri ML, Lucas FL, Rappold J, Kramer RS. Comparison of intraoperative tranexamic acid and epsilon-aminocaproic acid in cardiopulmonary bypass patients. JTCVS OPEN 2020; 3:114-125. [PMID: 36003884 PMCID: PMC9390169 DOI: 10.1016/j.xjon.2020.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/08/2020] [Accepted: 05/15/2020] [Indexed: 02/06/2023]
Abstract
Objective To compare tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) in patients undergoing cardiac surgery with cardiopulmonary bypass. Methods Over a consecutive 2-year period, 824 adult cardiac surgery patients who received TXA during an EACA shortage were compared with 778 patients who received EACA postshortage. Patient characteristics and process and outcome variables were collected through chart review and database queries. This retrospective analysis used inverse probability of treatment weighting to control for confounding by indication, and propensity scores were calculated using a logistic regression model. Results In adjusted models, overall transfusion rates for the TXA cohort (odds ratio [OR], 0.94; 95% confidence interval [95% CI], 0.81-1.10) and administration of platelets (OR, 1.04; 95% CI, 0.85-1.27), red blood cells (OR, 0.93; 95% CI, 0.80-1.09), fresh frozen plasma (OR, 1.00; 95% CI, 0.79-1.25), and cryoprecipitate (OR, 1.08; 95% CI, 0.71-1.64) were equivalent to the EACA cohort. In addition, there was no statistical difference with respect to stroke, seizure, mortality, reoperation for bleeding, chest tube drainage, and acute kidney injury. Patients who received TXA had shorter ventilator times (difference in medians -1.33 hours [95% CI, -1.86 to -0.80]) and lower postsurgical charges (difference of medians -$2913 [95% CI, -5147 to -679]). Conclusions Substituting TXA for EACA during cardiac surgery with cardiopulmonary bypass did not change transfusion rate or amount, nor was there a significant difference in chest tube drainage. Patients who received TXA had a statistically significant but not clinically significant lower postoperative ventilator times and charges without an increase in mortality, stroke, reoperation for bleeding, acute kidney injury, or seizures.
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Affiliation(s)
- Mark Broadwin
- Cardiovascular Institute, Maine Medical Center, Portland, Me
| | | | | | | | - Frances L. Lucas
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Scarborough, Me
| | - Joseph Rappold
- Department of Surgery, Maine Medical Center, Portland, Me
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Bolliger D, Erb JM. Individualized Perioperative Antifibrinolytic Therapy: The Next Goal in Cardiac Surgery? J Cardiothorac Vasc Anesth 2020; 35:418-420. [PMID: 32921617 DOI: 10.1053/j.jvca.2020.08.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel Bolliger
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Joachim M Erb
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
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Verma S, Srinivas U, Sathpathy AK, Mittal P. Comparison of effectiveness of tranexamic acid and epsilon-amino-caproic-acid in decreasing postoperative bleeding in off-pump CABG surgeries: A prospective, randomized, double-blind study. Ann Card Anaesth 2020; 23:65-69. [PMID: 31929250 PMCID: PMC7034205 DOI: 10.4103/aca.aca_142_18] [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] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context Off-pump coronary artery bypass graft (CABG) surgeries have been shown to have increased fibrinolysis due to tissue plasminogen activator release. There are no trials comparing the two available antifibrinolytics (tranexemic acid and epsilon-amino-caproic acid) in off-pump CABG surgeries. Aims The aim of the present study was to compare the effectiveness of tranexamic acid and epsilon-amino-caproic acid with respect to postoperative bleeding at 4 and 24 hours as the primary outcome, and rate of postoperative transfusion, re-operations, complication rate, serum fibrinogen, and D-dimer levels as secondary outcomes. Settings and Design The study was carried out at a tertiary-level hospital between June 2017 and June 2018. It was a prospective, randomized, double-blind study. Materials and Methods Eighty patients undergoing off-pump CABG, were randomly allocated to receive tranexamic acid or epsilon-amino-caproic acid. The patients were followed up in the postoperative period and were assessed for primary and secondary outcomes. Statistical Analysis Used Statistical analysis was performed using SPSS software, version 19.0 (SPSS Inc., Chicago, IL). Nonparametric data were expressed as median with interquartile range and compared using Mann-Whitney U-test, parametric data was represented as mean with standard deviation and analyzed using Student's t-test. Nominal data were analyzed using Chi-square test. Results Bleeding at 4 hours did not show significant difference between groups, 180 ml (80-250) vs 200 ml (100-310). Bleeding at 24 hours was significantly lesser in tranexamic acid group as compared to epsilon-amino-caproic acid group, 350 ml (130-520) vs 430 ml (160-730) (P = 0.0022) The rate of transfusion, re-operations, seizures, renal dysfunction, fibrinogen levels, and D-dimer levels did not show significant difference between the groups. Conclusions Tranexamic acid significantly reduced postoperative bleeding in off-pump CABG at 24 hours as compared to epsilon-amino-caproic-acid.
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Affiliation(s)
- Swapnil Verma
- Department of Anaesthesia, Apollo Hospital, Jubilee Hills, Hyderabad, Telangana, India
| | - Upadhyayula Srinivas
- Department of Anaesthesia, Apollo Hospital, Jubilee Hills, Hyderabad, Telangana, India
| | - Anand Kumar Sathpathy
- Department of Anaesthesia, Apollo Hospital, Jubilee Hills, Hyderabad, Telangana, India
| | - Priyanka Mittal
- Department of Anaesthesia, Apollo Hospital, Jubilee Hills, Hyderabad, Telangana, India
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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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Cardenas JC. Mechanisms of Traumatic Hyperfibrinolysis and Implications for Antifibrinolytic Therapy. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-00175-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Steinmetzer T, Pilgram O, Wenzel BM, Wiedemeyer SJA. Fibrinolysis Inhibitors: Potential Drugs for the Treatment and Prevention of Bleeding. J Med Chem 2019; 63:1445-1472. [PMID: 31658420 DOI: 10.1021/acs.jmedchem.9b01060] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hyperfibrinolytic situations can lead to life-threatening bleeding, especially during cardiac surgery. The approved antifibrinolytic agents such as tranexamic acid, ε-aminocaproic acid, 4-aminomethylbenzoic acid, and aprotinin were developed in the 1960s without the structural insight of their respective targets. Crystal structures of the main antifibrinolytic targets, the lysine binding sites on plasminogen's kringle domains, and plasmin's serine protease domain greatly contributed to the structure-based drug design of novel inhibitor classes. Two series of ligands targeting the lysine binding sites have been recently described, which are more potent than the most-widely used antifibrinolytic agent, tranexamic acid. Furthermore, four types of promising active site inhibitors of plasmin have been developed: tranexamic acid conjugates targeting the S1 pocket and primed sites, substrate-analogue linear homopiperidylalanine-containing 4-amidinobenzylamide derivatives, macrocyclic inhibitors addressing nonprimed binding regions, and bicyclic 14-mer SFTI-1 analogues blocking both, primed and nonprimed binding sites of plasmin. Furthermore, several allosteric plasmin inhibitors based on heparin mimetics have been developed.
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Affiliation(s)
- Torsten Steinmetzer
- Department of Pharmacy, Institute of Pharmaceutical Chemistry , Philipps University Marburg , Marbacher Weg 6 , D-35032 Marburg , Germany
| | - Oliver Pilgram
- Department of Pharmacy, Institute of Pharmaceutical Chemistry , Philipps University Marburg , Marbacher Weg 6 , D-35032 Marburg , Germany
| | - Benjamin M Wenzel
- Department of Pharmacy, Institute of Pharmaceutical Chemistry , Philipps University Marburg , Marbacher Weg 6 , D-35032 Marburg , Germany
| | - Simon J A Wiedemeyer
- Department of Pharmacy, Institute of Pharmaceutical Chemistry , Philipps University Marburg , Marbacher Weg 6 , D-35032 Marburg , Germany
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Leff J, Romano CA, Gilbert S, Nair S. Validation Study of the Transfusion Risk and Clinical Knowledge (TRACK) Tool in Cardiac Surgery Patients: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2019; 33:2669-2675. [DOI: 10.1053/j.jvca.2019.05.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/21/2019] [Accepted: 05/25/2019] [Indexed: 11/11/2022]
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Ertugay S, Kudsioğlu T, Şen T. Consensus Report on Patient Blood Management in Cardiac Surgery by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care (SCTAIC). TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2019; 27:429-450. [PMID: 32082905 PMCID: PMC7018143 DOI: 10.5606/tgkdc.dergisi.2019.01902] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 01/18/2023]
Abstract
Anemia, transfusion and bleeding independently increase the risk of complications and mortality in cardiac surgery. The main goals of patient blood management are to treat anemia, prevent bleeding, and optimize the use of blood products during the perioperative period. The benefit of this program has been confirmed in many studies and its utilization is strongly recommended by professional organizations. This consensus report has been prepared by the authors who are the task members appointed by the Turkish Society of Cardiovascular Surgery, Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care to raise the awareness of patient blood management. This report aims to summarize recommendations for all perioperative blood- conserving strategies in cardiac surgery.
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Affiliation(s)
- Serkan Ertugay
- Department of Cardiovascular Surgery, Ege University School of Medicine, İzmir, Turkey
| | - Türkan Kudsioğlu
- Anesthesiology and Reanimation, University of Health Sciences, Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
| | - Taner Şen
- Department of Cardiology, University of Health Sciences, Kütahya
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Bradley KE, Ryan SP, Penrose CT, Grant SA, Wellman SS, Attarian DE, Green CL, Risoli T, Bolognesi MP. Tranexamic acid or epsilon-aminocaproic acid in total joint arthroplasty? A randomized controlled trial. Bone Joint J 2019; 101-B:1093-1099. [PMID: 31474134 DOI: 10.1302/0301-620x.101b9.bjj-2018-1096.r1] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIMS Antifibrinolytic agents, including tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), have been shown to be safe and effective for decreasing perioperative blood loss and transfusion following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, there are few prospective studies that directly compare these agents. The purpose of this study was to compare the benefits of intraoperative intravenous TXA with EACA. PATIENTS AND METHODS A total of 235 patients (90 THA and 145 TKA) were enrolled in this prospective, randomized controlled trial at a single tertiary-care referral centre. In the THA cohort, 53.3% of the patients were female with a median age of 59.8 years (interquartile range (IQR) 53.3 to 68.1). In the TKA cohort, 63.4% of the patients were female with a median age of 65.1 years (IQR 59.4 to 69.5). Patients received either TXA (n = 119) or EACA (n = 116) in two doses intraoperatively. The primary outcome measures included change in haemoglobin level and blood volume, postoperative drainage, and rate of transfusion. Secondary outcome measures included postoperative complications, cost, and length of stay (LOS). RESULTS TKA patients who received EACA had greater drainage (median 320 ml (IQR 185 to 420) vs 158 ml (IQR 110 to 238); p < 0.001), increased loss of blood volume (891 ml (IQR 612 to 1203) vs 661 ml (IQR 514 to 980); p = 0.014), and increased haemoglobin change from the preoperative level (2.1 ml (IQR 1.7 to 2.8) vs 1.9 ml (IQR 1.2 to 2.4); p = 0.016) compared with patients who received TXA. For the THA cohort, no statistically significant differences were observed in any haematological outcome measure. One patient in the EACA group required transfusion. No patient in the TXA group required transfusion. There were no statistically significant differences in number or type of postoperative complications or LOS for either THA or TKA patients regardless of whether they received TXA or EACA. CONCLUSION For hip and knee arthroplasty procedures, EACA is associated with increased perioperative blood loss compared with TXA. However, there is no significant difference in transfusion rate. While further prospective studies are needed to compare the efficacy of each agent, we currently recommend orthopaedic surgeons to select their antifibrinolytic based on cost and regional availability. Cite this article: Bone Joint J 2019;101-B:1093-1099.
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Affiliation(s)
- Kendall E Bradley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Colin T Penrose
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Stuart A Grant
- Department of Anesthesiology-Regional Division, Duke University Medical Center, Durham, North Carolina, USA
| | - Samuel S Wellman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - David E Attarian
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Cynthia L Green
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Thomas Risoli
- Duke CTSI Biostatistics, Epidemiology and Research Design (BERD) Methods Core, Durham, North Carolina, USA
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Richards JE, Samet RE, Koerner AK, Grissom TE. Tranexamic Acid in the Perioperative Period: Yes, No, Maybe? Adv Anesth 2019; 37:87-110. [PMID: 31677661 DOI: 10.1016/j.aan.2019.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Justin E Richards
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Ron E Samet
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - A Kennedy Koerner
- Department of Anesthesiology, University of Maryland School of Medicine, Center for the Sustainment of Trauma and Readiness Skills (CSTARS)-Baltimore, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA.
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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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Pena JJ, Bottiger BA, Miltiades AN. Perioperative Management of Bleeding and Transfusion for Lung Transplantation. Semin Cardiothorac Vasc Anesth 2019; 24:74-83. [DOI: 10.1177/1089253219869030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Perioperative allogeneic blood product transfusion is common in lung transplantation and has various implications on the short- and long-term outcomes of lung recipients. This review summarizes the effect of transfusion on outcomes including primary graft dysfunction, chronic lung allograft dysfunction, and all-cause mortality. We outline known risk factors for increased transfusion requirement in lung transplantation and present current evidence regarding the effect of hemostatic agents including antifibrinolytics, recombinant factor VII, and prothrombin complex concentrates. Finally, we highlight the roles of point-of-care coagulation testing and goal-directed transfusion strategies in reducing transfusion requirements in lung transplantation.
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Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman RM, Gregory AJ, Boyle EM. Guidelines for Perioperative Care in Cardiac Surgery. JAMA Surg 2019; 154:755-766. [DOI: 10.1001/jamasurg.2019.1153] [Citation(s) in RCA: 347] [Impact Index Per Article: 69.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Daniel T. Engelman
- Heart and Vascular Program, Baystate Medical Center, Springfield, Massachusetts
| | | | | | | | - V. Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rakesh C. Arora
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
- Now with Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Ali Khoynezhad
- MemorialCare Heart and Vascular Institute, Los Angeles, California
| | - Marc Gerdisch
- Franciscan Health Heart Center, Indianapolis, Indiana
| | | | - Kevin Lobdell
- Atrium Health, Department of Cardiovascular and Thoracic Surgery, North Carolina
| | - Nick Fletcher
- St Georges University of London, London, United Kingdom
| | - Matthias Kirsch
- Centre Hospitalier Universitaire Vaudois Cardiac Surgery Centre, Lausanne, Switzerland
| | | | | | | | - Edward M. Boyle
- Department of Cardiac Surgery, St Charles Medical Center, Bend, Oregon
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Gamble JF, Maxwell CD, Gaca J, Guinn NR, Cho BC, Frank SM, Tibi PR. Successful Ascending Aorta and Hemiarch Replacement and Aortic Valve Resuspension Via Redo Median Sternotomy Using Hypothermic Circulatory Arrest in a Practicing Jehovah's Witnesses Patient. J Cardiothorac Vasc Anesth 2019; 33:1447-1454. [DOI: 10.1053/j.jvca.2018.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Indexed: 11/11/2022]
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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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Looby NT, Tascon M, Acquaro VR, Reyes-Garcés N, Vasiljevic T, Gomez-Rios GA, Wąsowicz M, Pawliszyn J. Solid phase microextraction coupled to mass spectrometry via a microfluidic open interface for rapid therapeutic drug monitoring. Analyst 2019; 144:3721-3728. [PMID: 30968079 DOI: 10.1039/c9an00041k] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic used during cardiac surgery that presents high inter-patient variability.
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Affiliation(s)
- Nikita T. Looby
- Department of Chemistry
- University of Waterloo
- 200 University Avenue west
- Waterloo
- Canada
| | - Marcos Tascon
- Department of Chemistry
- University of Waterloo
- 200 University Avenue west
- Waterloo
- Canada
| | - Vinicius R. Acquaro
- Department of Chemistry
- University of Waterloo
- 200 University Avenue west
- Waterloo
- Canada
| | - Nathaly Reyes-Garcés
- Department of Chemistry
- University of Waterloo
- 200 University Avenue west
- Waterloo
- Canada
| | - Tijana Vasiljevic
- Department of Chemistry
- University of Waterloo
- 200 University Avenue west
- Waterloo
- Canada
| | | | - Marcin Wąsowicz
- Department of Anaesthesia and Pain Management
- Toronto General Hospital
- Toronto
- Canada M5G 2C4
| | - Janusz Pawliszyn
- Department of Chemistry
- University of Waterloo
- 200 University Avenue west
- Waterloo
- Canada
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41
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Tranexamic Acid Does Not Influence Cardioprotection by Ischemic Preconditioning and Remote Ischemic Preconditioning. Anesth Analg 2018; 126:439-442. [PMID: 28678070 DOI: 10.1213/ane.0000000000002230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Prior studies have suggested that the antifibrinolytic drug aprotinin increases the infarct size after ischemia and reperfusion (I/R) and attenuates the effect of ischemic preconditioning (IPC). Aprotinin was replaced by tranexamic acid (TXA) in clinical practice. Here, we investigated whether TXA influences I/R injury and/or cardioprotection initiated by IPC and/or remote ischemic preconditioning (RIPC). Anesthetized male Wistar rats were randomized to 6 groups. Control animals were not further treated. Administration of TXA was combined with and without IPC and RIPC. Estimated treatment effect was 20%. Compared to control group (56% ± 11%), IPC reduced infarct size by 46% (30% ± 6%; mean difference, 26%; 95% confidence interval, 19-33; P < .0001), and RIPC reduced infarct size by 29% (40% ± 8%; mean difference, 16%; 95% confidence interval, 9-24; P < .011). Additional application of TXA had no effect on I/R injury and cardioprotection by IPC or RIPC. TXA does not abolish infarct size reduction by IPC or RIPC.
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Jing J, Du Z, Ji S, Han K. Urinary proteome analysis of acute hypercoagulable state in rat model induced by ε-aminocaproic acid. Biomed Pharmacother 2018; 110:275-284. [PMID: 30513505 DOI: 10.1016/j.biopha.2018.11.148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 11/27/2018] [Accepted: 11/28/2018] [Indexed: 12/16/2022] Open
Abstract
The hypercoagulable state occurs in a group of prothrombotic disorders associated with an increased risk for thromboembolic events, but it is difficult to diagnose due to the lack of available biomarkers. This study aimed to investigate systematic changes of urinary proteome in acute hypercoagulable state induced by certain antifibrinolytics. To reduce the effects of both genetic and environmental factors on the urinary proteome, we used a rat model of acute hypercoagulable state induced by an antifibrinolytic agent ε-aminocaproic acid, resembling human hypercoagulable state. Urine samples were collected during acute hypercoagulable state for analysis by liquid chromatography-tandem mass spectrometry (LCMS/MS). Of 65 significantly changed proteins in acute hypercoagulable state, 38 proteins had human orthologs, and 18 proteins were identified as stable in normal human urine. None of the identified proteins have been found to be clotting factors, but 4 proteins are known to be involved in the regulation of blood coagulation factors. Two proteins were verified as the markers associated with acute hypercoagulable state by Western blot analysis. In addition, four common differential urinary proteins have been found in acute hypercoagulable state induced by another antifibrinolytics tranexamic acid. These four proteins are potential biomarkers for early diagnosis of hypercoagulable state to prevent the development of thrombotic diseases.
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Affiliation(s)
- Jian Jing
- Beijing Key Lab of Genetic Engineering and Biotechnology, College of Life Sciences, Beijing Normal University, Xinwai St 19, Haidian District, Beijing, 100875, China.
| | - Zhenhuan Du
- Beijing Key Lab of Genetic Engineering and Biotechnology, College of Life Sciences, Beijing Normal University, Xinwai St 19, Haidian District, Beijing, 100875, China
| | - Songyang Ji
- Beijing Key Lab of Genetic Engineering and Biotechnology, College of Life Sciences, Beijing Normal University, Xinwai St 19, Haidian District, Beijing, 100875, China
| | - Keqiang Han
- Beijing Key Lab of Genetic Engineering and Biotechnology, College of Life Sciences, Beijing Normal University, Xinwai St 19, Haidian District, Beijing, 100875, China
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Zhang Y, Gao X, Yuan S, Guo J, Lv H, Zhou Y, Wang Y, Ji H, Wang G, Li L, Shi J. Effects of tranexamic acid on short‐term and long‐term outcomes of on‐pump coronary artery bypass grafting: Randomized trial and 7‐year follow‐up. Cardiovasc Ther 2018; 36:e12472. [PMID: 30372588 DOI: 10.1111/1755-5922.12472] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 09/30/2018] [Accepted: 10/22/2018] [Indexed: 11/26/2022] Open
Affiliation(s)
- Yu Zhang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Xurong Gao
- Department of Transfusion, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Jingfei Guo
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Huanran Lv
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Yong Zhou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Yuefu Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Hongwen Ji
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Guyan Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Lihuan Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Jia Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
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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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Sierra P, Gómez-Luque A, Llau JV, Ferrandis R, Cassinello C, Hidalgo F. Recommendations for perioperative antiplatelet treatment in non-cardiac surgery. Working Group of the Spanish Society of Anaesthesiology-Resuscitation and Pain Therapy, Division of Haemostasis, Transfusion Medicine, and Perioperative Fluid Therapy. Update of the Clinical practice guide 2018. ACTA ACUST UNITED AC 2018; 66:18-36. [PMID: 30166124 DOI: 10.1016/j.redar.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 12/24/2022]
Affiliation(s)
- P Sierra
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Fundación Puigvert (IUNA), Barcelona, España.
| | - A Gómez-Luque
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, España
| | - J V Llau
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Dr. Peset, Universitat de València, Valencia, España
| | - R Ferrandis
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hopital Clínic i Universitari La Fe, Universitat de València, Valencia, España
| | - C Cassinello
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Miguel Servet, Zaragoza, España
| | - F Hidalgo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Clínica Universidad de Navarra, Pamplona, España
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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: 94] [Impact Index Per Article: 15.7] [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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48
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Wang M, Tan H, Wu Z, Liang Y. The efficacy and safety of anti-fibrinolytic agents in blood management following peri-acetabular osteotomy: A meta-analysis. Medicine (Baltimore) 2018; 97:e11967. [PMID: 30142824 PMCID: PMC6112897 DOI: 10.1097/md.0000000000011967] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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 Blood management after peri-acetabular osteotomy (PAO) has become a serious problem. We performed a meta-analysis to evaluate the efficacy and safety of antifibrinolytics for blood management after PAO. METHODS PubMed, OVID, Embase, ScienceDirect, and Web of Science were searched up to January, 2018 without restrictions on publication date and language. We also searched the relevant publication sources. The research was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Randomized controlled trials (RCTs) and non-RCTs were included in our study. Weighted mean differences, risk difference, and 95% confidence intervals were calculated. We assessed statistical heterogeneity for each outcome with the use of a standard chi-square test and I statistic. The data were extracted by 2 of the co-authors independently and were analyzed by RevMan5.3. Primary outcomes were total blood loss, postoperative hemoglobin decline, and transfusion rates. Secondary outcomes were length of a hospital stay and postoperative complications. RESULTS Four studies including 1 RCT and 3 non-RCTs were included in our study. The present meta-analysis indicated that antifibrinolytics was associated with a significant reduction of the total blood loss, postoperative hemoglobin decline, transfusion rates, and length of a hospital stay compared with control groups. No significant differences were identified in terms of the incidence of postoperative complications. CONCLUSION Intravenous antifibrinolytics was efficacious in reduction of total blood loss, postoperative hemoglobin decline, and length of a hospital stay after PAO without increasing the risk of thromboembolic complications. More high-quality RCTs with long follow-up period were necessary for proper comparisons of the efficacy and safety of antifibrinolytics with placebo.
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Affiliation(s)
- Mian Wang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University
| | - Hongzhuan Tan
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University
| | - Zhaozhao Wu
- Hunan Center for Drug Evaluation Certification & ADR Monitoring, Hunan, China
| | - Ying Liang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University
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49
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Seelhammer TG, Mangla J, Demirci O. The Use of Thromboelastography to Titrate Tranexamic Acid Therapy for Abatement of Lysis-Induced Hemorrhagic Complications During Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2018; 33:1059-1062. [PMID: 30765211 DOI: 10.1053/j.jvca.2018.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Troy G Seelhammer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| | - Jimmi Mangla
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Onur Demirci
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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Fang ZA, Wesley M, DiNardo JA. Berlin Heart Explant in an Infant. J Cardiothorac Vasc Anesth 2018; 32:1383-1385. [DOI: 10.1053/j.jvca.2017.08.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Indexed: 11/11/2022]
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