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Wang E, Wang Y, Li Y, Hu S, Yuan S. Tranexamic acid is associated with improved hemostasis in elderly patients undergoing coronary-artery surgeries in a retrospective cohort study. Front Surg 2023; 10:1117974. [PMID: 36896258 PMCID: PMC9989169 DOI: 10.3389/fsurg.2023.1117974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/03/2023] [Indexed: 02/23/2023] Open
Abstract
Background More elderly patients undergo coronary artery bypass surgery (CABG) than younger patients. Whether tranexamic acid (TA) is still effective and safe in elderly patients undergoing CABG surgeries is still unclear. Methods In this study, a cohort of 7,224 patients ≥70 years undergoing CABG surgery were included. Patients were categorized into the no TA group, TA group, high-dose group, and low-dose group according whether TA was administered and the dose administered. The primary endpoint was blood loss and blood transfusion after CABG. The secondary endpoints were thromboembolic events and in-hospital death. Results The blood loss at 24 and 48 h and the total blood loss after surgery in patients in the TA group were 90, 90, and 190 ml less than those in the no-TA group, respectively (p < 0.0001). The total blood transfusion was reduced 0.38-fold with TA administration compared to that without TA (OR = 0.62, 95% CI 0.56-0.68, p < 0.0001). Blood component transfusion was also reduced. High-dose TA administration reduced the blood loss by 20 ml 24 h after surgery (p = 0.032) but had no relationship with the blood transfusion. TA increased the risk of perioperative myocardial infarction (PMI) by 1.62-fold [p = 0.003, OR = 1.62, 95% CI (1.18-2.22)] but reduced the hospital stay time in patients who were administered TA compared to that of patients who did not receive TA (p = 0.026). Conclusion We revealed that elderly patients undergoing CABG surgeries had better hemostasis after TA administration but increased the risk of PMI. High-dose TA was effective and safe compared with low-dose TA administration in elderly patients undergoing CABG surgery.
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Affiliation(s)
- Enshi Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yang Wang
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Yuan Li
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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The effect of tranexamic acid on myocardial injury in cardiac surgical patients: a systematic review and meta-analysis. Blood Coagul Fibrinolysis 2022; 33:429-437. [PMID: 35946446 DOI: 10.1097/mbc.0000000000001158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Tranexamic acid (TXA) is one of the most commonly used antifibrinolytic agents for surgical patients. However, the effect of TXA on myocardial injury remains controversial. We systemically reviewed literature regarding the effectiveness of TXA on myocardial injury in patients who have undergone a cardiac surgery. We included all randomized controlled trials (RCTs) comparing TXA and control (saline) in cardiac surgical patients. Relevant studies were identified by a comprehensive electronic literature search from database inception to 15 August 2021. A standardized data extraction form was used to collect methodological and outcome variables from each eligible study. We conducted a meta-analysis to estimate the pooled effect size of TXA administration on myocardial injury. In total, eight RCTs were identified, with 292 patients in the TXA group, and 241 patients in saline or control group. The meta-analysis demonstrated that patients in the TXA group had lower levels of CK-MB and cTnI within 24 h postoperatively (CK-MB: P = 0.005; cTnI: P = 0.01), compared with the saline group. No significant difference was found with respect to AST level ( P = 0.71) between TXA and saline groups within 24 h postoperatively. TXA administration was found to be associated with less myocardial injury among patients who have undergone cardiac surgery. High-quality randomized controlled trials are warranted to further examine the cardioprotective effects of TXA.
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Grassin-Delyle S, Semeraro M, Lamy E, Urien S, Runge I, Foissac F, Bouazza N, Treluyer JM, Arribas M, Roberts I, Shakur-Still H. Pharmacokinetics of tranexamic acid after intravenous, intramuscular, and oral routes: a prospective, randomised, crossover trial in healthy volunteers. Br J Anaesth 2022; 128:465-472. [PMID: 34998508 DOI: 10.1016/j.bja.2021.10.054] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/20/2021] [Accepted: 10/31/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In response to the World Health Organization call for research on alternative routes for tranexamic acid (TXA) administration in women with postpartum haemorrhage, we examined the pharmacokinetics of TXA after i.v., i.m., or oral administration. METHODS We conducted a randomised, open-label, crossover trial in 15 healthy volunteers who received i.v. TXA 1 g, i.m. TXA 1 g, or oral TXA solution 2 g. Blood samples were drawn up to 24 h after administration. Tranexamic acid concentration was measured with liquid chromatography-mass spectrometry, and the parameters of the pharmacokinetic models were estimated using population pharmacokinetics. RESULTS The median time to reach a concentration of 10 mg L-1 was 3.5 min for the i.m. route and 66 min for the oral route, although with the oral route the target concentration was reached in only 11 patients. Median peak concentrations were 57.5, 34.4, and 12.8 mg L-1 for i.v., i.m., and oral routes, respectively. A two-compartment open model with body weight as the main covariate best fitted the data. For a 70 kg volunteer, the population estimates were 10.1 L h-1 for elimination clearance, 15.6 L h-1 for intercompartmental clearance, 7.7 L for the volume of central compartment, and 10.8 L for the volume of the peripheral compartment. Intramuscular and oral bioavailabilities were 1.0 and 0.47, respectively, showing that i.m. absorption is fast and complete. Adverse events were mild and transient, mainly local reactions and low-intensity pain. CONCLUSIONS The i.m. (but not oral) route appears to be an efficient alternative to i.v. tranexamic acid. Studies in pregnant women are needed to examine the impact of pregnancy on the pharmacokinetics. CLINICAL TRIAL REGISTRATION EudraCT 2019-000285-38; NCT03777488.
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Affiliation(s)
- Stanislas Grassin-Delyle
- Infection et inflammation, Département de Biotechnologie de la Santé, Université Paris-Saclay, University of Versailles Saint-Quentin-en-Yvelines, INSERM, Montigny le Bretonneux, France; Département des maladies des voies respiratoires, Hôpital Foch, Suresnes, France.
| | - Michaela Semeraro
- Centre d'Investigation Clinique P1419, INSERM, Hôpital Cochin-Necker, Université de Paris, Paris, France
| | - Elodie Lamy
- Infection et inflammation, Département de Biotechnologie de la Santé, Université Paris-Saclay, University of Versailles Saint-Quentin-en-Yvelines, INSERM, Montigny le Bretonneux, France
| | - Saïk Urien
- Unité de Recherche Clinique, Hôpital Cochin-Necker, Université de Paris, Paris, France
| | - Iléana Runge
- Infection et inflammation, Département de Biotechnologie de la Santé, Université Paris-Saclay, University of Versailles Saint-Quentin-en-Yvelines, INSERM, Montigny le Bretonneux, France
| | - Frantz Foissac
- Unité de Recherche Clinique, Hôpital Cochin-Necker, Université de Paris, Paris, France
| | - Naim Bouazza
- Unité de Recherche Clinique, Hôpital Cochin-Necker, Université de Paris, Paris, France
| | - Jean-Marc Treluyer
- Centre d'Investigation Clinique P1419, INSERM, Hôpital Cochin-Necker, Université de Paris, Paris, France; Unité de Recherche Clinique, Hôpital Cochin-Necker, Université de Paris, Paris, France
| | - Monica Arribas
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
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Lisman T, Adelmeijer J, Huskens D, Meijers JCM. Aprotinin Inhibits Thrombin Generation by Inhibition of the Intrinsic Pathway, but is not a Direct Thrombin Inhibitor. TH OPEN 2021; 5:e363-e375. [PMID: 34485811 PMCID: PMC8407936 DOI: 10.1055/s-0041-1735154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/29/2021] [Indexed: 12/01/2022] Open
Abstract
Background
Aprotinin is a broad-acting serine protease inhibitor that has been clinically used to prevent blood loss during major surgical procedures including cardiac surgery and liver transplantation. The prohemostatic properties of aprotinin likely are related to its antifibrinolytic effects, but other mechanisms including preservation of platelet function have been proposed.
Aim
Here we assessed effects of aprotinin on various hemostatic pathways in vitro, and compared effects to tranexamic acid(TXA), which is an antifibrinolytic but not a serine protease inhibitor.
Methods
We used plasma-based clot lysis assays, clotting assays in whole blood, plasma, and using purified proteins, and platelet activation assays to which aprotinin or TXA were added in pharmacological concentrations.
Results
Aprotinin and TXA dose-dependently inhibited fibrinolysis in plasma. Aprotinin inhibited clot formation and thrombin generation initiated via the intrinsic pathway, but had no effect on reactions initiated by tissue factor. However, in the presence of thrombomodulin, aprotinin enhanced thrombin generation in reactions started by tissue factor. TXA had no effect on coagulation. Aprotinin did not inhibit thrombin, only weakly inhibited the TF-VIIa complex and had no effect on platelet activation and aggregation by various agonists including thrombin. Aprotinin and TXA inhibited plasmin-induced platelet activation.
Conclusion
Pharmacologically relevant concentrations of aprotinin inhibit coagulation initiated via the intrinsic pathway. The antifibrinolytic activity of aprotinin likely explains the prohemostatic effects of aprotinin during surgical procedures. The anticoagulant properties may be beneficial during surgical procedures in which pathological activation of the intrinsic pathway, for example by extracorporeal circuits, occurs.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jelle Adelmeijer
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dana Huskens
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Synapse Research Institute, Maastricht, The Netherlands
| | - Joost C M Meijers
- Department of Molecular Hematology, Sanquin Research, Amsterdam, The Netherlands.,Department of Experimental Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Jamal L, Saini A, Quencer K, Altun I, Albadawi H, Khurana A, Naidu S, Patel I, Alzubaidi S, Oklu R. Emerging approaches to pre-hospital hemorrhage control: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1192. [PMID: 34430633 PMCID: PMC8350651 DOI: 10.21037/atm-20-5452] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/18/2021] [Indexed: 12/18/2022]
Abstract
In the United States, trauma claims the lives of over 150,000 civilians each year. In military settings, trauma and exsanguination result in 50% of combat related deaths. The majority of these deaths result from uncontrolled non-compressible hemorrhage. Non-compressible hemorrhage often results from deep vascular injuries within the torso, however can also occur secondary to penetrating injuries that involve the extremities. Given the high mortality rates for non-compressible hemorrhage, rapid and effective management of patients suffering from hemorrhage is essential to good patient outcomes. Consequently, there has been increasing interest in solutions for point-of-injury hemorrhage control in trauma and military medicine. Undoubtedly there is a great need for prehospital hemostatic interventions that can be deployed by trained and untrained personnel. Since 2001, various hemostatic agents have been developed, each with its advantages based upon the type and severity of injury, wound size, wound location, accessibility to injury site, and the coagulation status of the patient. These agents are often used in the military setting as a temporizing measure prior to definitive therapy and include techniques such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and bioengineered agents including ResQFoam, RevMedx’s XSTAT, Tranexamic acid (TXA), and QuikClot Combat Gauze (QCG). Here, we review the indications, composition, technique, efficacy, and outcomes of these hemostatic agents.
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Affiliation(s)
- Leila Jamal
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Aman Saini
- Department of Radiology, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Keith Quencer
- Department of Radiology, University of Utah, Salt Lake City, Utah, USA
| | - Izzet Altun
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Hassan Albadawi
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Aditya Khurana
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Sailendra Naidu
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Indravadan Patel
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Sadeer Alzubaidi
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
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Kane Z, Picetti R, Wilby A, Standing JF, Grassin-Delyle S, Roberts I, Shakur-Still H. Physiologically based modelling of tranexamic acid pharmacokinetics following intravenous, intramuscular, sub-cutaneous and oral administration in healthy volunteers. Eur J Pharm Sci 2021; 164:105893. [PMID: 34087356 PMCID: PMC8299544 DOI: 10.1016/j.ejps.2021.105893] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 04/20/2021] [Accepted: 05/29/2021] [Indexed: 11/15/2022]
Abstract
Tranexamic acid (TXA) as a treatment for post-partum haemorrhage (PPH) depends on early intervention and rapid systemic exposure. This study uses PBPK modelling to evaluate the pharmacokinetics of TXA given by different routes of administration; intravenous, intramuscular, sub-cutaneous and oral. Intramuscular administration of 1000 mg TXA is predicted to achieve >15 mg/L in plasma in <15 min and exceed this level for approximately 3 h post dose.
Background : Tranexamic acid (TXA) is an antifibrinolytic drug that reduces surgical blood loss and death due to bleeding after trauma and post-partum haemorrhage. Treatment success is dependant on early intervention and rapid systemic exposure to TXA. The requirement for intravenous (IV) administration can in some situations limit accessibility to TXA therapy. Here we employ physiologically based pharmacokinetic modelling (PBPK) to evaluate if adequate TXA exposure maybe achieved when given via different routes of administration. Methods : A commercially available PBPK software (GastroPlus®) was used to model published TXA pharmacokinetics. IV, oral and intramuscular (IM) models were developed using healthy volunteer PK data from twelve different single dose regimens (n = 48 participants). The model was verified using separate IV and oral validation datasets (n = 26 participants). Oral, IM and sub-cutaneous (SQ) dose finding simulations were performed. Results : Across the different TXA regimens evaluated TXA plasma concentrations varied from 0.1 to 94.0 µg/mL. Estimates of the total plasma clearance of TXA ranged from 0.091 to 0.104 L/h/kg, oral bioavailability from 36 to 67% and Tmax from 2.6 to 3.2 and 0.4 to 1.0 h following oral and intramuscular administration respectively. Variability in the observed TXA PK could be captured through predictable demographic effects on clearance, combined with intestinal permeability and stomach transit time following oral administration and muscle blood flow and muscle/plasma partition coefficients following intra-muscular dosing. Conclusions : This study indicates that intramuscular administration is the non-intravenous route of administration with the most potential for achieving targeted TXA exposures. Plasma levels following an IM dose of 1000 mg TXA are predicted to exceed 15 mg/mL in < 15 min and be maintained above this level for approximately 3 h, achieving systemic exposure (AUC0–6) of 99 to 105 µg*hr/mL after a single dose. Well-designed clinical trials to verify these predictions and confirm the utility of intramuscular TXA are recommended.
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Affiliation(s)
- Zoe Kane
- Quotient Sciences, Mere Way, Ruddington, Nottingham, United Kingdom; Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Roberto Picetti
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alison Wilby
- Quotient Sciences, Mere Way, Ruddington, Nottingham, United Kingdom
| | - Joseph F Standing
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Stanislas Grassin-Delyle
- 3 Hôpital Foch, Suresnes, and Université Paris-Saclay, UVSQ, INSERM, Infection et inflammation, Montigny le Bretonneux, France
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Haleema Shakur-Still
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, United Kingdom.
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Wong J, George RB, Hanley CM, Saliba C, Yee DA, Jerath A. Tranexamic acid: current use in obstetrics, major orthopedic, and trauma surgery. Can J Anaesth 2021; 68:894-917. [PMID: 33993459 DOI: 10.1007/s12630-021-01967-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE In this Continuing Professional Development module, we review the practical pharmacology of tranexamic acid and its clinical use in trauma, obstetrics, and major orthopedic surgery. PRINCIPAL FINDINGS Tranexamic acid is a synthetic drug that inhibits fibrinolysis. Multiple clinical trials in various clinical settings have shown that it can reduce blood loss, transfusion rates, and bleeding-associated mortality. In trauma and obstetrical bleeding, early tranexamic acid administration (< three hours) may have greater clinical benefits. Overall, tranexamic acid use appears safe with no significant increase of thromboembolic or seizure events. Nevertheless, current evidence has limitations related to wide heterogeneity in dose, route, and timing of drug administration, as well as generalizability of the large-scale trial findings to higher income nations. CONCLUSIONS Tranexamic acid is an efficacious and safe pharmacological-based blood conservation technique in the management of clinically significant hemorrhage. All anesthesiologists should have a good understanding of the pharmacotherapeutic properties and perioperative role of tranexamic acid therapy both inside and outside of the operating room. The use of tranexamic acid is likely to continue to rise with endorsement by various clinical guidelines and healthcare organizations. Further quantitative research is needed to evaluate optimal dosing and drug efficacy in these clinical scenarios.
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Affiliation(s)
- Jean Wong
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network and Women's College Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Ronald B George
- Department of Anesthesia and Perioperative Care, UCSF, San Francisco, CA, USA
| | - Ciara M Hanley
- Department of Anesthesia, Sunnybrook Health Science Centre, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Chadi Saliba
- Department of Anesthesia, Sunnybrook Health Science Centre, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Doreen A Yee
- Department of Anesthesia, Sunnybrook Health Science Centre, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Angela Jerath
- Department of Anesthesia, Sunnybrook Health Science Centre, Toronto, ON, Canada.
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Sunnybrook Research Institute, Sunnybrook Health Science Centre, Toronto, ON, Canada.
- Toronto General Hospital Research Institute, Toronto, ON, Canada.
- Institute of Clinical Evaluative Sciences, Toronto, ON, Canada.
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Abstract
BACKGROUND It is unclear whether high-dose regimens of tranexamic acid in cardiac surgery (total dose, 80 to 100 mg/kg) confer a clinical advantage over low-dose regimens (total dose, approximately 20 mg/kg), particularly as tranexamic acid-associated seizure may be dose-related. The authors' aim was to characterize the exposure-response relationship of this drug. METHODS Databases were searched for randomized controlled trials of intravenous tranexamic acid in adult patients undergoing cardiopulmonary bypass surgery. Observational studies were added for seizure assessment. Tranexamic acid concentrations were predicted in each arm of each study using a population pharmacokinetic model. The exposure-response relationship was evaluated by performing a model-based meta-analysis using nonlinear mixed-effect models. RESULTS Sixty-four randomized controlled trials and 18 observational studies (49,817 patients) were included. Seventy-three different regimens of tranexamic acid were identified, with the total dose administered ranging from 5.5 mg/kg to 20 g. The maximum effect of tranexamic acid for postoperative blood loss reduction was 40% (95% credible interval, 34 to 47%), and the EC50 was 5.6 mg/l (95% credible interval, 0.7 to 11 mg/l). Exposure values with low-dose regimens approached the 80% effective concentration, whereas with high-dose regimens, they exceeded the 90% effective concentration. The predicted cumulative blood loss up to 48 h postsurgery differed by 58 ml between the two regimens, and the absolute difference in erythrocyte transfusion rate was 2%. Compared to no tranexamic acid, low-dose and high-dose regimens increased the risk of seizure by 1.2-fold and 2-fold, respectively. However, the absolute risk increase was only clinically meaningful in the context of prolonged open-chamber surgery. CONCLUSIONS In cardiopulmonary bypass surgery, low-dose tranexamic acid seems to be an appropriate regimen for reducing bleeding outcomes. This meta-analysis has to be interpreted with caution because the results are observational and dependent on the lack of bias of the predicted tranexamic acid exposures and the quality of the included studies. EDITOR’S PERSPECTIVE
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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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10
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Analysis of serum tranexamic acid in patients undergoing open heart surgery. Clin Biochem 2020; 87:74-78. [PMID: 33188769 DOI: 10.1016/j.clinbiochem.2020.10.010] [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: 05/31/2020] [Revised: 10/07/2020] [Accepted: 10/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Tranexamic acid is a drug used during open cardiac surgery to prevent blood loss. The blood levels of 10-100 µg/mL are reported to be in the therapeutic range and higher levels are linked to increased incidence of adverse effects. The aim of this study was to optimize and validate an LC-MS/MS method for serum tranexamic acid and measure its levels in patients from the DEPOSITION Pilot trial in order to prove the concept that topical administration will yield lower serum concentration. METHODS The method development was carried out in several steps including sample preparation, and optimization of chromatography and tandem mass spectrometry parameters. Method validation including day-to-day precision with 4 QC levels, limit of detection, sample stability, carryover, and concentration-signal linearity was carried out. Ninety patient samples were analyzed using the validated method. RESULTS Fast and efficient LC-MS/MS method for analysis of tranexamic acid in serum was developed. The run time was 7 min with the total time of one hour including the sample preparation. The method precision was acceptable (%CV = 10.5-12.6%) with no sample carryover observed. The matrix effect on the analytical sensitivity was negligible and the lower limit of detection was 0.5 µg/mL. The difference in the mean adjusted concentrations between topical (45 patients) and intravenous (45 patients) groups was statistically significant (0.1154 µg/mL/kg vs. 0.2542 µg/mL/kg, p < 0.0001) CONCLUSIONS: Rapid and simple LC-MS/MS method for analysis of tranexamic acid was optimized and validated. The laboratory has played a crucial role in proving the concept that topical administration yields significantly lower systemic levels of tranexamic acid, and thus decreases the risk of adverse outcomes in patients undergoing open cardiac surgery.
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Besser V, Albert A, Sixt SU, Ackerstaff S, Roussel E, Ullrich S, Lichtenberg A, Hoffmann T. Fibrinolysis and the Influence of Tranexamic Acid Dosing in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:2664-2673. [DOI: 10.1053/j.jvca.2020.03.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/14/2020] [Accepted: 03/18/2020] [Indexed: 12/27/2022]
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Hypothesis for a partially non urinary elimination of tranexamic acid in haemorrhagic caesarean section: Traces pilot pharmacokinetic study: Pharmacokinetics of tranexamic acid in obstetrics. Eur J Pharm Sci 2020; 153:105486. [PMID: 32717429 DOI: 10.1016/j.ejps.2020.105486] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 07/19/2020] [Accepted: 07/20/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND In previous studies, the choice of doses of tranexamic acid was empirically defined as no pharmacokinetic study had been conducted in haemorrhagic caesarean section. OBJECTIVE The objective was to build a pharmacokinetic model in patients receiving a single 0.5, 1 or 2 g intravenous bolus. METHOD A preliminary monocentric open study was performed in the Lille centre. Blood samples and one urinary sample were collected in the 6 h following the injection. Nine patients were included. Tranexamic acid concentration was measured using liquid chromatography system coupled with tandem mass spectrometry. We used Monolix 2019R1 for population pharmacokinetic modelling. A structural model was constructed followed by the investigation of potential covariates. RESULTS Data were best described with a two-compartment model with a double first-order elimination from the central compartment. The model was improved when the variable ideal weight per dose was affected as a covariate for the apparent volume of distribution. Assuming a dose of 1 g and a height of 160 cm, the pharmacokinetic parameters were estimated at 10.26 L.h-1 for total clearance, 11.5 L for the volume of the central compartment, 15.8 L for the volume of the second compartment, a diffusional clearance of 30.36 L.h-1 , and a urinary excretion fraction of 25.8%. CONCLUSIONS The population pharmacokinetic model of tranexamic acid in haemorrhagic caesarean section was successfully established in our tiny sample of patients. The results of this preliminary TRACES pharmacokinetic study suggested that elimination of tranexamic acid is partially non urinary in contrast with healthy patients.
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Aggarwal NK, Subramanian A. Antifibrinolytics and cardiac surgery: The past, the present, and the future. Ann Card Anaesth 2020; 23:193-199. [PMID: 32275035 PMCID: PMC7336973 DOI: 10.4103/aca.aca_205_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/05/2019] [Accepted: 03/09/2019] [Indexed: 12/02/2022] Open
Abstract
Cardiac surgery is usually associated with significant blood loss, which often necessitates blood transfusion. In order to decrease the risks associated with the latter, pharmacological as well as nonpharmacological strategies have been used to reduce blood loss. Among the pharmacological approaches, antifibrinolytic drugs are the mainstay. Aprotinin, which was the first ubiquitously used drug, fell into disrepute only to re-emerge after much debate. The decline of aprotinin paved the way for the lysine analogs. However, we must be aware with the side effects of these drugs as well as the dose modification required in special situations. Nonsaccharide glycosaminoglycans have been under investigation to overcome the drawbacks of the lysine analogs. It remains to be seen whether these drugs can replace the traditional antifibrinolytics.
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Affiliation(s)
- Naresh K Aggarwal
- Department of Cardiac Anesthesia, Manipal Hospitals, New Delhi, India
| | - Arun Subramanian
- Department of Cardiac Anesthesia, Manipal Hospitals, New Delhi, India
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Abstract
Hemorrhage is the leading cause of preventable death in combat trauma and the secondary cause of death in civilian trauma. A significant number of deaths due to hemorrhage occur before and in the first hour after hospital arrival. A literature search was performed through PubMed, Scopus, and Institute of Scientific Information databases for English language articles using terms relating to hemostatic agents, prehospital, battlefield or combat dressings, and prehospital hemostatic resuscitation, followed by cross-reference searching. Abstracts were screened to determine relevance and whether appropriate further review of the original articles was warranted. Based on these findings, this paper provides a review of a variety of hemostatic agents ranging from clinically approved products for human use to newly developed concepts with great potential for use in prehospital settings. These hemostatic agents can be administered either systemically or locally to stop bleeding through different mechanisms of action. Comparisons of current hemostatic products and further directions for prehospital hemorrhage control are also discussed.
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Affiliation(s)
- Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, 1133 Sheppard Avenue West, Toronto, ON, M3K 2C9, Canada.
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Taam J, Yang QJ, Pang KS, Karanicolas P, Choi S, Wasowicz M, Jerath A. Current Evidence and Future Directions of Tranexamic Acid Use, Efficacy, and Dosing for Major Surgical Procedures. J Cardiothorac Vasc Anesth 2020; 34:782-790. [DOI: 10.1053/j.jvca.2019.06.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/21/2019] [Accepted: 06/27/2019] [Indexed: 12/26/2022]
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Phillips JM, van den Anker JN, Ahmadzia HK. Next Generation Medical Management of Postpartum Hemorrhage. Curr Pharm Des 2020; 25:549-555. [PMID: 30894102 DOI: 10.2174/1381612825666190320155337] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/18/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Postpartum hemorrhage remains a significant contributor to morbidity and mortality of women of childbearing age worldwide. Trends in both incidence and severity of postpartum hemorrhage are increasing which makes it imperative to identify drugs that could target prevention and/or treatment of these postpartum hemorrhages for women living in high, middle and low-income countries. METHODS We have reviewed current advances in the medical management of postpartum hemorrhage focusing on non-uterotonic therapy. We specifically describe the use and mechanism of action of tranexamic acid (TXA) and fibrinogen concentrate. Furthermore, we address the existing data for using these medications in postpartum hemorrhage, highlighting both strengths and limitations. RESULTS This review describes a new generation of medications that are promising for the prevention and/or treatment of postpartum hemorrhage. For patients at risk for significant hemorrhage, TXA has been shown to reduce intraoperative blood loss and can be given as a prophylactic agent. For the treatment of postpartum hemorrhage, early use of TXA has the potential to reduce mortality. In addition, some data exists supporting the use of fibrinogen concentrate, though more studies are required to help formulate guidelines for its use. CONCLUSION A promising new approach for the management of severe postpartum hemorrhage is using medications that alter coagulation. More data are needed to describe ideal patient populations, dosing, the time of administration, and infusion rate.
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Affiliation(s)
- Jaclyn M Phillips
- The George Washington University, School of Medicine and Health Sciences, Washington, DC, United States
| | - John N van den Anker
- The George Washington University, School of Medicine and Health Sciences, Washington, DC, United States.,Children's National Medical Center, Washington, DC, United States
| | - Homa K Ahmadzia
- The George Washington University, School of Medicine and Health Sciences, Washington, DC, United States
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Guo J, Gao X, Ma Y, Lv H, Hu W, Zhang S, Ji H, Wang G, Shi J. Different dose regimes and administration methods of tranexamic acid in cardiac surgery: a meta-analysis of randomized trials. BMC Anesthesiol 2019; 19:129. [PMID: 31307381 PMCID: PMC6631782 DOI: 10.1186/s12871-019-0772-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 05/28/2019] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The efficacy of tranexamic acid (TXA) to reduce perioperative blood loss and allogeneic blood transfusion in cardiac surgeries has been proved in previous studies, but its adverse effects especially seizure has always been a problem of concern. This meta-analysis aims to provide information on the optimal dosage and delivery method which is effective with the least adverse outcomes. METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE for all relevant articles published before 2018/12/31. Inclusion criteria were adult patients undergoing elective heart surgeries, and only randomized control trials comparing TXA with placebo were considered. Two authors independently assessed trial quality and extracted relevant data. RESULTS We included 49 studies with 10,591 patients into analysis. TXA significantly reduced transfusion rate (RR 0.71, 95% CI 0.65 to 0.78, P<0.00001). The overall transfusion rate was 35%(1573/4477) for patients using TXA and 49%(2190/4408) for patients in the control group. Peri-operative blood loss (MD - 246.98 ml, 95% CI - 287.89 to - 206.06 ml, P<0.00001) and re-operation rate (RR 0.62, 95% CI 0.49 to 0.79, P<0.0001) were also reduced significantly. TXA usage did not increase risk of mortality, myocardial infarction, stroke, pulmonary embolism and renal dysfunction, but was associated with a significantly increase in seizure attack (RR 3.21, 95% CI 1.04 to 9.90, P = 0.04).The overall rate of seizure attack was 0.62%(21/3378) for patients using TXA and 0.15%(5/3406) for patients in the control group. In subgroup analysis, TXA was effective for both on-pump and off-pump surgeries. Topical application didn't reduce the need for transfusion requirement, while intravenous delivery no matter as bolus injection alone or bolus plus continuous infusion were effective. Intravenous high-dose TXA didn't further decrease transfusion rate compared with low-dose regimen, and increased the risk of seizure by 4.83 times. No patients in the low-dose group had seizure attack. CONCLUSIONS TXA was effective in reducing transfusion requirement in all kinds of cardiac surgeries. Low-dose intravenous infusion was the most preferable delivery method which was as effective as high-dose regimen in reducing transfusion rate without increasing the risk of seizure.
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Affiliation(s)
- Jingfei Guo
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Xurong Gao
- Department of Blood Transfusion, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Yan Ma
- Operating room, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Huran Lv
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Wenjun Hu
- Department of Anesthesiology, The 305th Hospital of the Chinese People’s Liberation Army, No.13 Wenjin Road, Xicheng district, Beijing, China
| | - Shijie Zhang
- Department of Anesthesiology, Wu’an First People’s Hospital, Kuangjian Road, Handan, Hebei Province China
| | - Hongwen Ji
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Guyan Wang
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Jia Shi
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
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Grassin‐Delyle S, Semeraro M, Foissac F, Bouazza N, Shakur‐Still H, Roberts I, Treluyer J, Urien S. Tranexamic acid through intravenous, intramuscular and oral routes: an individual participant data meta‐analysis of pharmacokinetic studies in healthy volunteers. Fundam Clin Pharmacol 2019; 33:670-678. [DOI: 10.1111/fcp.12474] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/09/2019] [Accepted: 04/18/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Stanislas Grassin‐Delyle
- Centre d'Investigation Clinique P1419 INSERM Hôpital Cochin‐Necker Université Paris Descartes Sorbonne‐Paris Cité Paris Bâtiment Imagine, 149 rue de Sèvres, 75 743 Paris cedex 15 France
| | - Michaela Semeraro
- Centre d'Investigation Clinique P1419 INSERM Hôpital Cochin‐Necker Université Paris Descartes Sorbonne‐Paris Cité Paris Bâtiment Imagine, 149 rue de Sèvres, 75 743 Paris cedex 15 France
| | - Frantz Foissac
- Unité de Recherche Clinique INSERM Hôpital Cochin‐Necker Université Paris Descartes Sorbonne‐Paris Cité Paris Hôpital Tarnier, 89 rue d'Assas 75006 Paris France
| | - Naim Bouazza
- Unité de Recherche Clinique INSERM Hôpital Cochin‐Necker Université Paris Descartes Sorbonne‐Paris Cité Paris Hôpital Tarnier, 89 rue d'Assas 75006 Paris France
| | - Haleema Shakur‐Still
- Clinical Trials Unit London School of Hygiene and Tropical Medicine Keppel Street London WC1E 7HT UK
| | - Ian Roberts
- Clinical Trials Unit London School of Hygiene and Tropical Medicine Keppel Street London WC1E 7HT UK
| | - Jean‐Marc Treluyer
- Centre d'Investigation Clinique P1419 INSERM Hôpital Cochin‐Necker Université Paris Descartes Sorbonne‐Paris Cité Paris Bâtiment Imagine, 149 rue de Sèvres, 75 743 Paris cedex 15 France
- Unité de Recherche Clinique INSERM Hôpital Cochin‐Necker Université Paris Descartes Sorbonne‐Paris Cité Paris Hôpital Tarnier, 89 rue d'Assas 75006 Paris France
| | - Saïk Urien
- Unité de Recherche Clinique INSERM Hôpital Cochin‐Necker Université Paris Descartes Sorbonne‐Paris Cité Paris Hôpital Tarnier, 89 rue d'Assas 75006 Paris France
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Jerath A, Yang QJ, Pang KS, Looby N, Reyes-Garces N, Vasiljevic T, Bojko B, Pawliszyn J, Wijeysundera D, Beattie WS, Yau TM, Wąsowicz M. Tranexamic Acid Dosing for Cardiac Surgical Patients With Chronic Renal Dysfunction. Anesth Analg 2018; 127:1323-1332. [DOI: 10.1213/ane.0000000000002724] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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20
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Li ZJ, Zhao MW, Zeng L. Additional Dose of Intravenous Tranexamic Acid after Primary Total Knee Arthroplasty Further Reduces Hidden Blood Loss. Chin Med J (Engl) 2018. [PMID: 29521284 PMCID: PMC5865307 DOI: 10.4103/0366-6999.226884] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Total knee arthroplasty (TKA) is the most frequently performed procedure in treating advanced knee osteoarthritis. Excessive perioperative blood loss can sometimes lead to postoperative anemia. Tranexamic acid (TXA) is a potent fibrinolysis inhibitor which has been extensively used at the surgical incision and closure to lower overall blood loss in adult reconstruction surgery. Our previous study suggested that about two-thirds of the total blood loss (TBL) came from hidden blood loss (HBL) on postoperative days 1 and 2. The role of reducing HBL with TXA administration in postoperative TKA patients is unknown. The current study was designed to evaluate the efficiency and safety of supplemental intravenous (IV) TXA in further reducing HBL after primary TKA. Methods A prospective pilot study was conducted at a single institution on 43 consecutive patients who underwent unilateral TKA from September 2014 to February 2015. All patients were given 1 g of IV TXA 10-15 min before operation and another 1 g of IV TXA at the time of wound closure on the day of surgery. On postoperative days 1 and 2, the supplemental group (n = 21) was given additional 1 g of TXA intravenously twice a day, whereas the control group (n = 22) received an equal volume of saline. Drain output, hemoglobin (Hb), and hematocrit (HCT) were recorded preoperatively and 5 consecutive days postoperatively in both groups. HBL was calculated with the Gross formula. Pre- and post-operative lower extremity Doppler venous ultrasound was performed in all patients to detect deep vein thrombosis (DVT). The indexes were compared using the Mann-Whitney test, whereas the results of Hb and HCT were analyzed by repeated-measures analysis of variance. The difference was considered statistically significant if P < 0.05. Results The demographics and surgical characteristics of the two groups were comparable. Supplemental group had higher Hb level on postoperative days 1-5 compared to the control; however, the difference was not significant (F = 2.732, P = 0.106). The HCT of the supplemental group was significantly higher than that of the control group on postoperative day 5 (F = 5.254, P = 0.027). No significant difference was found in drainage volume and TBL, but the HBL was reduced in the supplemental group (supplemental 133.1 [71.8, 287.3] ml and control 296.0 [185.3, 421.4] ml, Z = 2.478, P = 0.013, median [interquartile range]). There was one DVT in the control group and none in the supplemental group. All patients were followed at 1 year after surgery, and no further complications were reported. Conclusion Based on the current study, additional doses of IV TXA could potentially further reduce HBL after primary TKA without increasing the risk of venous thromboembolism.
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Affiliation(s)
- Zi-Jian Li
- Department of Orthopaedics, Peking University Third Hospital, Beijing 100191, China
| | - Min-Wei Zhao
- Department of Orthopaedics, Peking University Third Hospital, Beijing 100191, China
| | - Lin Zeng
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing 100191, China
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Levy JH, Koster A, Quinones QJ, Milling TJ, Key NS. Antifibrinolytic Therapy and Perioperative Considerations. Anesthesiology 2018; 128:657-670. [PMID: 29200009 PMCID: PMC5811331 DOI: 10.1097/aln.0000000000001997] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Fibrinolysis is a physiologic component of hemostasis that functions to limit clot formation. However, after trauma or surgery, excessive fibrinolysis may contribute to coagulopathy, bleeding, and inflammatory responses. Antifibrinolytic agents are increasingly used to reduce bleeding, allogeneic blood administration, and adverse clinical outcomes. Tranexamic acid is the agent most extensively studied and used in most countries. This review will explore the role of fibrinolysis as a pathologic mechanism, review the different pharmacologic agents used to inhibit fibrinolysis, and focus on the role of tranexamic acid as a therapeutic agent to reduce bleeding in patients after surgery and trauma.
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Affiliation(s)
- Jerrold H. Levy
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Andreas Koster
- Institute of Anesthesiology, Heart and Diabetes Center NRW, Bad Oeynhausen, Ruhr-University Bochum, Germany
| | - Quintin J. Quinones
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | | | - Nigel S. Key
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina, Chapel Hill, NC
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Zhu J, Zhu Y, Lei P, Zeng M, Su W, Hu Y. Efficacy and safety of tranexamic acid in total hip replacement: A PRISMA-compliant meta-analysis of 25 randomized controlled trials. Medicine (Baltimore) 2017; 96:e9552. [PMID: 29384974 PMCID: PMC6393088 DOI: 10.1097/md.0000000000009552] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hip osteoarthritis is one of the most prevalent musculoskeletal degenerative diseases in elderly. Total hip arthroplasty (THA) is the most effective surgical treatment for end stage hip osteoarthritis. Tranexamic acid (TA) is a potent drug to reduce surgical blood loss in surgery, therefore, as a potential drug for application in THA. OBJECTIVES To identify the combined efficacy of TA administration in THA. A meta-analysis including 25 randomized controlled trials was conducted for generating synthesized effects. METHODS This meta-analysis followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines for reporting systematic reviews and meta-analysis. A total of 25 Randomized controlled trials (RCTs) were included for meta-analysis. RESULTS The pooled results illustrated that total blood loss, intraoperative blood loss, postoperative blood loss, hemoglobin drop, transfusion rate, and average hospital stay were significantly lower than controls (standardized mean difference or odds ratio (OR) (95%CI): -0.87, (-1.13,-0.61), -0.68, (-0.96,-0.39), -1.41, (-2.24,-0.59), -1.11, (-1.63,-0.58), 0.28, (0.20,-0.38), -0.17, (-0.49,0.14), P < .05, respectively). Moreover, TA acts efficiently without increasing risk of thromboembolic events with OR = 1.14, 95%CI = 0.50-2.62, P = .75. Subgroup analysis indicated no statistically significant differences between a higher dose of topical TA (≥2 g or 15 mg/kg) or a lower dose (<2 g or 15 mg/kg). CONCLUSION The findings indicated that TA is clinically effective and safe in patients receiving total hip arthroplasty.
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Gerstein NS, Brierley JK, Windsor J, Panikkath PV, Ram H, Gelfenbeyn KM, Jinkins LJ, Nguyen LC, Gerstein WH. Antifibrinolytic Agents in Cardiac and Noncardiac Surgery: A Comprehensive Overview and Update. J Cardiothorac Vasc Anesth 2017; 31:2183-2205. [DOI: 10.1053/j.jvca.2017.02.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Indexed: 12/19/2022]
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Spence J, Long S, Tidy A, Raymer K, Devereaux PJ, Lamy A, Whitlock R, Syed S. Tranexamic Acid Administration During On-Pump Cardiac Surgery. Anesth Analg 2017; 125:1863-1870. [DOI: 10.1213/ane.0000000000002422] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Couture P, Lebon JS, Laliberté É, Desjardins G, Chamberland MÈ, Ayoub C, Rochon A, Cogan J, Denault A, Deschamps A. Low-Dose Versus High-Dose Tranexamic Acid Reduces the Risk of Nonischemic Seizures After Cardiac Surgery With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2017; 31:1611-1617. [DOI: 10.1053/j.jvca.2017.04.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Indexed: 11/11/2022]
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Jansen JA, Lameijer JRC, Snoeker BAM. Combined intravenous, topical and oral tranexamic acid administration in total knee replacement: Evaluation of safety in patients with previous thromboembolism and effect on hemoglobin level and transfusion rate. Knee 2017; 24:1206-1212. [PMID: 28765007 DOI: 10.1016/j.knee.2017.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 06/02/2017] [Accepted: 07/05/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aims of this study were to investigate the safety of combined intravenous, oral and topical tranexamic acid (TXA) in primary total knee replacement. We assessed dose-related efficacy on hemoglobin level, transfusion, length of stay and thromboembolic complications. In addition, TXA safety in patients with previous history of thromboembolism >12months ago was monitored specifically. METHODS From January 2013 until January 2016, 922 patients were included who received TXA after primary total knee replacement. Patients without TXA administration or with thromboembolic events <12months ago were excluded. TXA dosage groups were divided into ≤10mg/kg, >10-25mg/kg and >25-50mg/kg. RESULTS Between the three TXA groups no significant difference was found in thromboembolic complications (deep venous thrombosis (DVT) and pulmonary embolism (PE)), wound leakage and transfusion rate. For patients with DVT or PE in their history >12months ago specifically, no more complications were noted in higher-TXA-dosage groups compared to the low-dosage group. Length of stay was shorter in the highest-TXA-dosage group compared with lower-dosage groups (median two vs three days). With high TXA dose a smaller difference between pre- and postoperative Hb was found: the >25-50mg/kg TXA group had a 0.419mmol/l smaller decrease in postoperative hemoglobin compared to the lowest-dosage group (P<0.05). CONCLUSION Combined intravenous, oral and topical TXA is effective in knee replacement and can safely be given to patients with a thromboembolic history >12months ago. High dosage (>25-50mg/kg) TXA resulted in the smallest decrease in postoperative hemoglobin.
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Affiliation(s)
- Joris A Jansen
- Department of Orthopedics, Alrijne Hospital Leiden, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands.
| | - Joost R C Lameijer
- Department of Orthopedics, Alrijne Hospital Leiden, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
| | - Barbara A M Snoeker
- Department of Orthopedics, Alrijne Hospital Leiden, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
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Abstract
BACKGROUND The antifibrinolytic drug tranexamic acid is structurally similar to the amino acid glycine and may cause seizures and myoclonus by acting as a competitive antagonist of glycine receptors. Glycine is an obligatory co-agonist of the N-methyl-D-aspartate (NMDA) subtype of glutamate receptors. Thus, it is plausible that tranexamic acid inhibits NMDA receptors by acting as a competitive antagonist at the glycine binding site. The aim of this study was to determine whether tranexamic acid inhibits NMDA receptors, as well as α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid and kainate subtypes of ionotropic glutamate receptors. METHODS Tranexamic acid modulation of NMDA, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid, and kainate receptors was studied using whole cell voltage-clamp recordings of current from cultured mouse hippocampal neurons. RESULTS Tranexamic acid rapidly and reversibly inhibited NMDA receptors (half maximal inhibitory concentration = 241 ± 45 mM, mean ± SD; 95% CI, 200 to 281; n = 5) and shifted the glycine concentration-response curve for NMDA-evoked current to the right. Tranexamic acid also inhibited α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors (half maximal inhibitory concentration = 231 ± 91 mM; 95% CI, 148 to 314; n = 5 to 6) and kainate receptors (half maximal inhibitory concentration = 90 ± 24 mM; 95% CI, 68 to 112; n = 5). CONCLUSIONS Tranexamic acid inhibits NMDA receptors likely by reducing the binding of the co-agonist glycine and also inhibits α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid and kainate receptors. Receptor blockade occurs at high millimolar concentrations of tranexamic acid, similar to the concentrations that occur after topical application to peripheral tissues. Glutamate receptors in tissues including bone, heart, and nerves play various physiologic roles, and tranexamic acid inhibition of these receptors may contribute to adverse drug effects.
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Fabresse N, Fall F, Etting I, Devillier P, Alvarez JC, Grassin-Delyle S. LC–MS/MS determination of tranexamic acid in human plasma after phospholipid clean-up. J Pharm Biomed Anal 2017; 141:149-156. [DOI: 10.1016/j.jpba.2017.04.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/09/2017] [Accepted: 04/16/2017] [Indexed: 01/22/2023]
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Yang QJ, Kluger M, Goryński K, Pawliszyn J, Bojko B, Yu AM, Noh K, Selzner M, Jerath A, McCluskey S, Pang KS, Wąsowicz M. Comparing early liver graft function from heart beating and living-donors: A pilot study aiming to identify new biomarkers of liver injury. Biopharm Drug Dispos 2017; 38:326-339. [DOI: 10.1002/bdd.2066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/28/2016] [Accepted: 01/16/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Qi Joy Yang
- Leslie Dan Faculty of Pharmacy; University of Toronto; Canada
| | - Michael Kluger
- Department of Anesthesia and Pain Management, Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Krzysztof Goryński
- Department of Chemistry; University of Waterloo; Canada
- Department of Pharmacodynamics and Molecular Pharmacology, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz; Nicolaus Copernicus University in Toruń; Poland
| | | | - Barbara Bojko
- Department of Chemistry; University of Waterloo; Canada
- Department of Pharmacodynamics and Molecular Pharmacology, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz; Nicolaus Copernicus University in Toruń; Poland
| | - Ai-Ming Yu
- Departments of Biochemistry and Molecular Medicine; Comprehensive Cancer Center; UC Davis; Davis CA 95817 USA
| | - Keumhan Noh
- Leslie Dan Faculty of Pharmacy; University of Toronto; Canada
| | - Markus Selzner
- Department of Surgery, Toronto General Hospital; University Health Network; Toronto ON M5G 2N2 Canada
| | - Angela Jerath
- Department of Anesthesia and Pain Management, Toronto General Hospital; University Health Network; Toronto Ontario Canada
- Department of Anesthesia, Faculty of Medicine; University of Toronto; Toronto ON M5G 1E2 Canada
| | - Stuart McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital; University Health Network; Toronto Ontario Canada
- Department of Anesthesia, Faculty of Medicine; University of Toronto; Toronto ON M5G 1E2 Canada
| | - K. Sandy Pang
- Leslie Dan Faculty of Pharmacy; University of Toronto; Canada
| | - Marcin Wąsowicz
- Department of Anesthesia and Pain Management, Toronto General Hospital; University Health Network; Toronto Ontario Canada
- Department of Anesthesia, Faculty of Medicine; University of Toronto; Toronto ON M5G 1E2 Canada
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Gertler R, Gruber M, Grassin-Delyle S, Urien S, Martin K, Tassani-Prell P, Braun S, Burg S, Wiesner G. Pharmacokinetics of tranexamic acid in neonates and infants undergoing cardiac surgery. Br J Clin Pharmacol 2017; 83:1745-1757. [PMID: 28245519 DOI: 10.1111/bcp.13274] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/15/2017] [Accepted: 02/21/2017] [Indexed: 11/30/2022] Open
Abstract
AIM Tranexamic acid (TXA) continues to be one of the antifibrinolytics of choice during paediatric cardiac surgery. However, in infants less than 1 year of age, the optimal dosing based on pharmacokinetic (PK) considerations is still under discussion. METHODS Forty-three children less than 1 year of age were enrolled, of whom 37 required the use of cardiopulmonary bypass (CPB) and six were operated on without CPB. Administration of 50 mg kg-1 TXA intravenously at the induction of anaesthesia was followed by 50 mg kg-1 into the CPB prime in the CPB group. Plasma concentrations of TXA were analysed by gas chromatography-mass spectrometry. PK data were investigated using nonlinear mixed-effect models. RESULTS A two-compartment model was fitted, with the main covariates being allometrically scaled bodyweight, CPB, postmenstrual age (PMA). Intercompartmental clearance (Q), peripheral volume (V2), systemic clearance, (CL) and the central volume (V1) were calculated. Typical values of the PK parameter estimates were as follows: CL = 3.78 [95 % confidence interval (CI) 2.52, 5.05] l h-1 ; central volume of distribution = 13.6 (CI 11.7, 15.5) l; Q = 16.3 (CI 13.5, 19.2) l h-1 ; V2 = 18.0 (CI 16.1, 19.9) l. Independently of age, 10 mg kg-1 TXA as a bolus, a subsequent infusion of 10 mg kg-1 h-1 , then a 4 mg kg-1 bolus into the prime and a reduced infusion of 4 mg kg-1 h-1 after the start of CPB are required to maintain TXA concentrations continuously above 20 μg ml-1 , the threshold value for an effective inhibition of fibrinolysis and far lower than the usual peak concentrations (the '10-10-4-4 rule'). CONCLUSIONS The introduction of a modified dosing regimen using a starting bolus followed by an infusion and a CPB prime bolus would prohibit the potential risk of seizures caused by high peak concentrations and also maintain therapeutic plasma concentration above 20 μg ml-1 .
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Affiliation(s)
- Ralph Gertler
- Klinik für Anaesthesie, operative und allgemeine Intensivmedizin, Notfallmedizin, Klinikum Links der Weser, University Medical Center Hamburg-Eppendorf, Bremen, Germany.,Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Michael Gruber
- Department of Anesthesia, University Hospital Regensburg, Regensburg, Germany
| | - Stanislas Grassin-Delyle
- Département des Maladies des Voies Respiratoires, Hôpital Foch, Université Versailles Saint Quentin en Yvelines, Université Paris Saclay, F-92150, Suresnes, France.,Plateforme de spectrométrie de masse et INSERM UMR1173, UFR Sciences de la Santé Simone Veil, Université Versailles Saint Quentin en Yvelines, Université Paris Saclay, F-78180, Montigny-le-Bretonneux, France
| | - Saïk Urien
- CIC1419 Inserm Necker-Cochin, URC Paris Descartes Necker Cochin, AP-HP, Paris, France.,EAU7323, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Klaus Martin
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Peter Tassani-Prell
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Siegmund Braun
- Institute of Laboratory Medicine, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Simon Burg
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Gunther Wiesner
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
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Karanicolas PJ, Lin Y, Tarshis J, Law CHL, Coburn NG, Hallet J, Nascimento B, Pawliszyn J, McCluskey SA. Major liver resection, systemic fibrinolytic activity, and the impact of tranexamic acid. HPB (Oxford) 2016; 18:991-999. [PMID: 27765582 PMCID: PMC5144548 DOI: 10.1016/j.hpb.2016.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/19/2016] [Accepted: 06/21/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hyperfibrinolysis may occur due to systemic inflammation or hepatic injury that occurs during liver resection. Tranexamic acid (TXA) is an antifibrinolytic agent that decreases bleeding in various settings, but has not been well studied in patients undergoing liver resection. METHODS In this prospective, phase II trial, 18 patients undergoing major liver resection were sequentially assigned to one of three cohorts: (i) Control (no TXA); (ii) TXA Dose I - 1 g bolus followed by 1 g infusion over 8 h; (iii) TXA Dose II - 1 g bolus followed by 10 mg/kg/hr until the end of surgery. Serial blood samples were collected for thromboelastography (TEG), coagulation components and TXA concentration. RESULTS No abnormalities in hemostatic function were identified on TEG. PAP complex levels increased to peak at 1106 μg/L (normal 0-512 μg/L) following parenchymal transection, then decreased to baseline by the morning following surgery. TXA reached stable, therapeutic concentrations early in both dosing regimens. There were no differences between patients based on TXA. CONCLUSIONS There is no thromboelastographic evidence of hyperfibrinolysis in patients undergoing major liver resection. TXA does not influence the change in systemic fibrinolysis; it may reduce bleeding through a different mechanism of action. Registered with ClinicalTrials.gov: NCT01651182.
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Affiliation(s)
- Paul J Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Yulia Lin
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Calvin H L Law
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Natalie G Coburn
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Julie Hallet
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Barto Nascimento
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Janusz Pawliszyn
- Department of Chemistry, University of Waterloo, Waterloo, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
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Lecker I, Wang DS, Whissell PD, Avramescu S, Mazer CD, Orser BA. Tranexamic acid-associated seizures: Causes and treatment. Ann Neurol 2015; 79:18-26. [PMID: 26580862 PMCID: PMC4738442 DOI: 10.1002/ana.24558] [Citation(s) in RCA: 161] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 11/03/2015] [Accepted: 11/10/2015] [Indexed: 11/16/2022]
Abstract
Antifibrinolytic drugs are routinely used worldwide to reduce the bleeding that results from a wide range of hemorrhagic conditions. The most commonly used antifibrinolytic drug, tranexamic acid, is associated with an increased incidence of postoperative seizures. The reported increase in the frequency of seizures is alarming, as these events are associated with adverse neurological outcomes, longer hospital stays, and increased in‐hospital mortality. However, many clinicians are unaware that tranexamic acid causes seizures. The goal of this review is to summarize the incidence, risk factors, and clinical features of these seizures. This review also highlights several clinical and preclinical studies that offer mechanistic insights into the potential causes of and treatments for tranexamic acid–associated seizures. This review will aid the medical community by increasing awareness about tranexamic acid–associated seizures and by translating scientific findings into therapeutic interventions for patients. ANN NEUROL 2016;79:18–26
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Affiliation(s)
- Irene Lecker
- Departments of Physiology, University of Toronto
| | | | | | - Sinziana Avramescu
- Anesthesia, University of Toronto.,Department of Anesthesia, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St Michael's Hospital
| | - C David Mazer
- Departments of Physiology, University of Toronto.,Anesthesia, University of Toronto.,Department of Anesthesia, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St Michael's Hospital
| | - Beverley A Orser
- Departments of Physiology, University of Toronto.,Anesthesia, University of Toronto.,Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Effective tranexamic acid concentration for 95% inhibition of tissue-type plasminogen activator induced hyperfibrinolysis in children with congenital heart disease. Eur J Anaesthesiol 2015; 32:844-50. [DOI: 10.1097/eja.0000000000000316] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Na HS, Shin HJ, Lee YJ, Kim JH, Koo KH, Do SH. The effect of tranexamic acid on blood coagulation in total hip replacement arthroplasty: rotational thromboelastographic (ROTEM®) analysis. Anaesthesia 2015; 71:67-75. [PMID: 26559015 DOI: 10.1111/anae.13270] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2015] [Indexed: 11/30/2022]
Abstract
We evaluated changes in rotational thromboelastometry (ROTEM(®) ) parameters and clinical outcomes in patients undergoing total hip replacement arthroplasty, with concomitant infusions of tranexamic acid and of 6% hydroxyethyl starch 130/0.4. Fifty-five patients were randomly assigned to either the tranexamic acid (n = 29) or the control (n = 26) group. Hydroxyethyl starch was administered in the range of 10-15 ml.kg(-1) during the operation in both groups. In the control group, the clot formation time and maximum clot firmness of APTEM showed significant differences when compared with those of EXTEM at one hour postoperatively, suggestive of fibrinolysis. In the tranexamic acid group, there was no significant difference between each postoperative EXTEM and APTEM parameter. In the tranexamic acid and control group, postoperative blood loss was 308 ml (210-420 [106-745]) and 488 ml (375-620 [170-910], p = 0.002), respectively, and total blood loss was 1168 ml (922-1470 [663-2107]) and 1563 ml (1276-1708 [887-1494], p = 0.003). Haemoglobin concentration was higher in the tranexamic acid group on the second postoperative day (10.5 (9.4-12.1 [7.9-14.0]) vs. 9.6 (8.9-10.5[7.3-16.0]) g.dl(-1) , p = 0.027). In patients undergoing total hip replacement arthroplasty, postoperative fibrinolysis aggravated by hydroxyethyl starch was attenuated by co-administration of 10 mg.kg(-1) tranexamic acid, which may have led to less postoperative blood loss.
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Affiliation(s)
- H S Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - H J Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - Y J Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - J H Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - K H Koo
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - S H Do
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
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Peña JJ, Llagunes J, Carmona P, Mateo E, De andres J. Ácido tranexámico en cirugía cardiaca. ¿Qué dosis es segura? CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2014.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Nadeau RP, Howard JL, Naudie DDR. Antifibrinolytic Therapy for Perioperative Blood Conservation in Lower-Extremity Primary Total Joint Arthroplasty. JBJS Rev 2015; 3:01874474-201506000-00001. [PMID: 27490016 DOI: 10.2106/jbjs.rvw.n.00068] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Richard P Nadeau
- Department of Surgery, Division of Orthopaedics, Schulich School of Medicine, Western University, London Health Sciences Center, University Hospital, 339 Windermere Road, London, Ontario, Canada, N6A 5A5
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Hodgson S, Larvin JT, Dearman C. What dose of tranexamic acid is most effective and safe for adult patients undergoing cardiac surgery?: Table 1:. Interact Cardiovasc Thorac Surg 2015; 21:384-8. [DOI: 10.1093/icvts/ivv134] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 05/05/2015] [Indexed: 11/12/2022] Open
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Yang QJ, Jerath A, Bies RR, Wąsowicz M, Pang KS. Pharmacokinetic modeling of tranexamic acid for patients undergoing cardiac surgery with normal renal function and model simulations for patients with renal impairment. Biopharm Drug Dispos 2015; 36:294-307. [DOI: 10.1002/bdd.1941] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 12/02/2014] [Accepted: 02/08/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Qi Joy Yang
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy; University of Toronto; 144 College Street Toronto Ontario Canada M5S 3M2
| | - Angela Jerath
- Department of Anesthesia and Pain Management, Toronto General Hospital; University Health Network; Toronto Ontario Canada M5G 2C4
| | - Robert R. Bies
- Division of Clinical Pharmacology, Department of Medicine; Indiana University School of Medicine, Indiana Clinical and Translational Sciences Institute; Indianapolis IN 46202 USA
- Centre for Addiction and Mental Health; Program in Geriatric Psychopharmacology; Toronto Ontario Canada
| | - Marcin Wąsowicz
- Department of Anesthesia and Pain Management, Toronto General Hospital; University Health Network; Toronto Ontario Canada M5G 2C4
| | - K. Sandy Pang
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy; University of Toronto; 144 College Street Toronto Ontario Canada M5S 3M2
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Effect of two doses of tranexamic acid on fibrinolysis evaluated by thromboelastography during cardiac surgery: a randomised, controlled study. Eur J Anaesthesiol 2015; 31:491-8. [PMID: 24557022 DOI: 10.1097/eja.0000000000000051] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tranexamic acid is used to decrease bleeding and transfusions during cardiac surgery. However, dosing based on pharmacokinetic data to optimally inhibit fibrinolysis is unknown. With increasing concerns regarding seizures associated with higher doses, lower dosing schemes may be important. OBJECTIVE To determine the effect of two dosing schemes compared with placebo on fibrinolysis and clinical outcomes. DESIGN A double-blind, randomised, controlled, pilot trial. SETTING Single tertiary centre. PATIENTS Cardiac surgery patients requiring cardiopulmonary bypass. INTERVENTION Patients were randomised to receive a 30 mg kg(-1) bolus and continuous infusion of 16 mg kg (-1) h(-1) (Group HIGH), a 5 mg kg(-1) bolus followed by 5 mg kg(-1) h(-1) (Group LOW) or Sodium chloride (Placebo). MAIN OUTCOME MEASURE Fibrinolysis was evaluated by thromboelastography and D-dimers. Secondary endpoints were blood loss, transfusion requirement and side effects. RESULTS Thirty-three patients were included. Significant fibrinolysis was defined by LY30 more than 7.5% based on thromboelastography and was not observed after cardiopulmonary bypass in any groups. After protamine administration, LY30 differences between groups were 0.7 [95% confidence interval (95% CI) -0.04 to 1.4] between Groups HIGH and Placebo, -0.08 (95% CI -0.82 to 0.66) between Groups HIGH and LOW, and 0.78 (95% CI 0.02 to 1.5) between Groups LOW and Placebo. A significant increase in D-dimers was observed in the Group Placebo compared with the two treatment groups. There were no differences in bleeding or transfusion requirement. CONCLUSION In this dose-finding study, there were no differences in fibrinolysis or clinical outcomes among the two tranexamic acid schemes and placebo. Any difference in fibrinolytic inhibition requires a larger adequately powered study. TRIAL REGISTRATION EudraCT number: 2010-024104-99.
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40
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Birjandi AP, Mirnaghi FS, Bojko B, Wąsowicz M, Pawliszyn J. Application of Solid Phase Microextraction for Quantitation of Polyunsaturated Fatty Acids in Biological Fluids. Anal Chem 2014; 86:12022-9. [PMID: 25403310 DOI: 10.1021/ac502627w] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Afsoon Pajand Birjandi
- Department
of Chemistry, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L3G1, Canada
| | - Fatemeh Sadat Mirnaghi
- Department
of Chemistry, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L3G1, Canada
| | - Barbara Bojko
- Department
of Chemistry, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L3G1, Canada
| | - Marcin Wąsowicz
- Department
of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario M5G 2C4, Canada
| | - Janusz Pawliszyn
- Department
of Chemistry, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L3G1, Canada
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Tengborn L, Blombäck M, Berntorp E. Tranexamic acid--an old drug still going strong and making a revival. Thromb Res 2014; 135:231-42. [PMID: 25559460 DOI: 10.1016/j.thromres.2014.11.012] [Citation(s) in RCA: 185] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 11/10/2014] [Accepted: 11/12/2014] [Indexed: 12/22/2022]
Abstract
Experience with tranexamic acid, an indirect fibrinolytic inhibitor, started as soon as it was released from Shosuke Okamoto's lab in the early 1960s. It was first prescribed to females with heavy menstrual blood loss and to patients with hereditary bleeding disorders. Soon the indications were widened to elective surgery because of its blood saving effects. Contraindications are few, most important is ongoing venous or arterial thrombosis and allergy to tranexamic acid, and the doses has to be reduced in renal insufficiency. In randomized controlled trials, however, patients with other risk factors are excluded as well (patients with history of cardiovascular disease, thromboembolism, bleeding diathesis, renal failure with creatinine >250μmol/L, pregnancy, and patients on treatment with anticoagulants). Recent meta-analyses of several randomized controlled trials in orthopedic arthroplasty have shown that tranexamic acid reduces peri- and postoperative blood loss, blood transfusion requirements and reoperations caused by bleedings. In general, the preoperative dose was 10-15mg/kg i.v. (or 1g), followed or not, by one or two doses, some as continuous infusion i.v. To validate relationship between dose and effect more data are needed. No evidence was found of increased thromboembolic accidents or other adverse events in the patients on tranexamic acid compared to the control groups. In major cardiac surgery tranexamic acid has been used in a large number of controlled trials with various dosing schemes in which the highest dosages seem to be associated with neurotoxicity; therefore a maximum total dose of 100mg/kg especially in patients over 50years of age is recommended by ISMICS (International Society for Minimally Invasive Cardiothoracic Surgery). Other indications for tranexamic acid are reviewed here as well. In recent years the extensive trial in severe trauma with massive bleedings using tranexamic acid was presented, CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage) comprising more than 20,000 patients. It showed that the survival was increased when tranexamic acid was given early after the accident compared to placebo; further studies are taking place is this field to get more information. Of utmost importance is the ongoing WOMAN (World Maternal Antifibrinolytic) a randomized, double-blind, placebo controlled trial among 15,000 with clinical diagnosis of postpartum haemorrhage bearing in mind that each year a large number of women in low and middle income countries, die from causes related to childbirth. In summary, we consider tranexamic acid is a drug of great value to reduce almost any kind of bleeding, it is cheap and convenient to use and has principally few contraindications. It may be added, that tranexamic acid is included in the WHOs list of essential medicines.
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Affiliation(s)
- Lilian Tengborn
- Lund University, Clinical Coagulation Research Unit, Skåne University Hospital, SE-205 02 Malmö, Sweden
| | - Margareta Blombäck
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Blood Coagulation, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Erik Berntorp
- Lund University, Clinical Coagulation Research Unit, Skåne University Hospital, SE-205 02 Malmö, Sweden.
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Du Y, Xu J, Wang G, Shi J, Yang L, Shi S, Lu H, Wang Y, Ji B, Zheng Z. Comparison of two tranexamic acid dose regimens in patients undergoing cardiac valve surgery. J Cardiothorac Vasc Anesth 2014; 28:1233-7. [PMID: 24447498 DOI: 10.1053/j.jvca.2013.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Tranexamic acid (TA), a synthetic antifibrinolytic drug, has been shown to reduce postoperative bleeding and the need for allogeneic blood transfusion in cardiac surgery. However, the optimal dose regimen of TA is still under debate. The aim of this study was to evaluate whether a lower-dose TA regimen produced equivalent efficacy to its higher-dose counterpart in reducing postoperative bleeding and transfusion needs. DESIGN A prospective, randomized, double-blind trial. SETTING National Center for Cardiovascular Diseases & University Hospital, Beijing, People's Republic of China. PARTICIPANTS One hundred seventy-five patients undergoing cardiac valve surgery were enrolled in the study. INTERVENTIONS All patients were divided randomly into 2 groups. The lower-dose TA group received a loading dose of 10 mg/kg, maintenance dose of 2 mg/kg/h, and a cardiopulmonary bypass pump prime dose of 40 mg; the higher-dose TA group received a loading dose of 30 mg/kg, maintenance dose of 16 mg/kg/h, and a pump prime dose of 2 mg/kg. MEASUREMENTS AND MAIN RESULTS The amount of postoperative bleeding, the amount and frequency of allogeneic transfusion, mortality, and morbidities were recorded. There was no significant difference in the volume of 24-hour postoperative bleeding between the lower-dose group and the higher-dose group. Other measurements also showed no statistical difference between the 2 groups, including the amount and frequency of allogeneic transfusion, mortality, and morbidities. CONCLUSION Lower-dose TA regimen was as effective as the higher-dose regimen in reducing postoperative bleeding and transfusion needs in patients undergoing cardiac valve surgery.
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Affiliation(s)
- Yingjie Du
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jiaying Xu
- Department of Anesthesiology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Guyan Wang
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
| | - Jia Shi
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Lijing Yang
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Sheng Shi
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Haisong Lu
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yuefu Wang
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhe Zheng
- Department of Cardiac Surgery, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Nunes de Paiva MJ, Menezes HC, de Lourdes Cardeal Z. Sampling and analysis of metabolomes in biological fluids. Analyst 2014; 139:3683-94. [DOI: 10.1039/c4an00583j] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Metabolome analysis involves the study of small molecules that are involved in the metabolic responses that occur through patho-physiological changes caused by genetic stimuli or chemical agents.
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Affiliation(s)
- Maria José Nunes de Paiva
- Departamento de Química
- ICEx
- Universidade Federal de Minas Gerais
- 6627-31270901 Belo Horizonte, Brazil
- Universidade Federal de São João Del Rei
| | - Helvécio Costa Menezes
- Departamento de Química
- ICEx
- Universidade Federal de Minas Gerais
- 6627-31270901 Belo Horizonte, Brazil
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Grassin-Delyle S, Tremey B, Abe E, Fischler M, Alvarez J, Devillier P, Urien S. Population pharmacokinetics of tranexamic acid in adults undergoing cardiac surgery with cardiopulmonary bypass. Br J Anaesth 2013; 111:916-24. [DOI: 10.1093/bja/aet255] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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45
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Abstract
When preparing for oral surgery, patients taking anticoagulants usually should not discontinue their medication because of the risk of a thromboembolic event. The therapeutic effect of many anticoagulants is not readily measured, so preoperatively, the surgeon cannot know the true risk for postoperative hemorrhage. The risk of a thromboembolic event usually outweighs the concerns of controlling postoperative hemorrhage. Hemophilia patients are also at risk for postoperative bleeding. Single extractions probably do not pose a serious risk for postoperative hemorrhage. However, when a mucogingival flap is raised in these patients, there may be prolonged bleeding. Surgical sponges saturated with aqueous tranexamic acid solution and compressed onto the bleeding site with biting pressure may stop bleeding. Bleeding was stopped in the case example presented here after three 10-minute compressions over 30 minutes in a patient taking aspirin and clopidogrel for a previous thromboembolic event and a metal coronary stent. The clot formed is very fragile and is prone to bleeding, so it should not be disturbed. This technique needs to be studied for efficacy.
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Topical tranexamic acid in total knee replacement: a systematic review and meta-analysis. Knee 2013; 20:300-9. [PMID: 23815893 DOI: 10.1016/j.knee.2013.05.014] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 05/25/2013] [Accepted: 05/29/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND To examine the safety and efficacy of topical use of tranexamic acid (TA) in total knee arthroplasty (TKA). METHODS An electronic literature search of PubMed Medline; Ovid Medline; Embase; and the Cochrane Library was performed, identifying studies published in any language from 1966 to February 2013. The studies enrolled adults undergoing a primary TKA, where topical TA was used. Inverse variance statistical method and either a fixed or random effect model, depending on the absence or presence of statistical heterogeneity were used; subgroup analysis was performed when possible. RESULTS We identified a total of seven eligible reports for analysis. Our meta-analysis indicated that when compared with the control group, topical application of TA limited significantly postoperative drain output (mean difference: -268.36ml), total blood loss (mean difference=-220.08ml), Hb drop (mean difference=-0.94g/dL) and lowered the risk of transfusion requirements (risk ratio=0.47, 95CI=0.26-0.84), without increased risk of thromboembolic events. Sub-group analysis indicated that a higher dose of topical TA (>2g) significantly reduced transfusion requirements. CONCLUSIONS Although the present meta-analysis proved a statistically significant reduction of postoperative blood loss and transfusion requirements with topical use of TA in TKA, the clinical importance of the respective estimates of effect size should be interpreted with caution. LEVEL OF EVIDENCE I, II.
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