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Eckhof ML, von Hertzberg-Bölch S, Eidmann A, Lüdemann M, Rudert M, Jakuscheit A. Total blood loss and early clinical outcomes under different tranexamic acid regimes in total knee arthroplasty. Arch Orthop Trauma Surg 2024; 144:2795-2802. [PMID: 38819459 DOI: 10.1007/s00402-024-05229-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/15/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Many different regimes of intravenous and local tranexamic acid (TXA) reduce total blood loss (TBL) in patients undergoing total knee arthroplasty (TKA). However, the most effective TXA regime in reducing blood loss might not be most beneficial for the patient. The aim of the present study was to investigate the effect of commonly used TXA regimes on blood loss and on early clinical outcomes. METHODS We performed this monocentric retrospective study in patients undergoing primary TKA. Primary outcome was the estimated TBL. Secondary outcomes were the rates of adverse events (AE) as well as the range of motion (ROM), mobility and pain intensity during the first three physiotherapy sessions (PTS). RESULTS We analysed the data of 1250 TKAs. 5 different TXA regimes were applied. TBL (mean ± SE) was 953 ± 64 ml (2xiv), 999 ± 19 ml (2xiv + 1xlocal), 1075 ± 19 ml (1xiv + 1xlocal), 1191 ± 39 ml (1xlocal) and 1241 ± 48 ml (1xiv) (p < 0.01). In the linear regression model for TBL a lower number of TXA applications was a predictor for increased blood loss (p < 0.01). AE rates were lowest under 2xiv (0%) and 2xiv + 1xlocal (4.8%). Highest mobility and lowest pain intensity were observed under 1x iv and 2x iv. The largest portions of fully mobile patients on day three were observed under 1xiv (100%), 2xiv (100%) and 2xiv + 1local TXA (86.9%). CONCLUSION Our results suggest that multiple applications of TXA are more effective in decreasing blood loss than excessive dosing of TXA. Interestingly, local use of TXA might be associated with higher pain intensity and decreased mobility on the first days after surgery.
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Affiliation(s)
- Mona-Lisa Eckhof
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany.
| | | | - Annette Eidmann
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Martin Lüdemann
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Axel Jakuscheit
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
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Li Y, Ge M, Tian J, Zhou J, Kang Y, Xia C, Shao H, Wang Y, Huang Y, Zhao T. Effect of Tranexamic Acid on Hidden Blood Loss in Percutaneous Endoscopic Transforaminal Lumbar Interbody Fusion: A Retrospective Study. Ther Clin Risk Manag 2024; 20:325-334. [PMID: 38827486 PMCID: PMC11144425 DOI: 10.2147/tcrm.s462784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/19/2024] [Indexed: 06/04/2024] Open
Abstract
Purpose Percutaneous endoscopic transforaminal lumbar interbody fusion (PE-TLIF) has become one of the most popular minimally invasive surgeries today. However, the issue of hidden blood loss (HBL) in this surgery has received little attention. This study aims to examine the HBL in PE-TLIF surgery and the effect of tranexamic acid (TXA) on blood loss. Methods In our research, We conducted a retrospective analysis of 300 patients who underwent PE-TLIF from September 2019 to August 2023. They were divided into 2 groups based on whether they received intravenous TXA injection before surgery. The variables compared included: demographic data, pre-and postoperative hemoglobin (HB), hematocrit (HCT), platelets (PLT), red blood cells (RBC), total blood loss (TBL), visible blood loss (VBL), HBL, operation time, postoperative hospital stay, inflammatory markers, coagulation parameters, and adverse events. Results Regarding demographic characteristics, besides the operation time, no significant differences were observed between the two groups. Compared with the control group, the TXA group showed a significant reduction trend in TBL, HBL, and VBL (P < 0.05). On the first day after surgery, there were significant differences in prothrombin (PT), activated partial thromboplastin time (APTT), and D-dimer (D-D) levels between the two groups. Similarly, HCT also found similar results on the third day after surgery. No adverse events occurred in either group. Conclusion Research has found that there is a significant amount of HBL in patients undergoing PE-TLIF. Intravenous injection of TXA can safely and effectively reduce perioperative HBL and VBL. Additionally, compared to the control group, the TXA group shows a significant reduction in operation time.
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Affiliation(s)
- Yanlei Li
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, People’s Republic of China
| | - Meng Ge
- Department of Orthopedics, Hospital of Traditional Chinese Medicine of Xiaoshan District, Hangzhou, Zhejiang, People’s Republic of China
| | - Jinlong Tian
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, People’s Republic of China
| | - Jinlei Zhou
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, People’s Republic of China
- Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, People’s Republic of China
| | - Yao Kang
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, People’s Republic of China
| | - Chen Xia
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, People’s Republic of China
| | - Haiyu Shao
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, People’s Republic of China
| | - Yongguang Wang
- Department of Orthopedics, Linping Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, Zhejiang, People’s Republic of China
| | - Yazeng Huang
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, People’s Republic of China
| | - Tingxiao Zhao
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, People’s Republic of China
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Benjumea A, Díaz-Navarro M, Gago-Campos ÁS, Visedo A, Hafian R, Cercenado E, Sánchez-Somolinos M, Muñoz P, Vaquero J, Chana F, Guembe M. Validation of the antibacterial effect of topically applied tranexamic acid using in vitro and in vivo models. Front Microbiol 2024; 15:1367884. [PMID: 38808275 PMCID: PMC11130467 DOI: 10.3389/fmicb.2024.1367884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/30/2024] [Indexed: 05/30/2024] Open
Abstract
Background Several studies have shown that tranexamic acid (TXA), an antifibrinolytic, reduces postoperative infection rates. Recent in vitro research showed that TXA alone and in combination with vancomycin and gentamicin had a synergistic effect against some staphylococcal strains. In the present study, this synergistic effect was validated in samples from patients with staphylococcal periprosthetic infection (PPI) and in an in vivo model. Methods We tested 19 clinical strains (5 Staphylococcus aureus and 14 coagulase-negative staphylococci [CoNS]) against 10 mg/ml TXA alone and in combination with serial dilutions of vancomycin and gentamicin. The standardized microtiter plate method was used. The minimal inhibitory concentration (MIC) were calculated using standard visualization of well turbidity. We also used an S. aureus (ATCC29213) murine subcranial PPI model to compare the synergistic effect of TXA and gentamicin with that of TXA or gentamicin alone after 4 days of monitoring. The mice were euthanized, and disks were removed for analysis of cfu/ml counts and cell viability rate. Biofilm structure of both in vitro and in vivo samples was also analyzed using scanning electron microscopy (SEM). Results When TXA was combined with vancomycin or gentamicin, the MIC decreased in 30% of the strains studied. According to species, the MIC50 for vancomycin and gentamicin alone and in combination with TXA against S. aureus strains was the same. This was also the case for CoNS with vancomycin and its corresponding combination, whereas with gentamicin and TXA, a reduction in MIC50 was observed (2 dilutions). In addition, in the in vivo model, the mean (SD) log cfu/ml and cell viability rate obtained from the implant was lower in the group of mice treated with TXA and gentamicin than in those treated only with TXA or gentamicin. SEM images also corroborated our findings in strains in which the MIC was reduced, as well as the in the mice implants, with the area occupied by biofilm being greater in samples treated only with gentamicin or TXA than in those treated with TXA+gentamicin. Conclusion We confirm that combining TXA with vancomycin or gentamicin exerts a synergistic effect. However, this only occurs in selected strains.
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Affiliation(s)
- Antonio Benjumea
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marta Díaz-Navarro
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | - Andrés Visedo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Rama Hafian
- Department of Biomedicine and Biotechnology, Universidad de Alcalá de Henares, Alcala de Henares, Spain
| | - Emilia Cercenado
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Mar Sánchez-Somolinos
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Vaquero
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Francisco Chana
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Guembe
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Barrett CD, Neal MD, Schoenecker JG, Medcalf RL, Myles PS. Tranexamic acid in trauma: After 3 hours from injury, when is it safe and effective to use again? Transfusion 2024; 64 Suppl 2:S11-S13. [PMID: 38461482 DOI: 10.1111/trf.17779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 03/12/2024]
Abstract
Tranexamic acid (TXA) has proven mortality benefit if used early after traumatic injury, likely related to a combination of bleeding reduction and other non-bleeding effects. If TXA is given more than 3 h after traumatic injury, there is a significant and paradoxical increased risk of death due to bleeding. TXA has level 1 evidence for use as a bleeding reduction agent in isolated orthopedic operations, but in polytrauma patients undergoing orthopedic operations, it is not clear if and when TXA is safe or effective once outside the 3-h window of proven trauma efficacy.
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Affiliation(s)
- Christopher D Barrett
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jonathan G Schoenecker
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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Dong W, Tang Y, Lei M, Ma Z, Zhang X, Shen J, Hao J, Jiang W, Hu Z. The effect of perioperative sequential application of multiple doses of tranexamic acid on postoperative blood loss after PLIF: a prospective randomized controlled trial. Int J Surg 2024; 110:2122-2133. [PMID: 38215261 PMCID: PMC11020010 DOI: 10.1097/js9.0000000000001083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/27/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Tranexamic acid (TXA) has been utilized in spinal surgery to effectively reduce intraoperative blood loss (IBL) and allogeneic blood transfusion rates. However, the traditional TXA regimen might last the entire duration of hyperfibrinolysis caused by surgical trauma, resulting in its limited ability to reduce postoperative blood loss (PBL). Therefore, the aim of this study was to investigate the effectiveness of perioperative sequential administration of multiple doses of TXA in reducing PBL in patients who underwent posterior lumbar interbody fusion (PLIF). METHODS From October 2022 to June 2023, 231 patients who were diagnosed with lumbar degenerative disease and scheduled to undergo PLIF were prospectively enrolled in the present study. The patients were randomly divided into three groups. Moreover, all patients received an intravenous injection of TXA at a dose of 15 mg/kg 15 min before the surgical skin incision. Patients in Group A received a placebo of normal saline after surgery, while patients in Group B received three additional intravenous injections of TXA at a dose of 15 mg/kg every 24 h. Patients in Group C received three additional intravenous injections of TXA at a dose of 15 mg/kg every 5 h. The primary outcome measure was PBL. In addition, this study assessed total blood loss (TBL), IBL, routine blood parameters, liver and kidney function, coagulation parameters, fibrinolysis indexes, inflammatory indicators, drainage tube removal time (DRT), length of hospital stay (LOS), blood transfusion rate, and incidence of complications for all subjects. RESULTS The PBL, TBL, DRT, and LOS of Group B and Group C were significantly lower than those of Group A ( P <0.05). The level of D-dimer (D-D) in Group C was significantly lower than that in Group A on the first day after the operation ( P =0.002), and that in Group B was significantly lower than that in Group A on the third day after the operation ( P =0.003). The interleukin-6 levels between the three groups from 1 to 5 days after the operation were in the order of Group A > Group B > Group C. No serious complications were observed in any patient. The results of multiple stepwise linear regression analysis revealed that PBL was positively correlated with incision length, IBL, smoking history, history of hypertension, preoperative fibrinogen degradation product level, and blood transfusion. It was negatively correlated with preoperative levels of fibrinogen, red blood cells, blood urea nitrogen, and age. Compared to female patients, male patients had an increased risk of PBL. Finally, the incidence of PBL was predicted. CONCLUSIONS Sequential application of multiple doses of TXA during the perioperative period could safely and effectively reduce PBL and TBL, shorten DRT and LOS, reduce postoperative D-D generation, and reduce the postoperative inflammatory response. In addition, this study provided a novel prediction model for PBL in patients undergoing PLIF.
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Affiliation(s)
- Wei Dong
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Yuchen Tang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Miao Lei
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Zhaoxin Ma
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Xiaojun Zhang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Jieliang Shen
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Jie Hao
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Wei Jiang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Zhenming Hu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
- Department of Orthopedics Surgery, University-Town Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
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Xie W, Jiang S, Donat A, Knapstein PR, Albertsen LC, Kokot JL, Erdmann C, Rolvien T, Frosch KH, Baranowsky A, Keller J. Tranexamic Acid Attenuates the Progression of Posttraumatic Osteoarthritis in Mice. Am J Sports Med 2024; 52:766-778. [PMID: 38305280 PMCID: PMC10905980 DOI: 10.1177/03635465231220855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/25/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Posttraumatic osteoarthritis (OA) is a common disorder associated with a high socioeconomic burden, particularly in young, physically active, and working patients. Tranexamic acid (TXA) is commonly used in orthopaedic trauma surgery as an antifibrinolytic agent to control excessive bleeding. Previous studies have reported that TXA modulates inflammation and bone cell function, both of which are dysregulated during posttraumatic OA disease progression. PURPOSE To evaluate the therapeutic effects of systemic and topical TXA treatment on the progression of posttraumatic OA in the knee of mice. STUDY DESIGN Controlled laboratory study. METHODS OA was induced via anterior cruciate ligament (ACL) transection on the right knee of female mice. Mice were treated with TXA or vehicle intraperitoneally daily or intra-articularly weekly for 4 weeks, starting on the day of surgery. Articular cartilage degeneration, synovitis, bone erosion, and osteophyte formation were scored histologically. Micro-computed tomography evaluation was conducted to measure the subchondral bone microstructure and osteophyte volume. Cartilage thickness and bone remodeling were assessed histomorphometrically. RESULTS Both systemic and topical TXA treatment significantly reduced cartilage degeneration, synovitis, and bone erosion scores and increased the ratio of hyaline to calcified cartilage thickness in posttraumatic OA. Systemic TXA reversed ACL transection-induced subchondral bone loss and osteophyte formation, whereas topical treatment had no effect. Systemic TXA decreased the number and surface area of osteoclasts, whereas those of osteoblasts were not affected. No effect of topical TXA on osteoblast or osteoclast parameters was observed. CONCLUSION Both systemic and topical TXA exerted protective effects on the progression of posttraumatic OA. Drug repurposing of TXA may, therefore, be useful for the prevention or treatment of posttraumatic OA, particularly after ACL surgery. CLINICAL RELEVANCE TXA might be beneficial in patients with posttraumatic OA of the knee.
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Affiliation(s)
- Weixin Xie
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Shan Jiang
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Antonia Donat
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paul Richard Knapstein
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lilly-Charlotte Albertsen
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Judith Luisa Kokot
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cordula Erdmann
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anke Baranowsky
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Keller
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Ziegler Rodríguez OR, De la Cruz Ku G, Chávez Díaz M, Ziegler Rodríguez GJ, Ziegler Gutiérrez OE. Safety and Outcomes in Multiplane Facial Rejuvenation with Tranexamic Acid: A Cohort Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5653. [PMID: 38463701 PMCID: PMC10923354 DOI: 10.1097/gox.0000000000005653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/17/2024] [Indexed: 03/12/2024]
Abstract
Background Tranexamic acid (TXA) has demonstrated promising outcomes in plastic surgery. Our aim was to assess the effect of TXA in intraoperative bleeding, operative time, and complications among patients undergoing facial surgical procedures. Methods A retrospective cohort study of patients who underwent multiplane facial rhytidectomy from January 2018 to September 2022 at the Clinica Ziegler, Lima, Peru. Patients were divided into two groups according to the use of intravenous plus local infiltration of TXA. We performed the chi square test to assess associations among categorical variables, the Student t test and Mann-Whitney U test for categorical with continuous variables, and Pearson correlation for quantitative variables. Results A total of 100 patients were included with 50 patients in each group. The median age was 59.5 years and the majority were women (88%). The median operative time was 288.5 minutes. The TXA group presented less intraoperative bleeding (40 versus 90 mL, P < 0.05) and shorter operative time (237 versus 353 minutes, P < 0.05); no differences in the development of hematoma (2% versus 12%, P = 0.11), less ecchymosis (2% versus 36%, P < 0.05), edema (2% versus 100%, P < 0.05), and time to drain removal (3 versus 6 days, P < 0.05). Conclusions TXA improves the short- and long-term outcomes of patients who undergo multiplane facial rhytidectomy. It also decreases intraoperative bleeding by more than half and reduces the operative time by one third. Moreover, patients receiving TXA presented significantly less ecchymosis, edema, and time to drain removal.
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Affiliation(s)
- Otto Rolando Ziegler Rodríguez
- From the Department of Aesthetic, Plastic and Reconstructive Surgery, Clínica Ziegler, Lima, Peru
- Universidad Peruana de Ciencias Aplicadas Lima, Peru
| | - Gabriel De la Cruz Ku
- University of Massachusetts Medical School, Worcester, Mass
- Universidad Cientifica del Sur, Lima, Peru
| | - Marcelo Chávez Díaz
- From the Department of Aesthetic, Plastic and Reconstructive Surgery, Clínica Ziegler, Lima, Peru
- Universidad Peruana de Ciencias Aplicadas Lima, Peru
| | - Gonzalo Javier Ziegler Rodríguez
- From the Department of Aesthetic, Plastic and Reconstructive Surgery, Clínica Ziegler, Lima, Peru
- Universidad Peruana de Ciencias Aplicadas Lima, Peru
| | - Otto Enrique Ziegler Gutiérrez
- From the Department of Aesthetic, Plastic and Reconstructive Surgery, Clínica Ziegler, Lima, Peru
- Universidad Peruana de Ciencias Aplicadas Lima, Peru
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Simovic MO, Bynum J, Liu B, Dalle Lucca JJ, Li Y. Impact of Immunopathy and Coagulopathy on Multi-Organ Failure and Mortality in a Lethal Porcine Model of Controlled and Uncontrolled Hemorrhage. Int J Mol Sci 2024; 25:2500. [PMID: 38473750 DOI: 10.3390/ijms25052500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024] Open
Abstract
Uncontrolled hemorrhage is a major preventable cause of death in patients with trauma. However, the majority of large animal models of hemorrhage have utilized controlled hemorrhage rather than uncontrolled hemorrhage to investigate the impact of immunopathy and coagulopathy on multi-organ failure (MOF) and mortality. This study evaluates these alterations in a severe porcine controlled and uncontrolled hemorrhagic shock (HS) model. Anesthetized female swine underwent controlled hemorrhage and uncontrolled hemorrhage by partial splenic resection followed with or without lactated Ringer solution (LR) or Voluven® resuscitation. Swine were surveyed 6 h after completion of splenic hemorrhage or until death. Blood chemistry, physiologic variables, systemic and tissue levels of complement proteins and cytokines, coagulation parameters, organ function, and damage were recorded and assessed. HS resulted in systemic and local complement activation, cytokine release, hypocoagulopathy, metabolic acidosis, MOF, and no animal survival. Resuscitation with LR and Voluven® after HS improved hemodynamic parameters (MAP and SI), metabolic acidosis, hyperkalemia, and survival but resulted in increased complement activation and worse coagulopathy. Compared with the LR group, the animals with hemorrhagic shock treated with Voluven® had worse dilutional anemia, coagulopathy, renal and hepatic dysfunction, increased myocardial complement activation and renal damage, and decreased survival rate. Hemorrhagic shock triggers early immunopathy and coagulopathy and appears associated with MOF and death. This study indicates that immunopathy and coagulopathy are therapeutic targets that may be addressed with a high-impact adjunctive treatment to conventional resuscitation.
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Affiliation(s)
- Milomir O Simovic
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - James Bynum
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Bin Liu
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | | | - Yansong Li
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
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Kristjansen KA, Engel Krag A, Schmidt H, Hölmich LR, Bønnelykke-Behrndtz ML. Perioperative treatment with tranexamic acid in melanoma (PRIME): protocol for a Danish multicentre randomised controlled trial investigating the prognostic and treatment-related impact of the plasminogen-plasmin pathway. BMJ Open 2024; 14:e077012. [PMID: 38309757 PMCID: PMC10840044 DOI: 10.1136/bmjopen-2023-077012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 01/18/2024] [Indexed: 02/05/2024] Open
Abstract
INTRODUCTION Inflammation is a hallmark of cancer and is involved in tumour growth and dissemination. However, the hallmarks of cancer are also the hallmarks of wound healing, and modulating the wound inflammatory response and immune contexture in relation to cancer surgery may represent effective targets of therapies.Repurposing anti-inflammatory drugs in a cancer setting has gained increasing interest in recent years. Interestingly, the known and thoroughly tested antifibrinolytic drug tranexamic acid reduces the risk of bleeding, but it is also suggested to play important roles in anti-inflammatory pathways, improving wound healing and affecting anti-carcinogenic mechanisms.As a novel approach, we will conduct a randomised controlled trial using perioperative treatment with tranexamic acid, aiming to prevent early relapses by >10% for patients with melanoma. METHODS AND ANALYSIS Design: investigator-initiated parallel, two-arm, randomised, blinded, Danish multicentre superiority trial. PATIENTS ≥T2 b melanoma and eligible for sentinel lymph node biopsy (n=1204).Project drug: tranexamic acid or placebo. TREATMENT before surgery (intravenous 15 mg/kg) and daily (peroral 1000 mg x 3) through postoperative day 4. PRIMARY OUTCOME relapse within 2 years after surgery.Primary analysis: risk difference between the treatment arms (χ2 test). SECONDARY OUTCOMES postoperative complications, adverse events and survival.Inclusion period: summer 2023 to summer 2026. ETHICS AND DISSEMINATION The trial will be initiated during the summer of 2023 and is approved by the National Committee on Health Research Ethics, the Danish Medicine Agency, and registered under the Data Protection Act. The study will be conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. Patients included in the study will adhere to normal Danish treatment protocols and standards of care, and we expect only mild and temporary side effects. Positive and negative results will be published in peer-reviewed journals, with authorships adhering to the Vancouver rules. TRIAL REGISTRATION NUMBER NCT05899465; ClinicalTrials.gov Identifier.
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Affiliation(s)
- Karoline Assifuah Kristjansen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Andreas Engel Krag
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Schmidt
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Lisbet Rosenkrantz Hölmich
- Department of Plastic Surgery, Herlev Hospital, Herlev, Denmark
- Department of Clinical Medicine, Copenhagen University Hospital, Kobenhavn, Denmark
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10
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Bae J, Lee DDU, Lee KT, Pyon JK, Jeon BJ, Mun GH. The early postoperative effects of rinsing the breast pocket with tranexamic acid in prepectoral prosthetic breast reconstruction. J Plast Reconstr Aesthet Surg 2024; 89:125-133. [PMID: 38181633 DOI: 10.1016/j.bjps.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/27/2023] [Accepted: 12/06/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND The efficacy of tranexamic acid (TXA) has been reported in breast surgery; however, its application and duration have varied across studies. This study aimed to assess the early postoperative outcomes of rinsing the breast pocket with TXA during prepectoral prosthetic breast reconstruction using an acellular dermal matrix (ADM). METHODS A retrospective chart review was conducted in consecutive patients who underwent immediate prosthetic prepectoral reconstruction between August 2021 and December 2022. For cases performed during the earlier part of the study period (up to April 2022), TXA was not administered (non-TXA group), whereas those performed after April 2022 received topical TXA application during surgery (TXA group). Postoperative outcomes including hematoma, seroma, drainage volume, and drain maintenance duration were compared between the two groups using propensity score matching (PSM). RESULTS A total of 674 breasts were analyzed; 280 in the TXA group and 394 were in the non-TXA group. There were 251 breasts in each group after PSM, and their characteristics were similar. The incidence of hematoma in the first 24 hours and total drain output were significantly lower in the TXA group than the non-TXA group. In cases of direct-to-implant cases, the TXA group showed a significantly lower seroma rate. CONCLUSIONS Rinsing the breast pocket with TXA can potentially reduce the occurrence of hematoma and decrease drain output in prepectoral ADM-assisted prosthetic breast reconstruction. Moreover, this approach may be beneficial in lowering the incidence of seroma in direct-to-implant reconstruction.
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Affiliation(s)
- Juyoung Bae
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dianne Dong Un Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jai Kyong Pyon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byung-Joon Jeon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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11
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Poston JN, Brown SP, Ilich A, Ginsburg AS, Herren H, El Kassar N, Jensen CE, Triulzi DJ, Key NS, May S, Gernsheimer TB. Fewer severe infections with tranexamic acid in patients with hematologic malignancies. Res Pract Thromb Haemost 2024; 8:102358. [PMID: 38666065 PMCID: PMC11043644 DOI: 10.1016/j.rpth.2024.102358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/22/2024] [Accepted: 02/13/2024] [Indexed: 04/28/2024] Open
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic agent that reduces bleeding in a multitude of clinical settings from postpartum hemorrhage to trauma. TXA may have clinical effects unrelated to bleeding; plasminogen, the target of TXA, alters immune responses, and TXA appears to decrease the risk of infection in patients undergoing cardiac surgery, as well as joint arthroplasty. Objectives To address whether TXA alters rates of infection and inflammatory outcomes in patients with hematologic malignancies. Methods We performed a post hoc analysis of outcomes of patients randomized to receive either TXA or placebo in the double-blinded, multicenter American Trial to Evaluate Tranexamic Acid Therapy in Thrombocytopenia (Clinicaltrials.gov identifier: NCT02578901). Results TXA did not change the overall rate of infections, but the rate of severe infections (Common Toxicology Criteria for Adverse Events grade 3+) was lower in patients who received TXA compared with the placebo group. Patients who experienced grade 3+ infections had higher rates of World Health Organization grade 2+ bleeding and red blood cell transfusion requirements than patients who did not experience a grade 3+ infection, irrespective of treatment group. TXA did not impact other inflammatory outcomes such as mucositis, rash, or graft vs host disease. Conclusion Patients with hematologic malignancies who received TXA had less severe infections than those who received placebo with no difference in overall rate of infection or other inflammatory outcomes. Further investigation is needed on the impact of TXA on infections in this population.
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Affiliation(s)
- Jacqueline N. Poston
- Division of Hematology, University of Washington School of Medicine and Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Hematology/Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Siobhan P. Brown
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Anton Ilich
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amy Sarah Ginsburg
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Heather Herren
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Nahed El Kassar
- Division of Blood Diseases and Resources, National Institutes of Health, National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
| | - Christopher E. Jensen
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Darrell J. Triulzi
- Department of Pathology, Division of Transfusion Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nigel S. Key
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Terry B. Gernsheimer
- Division of Hematology, University of Washington School of Medicine and Fred Hutchinson Cancer Center, Seattle, Washington, USA
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Al-Juhani A, Sharaf GF, Aseri S, Alosaimi H, Alharkan SA, AlGhamdi JK, Hariri FS, Daak L, Daak I. The Role of Tranexamic Acid in Sleeve Gastrectomy: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e54269. [PMID: 38496064 PMCID: PMC10944379 DOI: 10.7759/cureus.54269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
Tranexamic acid (TXA) is an essential procoagulant drug used in various intra- and postoperative situations. Its efficacy and safety profile in obese cases undergoing laparoscopic sleeve gastrectomy (LSG) is still unresolved. Therefore, this meta-analysis evaluated and investigated the current intra- and postoperative effects and hazards of TXA on patients undergoing LSG. As for methodology, Web of Science, Cochrane Library, Scopus, and PubMed were thoroughly searched for relevant studies. Retrieved results were prepared for screening through Endnote, helping to identify eligible studies. Relevant patient characteristics and outcomes were extracted. The methodological quality of the relevant studies was appraised using the respected appraisal tool. Six studies of different designs were enrolled, comprising 753 cases that underwent LSG and administered TXA. Their mean BMI and age went from 37.3 to 56.25 kg/m2 and 33.5 to 43.25 years, respectively. Tranexamic acid significantly linked to reduction in intraoperative bleeding instances, operative blood loss, and operative duration, compared to placebo ((RR = 0.66, 95% CI [0.44, 0.98], P=0.04, I2 = 81%); (MD = -39.64, 95%CI [-75.49, -3.78], P=0.03, I2=94%); (MD=-5.84, 95%CI [-9.62, -2.05], P=0.003, I2=73%)). Tranexamic acid also significantly showed superiority regarding postoperative bleeding events and duration of hospitalization compared to the control group ((RR= 0.45, 95%CI [0.29, 0.69], P=0.0002, I2 =0%); (MD=-0.24, 95%CI [-0.32, -0.17], P< 0.0000, I2 =0%)). Moreover, follow-up of the enrolled patients for a minimum of three to six months resulted in no reported thromboembolic instances, suggesting a negligible risk for thromboembolism among patients undergoing LSG and receiving TXA. In conclusion, tranexamic acid demonstrates a robust safety and efficacy profile for its use in patients undergoing LSG, with no reported instances of thromboembolism. Variations in TXA administration regimens, bleeding definitions, procedural techniques, and potential confounding medications could not be accounted for, necessitating additional large-scale RCTs to address and bridge knowledge gaps.
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Affiliation(s)
| | | | - Saeed Aseri
- Psychiatry, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | | | | | | | - Faris S Hariri
- Medicine, Batterjee Medical College, King Abdulaziz University Hospital, Jeddah, SAU
| | - Lojain Daak
- Medicine and Surgery, Jazan University, Jazan, SAU
| | - Ikhlas Daak
- Medicine, Jazan College of Medicine and Medical Sciences, Jazan University, Jazan, SAU
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13
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Cai L, Chen C, Zhao X, Kang P. Tranexamic acid modulates the immune response in primary total hip arthroplasty: A retrospective study. Asian J Surg 2024; 47:752-753. [PMID: 37879987 DOI: 10.1016/j.asjsur.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/06/2023] [Indexed: 10/27/2023] Open
Affiliation(s)
- Lijun Cai
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
| | - Changjun Chen
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China; Department of Orthopedic Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Jinan, People's Republic of China.
| | - Xin Zhao
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China; Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, People's Republic of China.
| | - Pengde Kang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
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14
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Mutch NJ, Medcalf RL. The fibrinolysis renaissance. J Thromb Haemost 2023; 21:3304-3316. [PMID: 38000850 DOI: 10.1016/j.jtha.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 11/26/2023]
Abstract
Fibrinolysis is the system primarily responsible for removal of fibrin deposits and blood clots in the vasculature. The terminal enzyme in the pathway, plasmin, is formed from its circulating precursor, plasminogen. Fibrin is by far the most legendary substrate, but plasmin is notoriously prolific and is known to cleave many other proteins and participate in the activation of other proteolytic systems. Fibrinolysis is often overshadowed by the coagulation system and viewed as a simplistic poorer relation. However, the primordial plasminogen activators evolved alongside the complement system, approximately 70 million years before coagulation saw the light of day. It is highly likely that the plasminogen activation system evolved with its roots in primordial immunity. Almost all immune cells harbor at least one of a dozen plasminogen receptors that allow plasmin formation on the cell surface that in turn modulates immune cell behavior. Similarly, numerous pathogens express their own plasminogen activators or contain surface proteins that provide binding sites for host plasminogen. The fibrinolytic system has been harnessed for clinical medicine for many decades with the development of thrombolytic drugs and antifibrinolytic agents. Our refined understanding and appreciation of the fibrinolytic system and its alliance with infection and immunity and beyond are paving the way for new developments and interest in novel therapeutics and applications. One must ponder as to whether the nomenclature of the system hampered our understanding, by focusing on fibrin, rather than the complex myriad of interactions and substrates of the plasminogen activation system.
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Affiliation(s)
- Nicola J Mutch
- Aberdeen Cardiovascular & Diabetes Centre, Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK.
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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15
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Ghaffari S, Fateh S, Faramarzi F, Rafiei A, Razavipour M, Zafari P. The effect of tranexamic acid on synovium of patients undergoing arthroplasty and anterior cruciate ligament reconstruction surgery. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:3733-3742. [PMID: 37318523 DOI: 10.1007/s00210-023-02555-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 05/26/2023] [Indexed: 06/16/2023]
Abstract
Preoperative hemorrhage can be reduced using anti-fibrinolytic medicine tranexamic acid (TXA). During surgical procedures, local administration is being used more and more frequently, either as an intra-articular infusion or as a perioperative rinse. Serious harm to adult soft tissues can be detrimental to the individual since they possess a weak ability for regeneration. Synovial tissues and primary fibroblast-like synoviocytes (FLS) isolated from patients were examined using TXA treatment in this investigation. FLS is obtained from rheumatoid arthritis (RA), osteoarthritis (OA), and anterior cruciate ligament (ACL)-ruptured patients. The in vitro effect of TXA on primary FLS was investigated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell viability assays for cell death, annexin V/propidium iodide (PI) staining for apoptotic rate, real-time PCR for p65 and MMP-3 expression, and enzyme-linked immunosorbent assay (ELISA) for IL-6 measurement. MTT assays revealed a significant decrease in cell viability in FLS of all groups of patients following treatment with 0.8-60 mg/ml of TXA within 24 h. There was a significant increase in cell apoptosis after 24 h of exposure to TXA (15 mg/ml) in all groups, especially in RA-FLS. TXA increases the expression of MMP-3 and p65 expression. There was no significant change in IL-6 production after TXA treatment. An increase in receptor activator of nuclear factor kappa-Β ligand (RANK-L) production was seen only in RA-FLS. This study demonstrates that TXA caused significant synovial tissue toxicity via the increase in cell death and elevation of inflammatory and invasive gene expression in FLS cells.
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Affiliation(s)
- Salman Ghaffari
- Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Soroosh Fateh
- Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Faramarzi
- Department of Immunology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Alireza Rafiei
- Department of Immunology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mehran Razavipour
- Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Parisa Zafari
- Ramsar Campus, Mazandaran University of Medical Sciences, Ramsar, Iran.
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Imanishi K, Kobayashi N, Kamono E, Yukizawa Y, Takagawa S, Choe H, Kumagai K, Inaba Y. Tranexamic acid administration for the prevention of periprosthetic joint infection and surgical site infection: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2023; 143:6883-6899. [PMID: 37355487 DOI: 10.1007/s00402-023-04914-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/21/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) has been widely utilized to reduce blood loss and allogeneic transfusions in patients who undergo lower limb arthroplasty. In recent years, there have been several articles reporting the incidence of periprosthetic joint infection (PJI) as a primary outcome of TXA administration, but no meta-analysis has been conducted to date. The present systematic review and meta-analysis evaluated the efficacy of TXA administration in preventing PJI and surgical site infection (SSI). MATERIALS AND METHODS Pubmed, CINAHL, and the Cochrane Library bibliographic databases were searched for studies published by May 24, 2022, that evaluated the effects of TXA on PJI and SSI. Two researchers screened the identified studies based on the PRISMA flow diagram. The quality of each randomized clinical trial was assessed using Version 2 of the Cochrane risk-of-bias tool for randomized trials (ROB2.0), and the quality of cohort and case-control studies was assessed by risk of bias for nonrandomized studies (ROBANS-I). RESULTS Of the 2259 articles identified from the database search, 31 were screened and selected. Treatment with TXA significantly reduced the incidence of overall infection, including PJI, SSI, and other infections (OR 0.55; 95% CI 0.49-0.62) (P < 0.00001), and that of PJI alone (OR 0.53; 95% CI 0.47-0.59) (P < 0.00001). TXA reduced the incidence of overall infection in patients who underwent total hip arthroplasty (THA; OR 0.51; 95% CI: 0.35-0.75) (P = 0.0005) and total knee arthroplasty (TKA; OR 0.55; 95% CI: 0.43-0.71) (P < 0.00001). Intravenous administration of TXA reduced the incidence of overall infection (OR 0.59; 95% CI 0.47-0.75) (P < 0.0001), whereas topical administration did not. CONCLUSIONS Intravenous administration of TXA reduces the incidence of overall infection in patients undergoing both THA and TKA. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Keiji Imanishi
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan
| | - Naomi Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan.
| | - Emi Kamono
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan
| | - Yohei Yukizawa
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan
| | - Shu Takagawa
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan
| | - Hyonmin Choe
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Ken Kumagai
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
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Abbasciano RG, Tomassini S, Roman MA, Rizzello A, Pathak S, Ramzi J, Lucarelli C, Layton G, Butt A, Lai F, Kumar T, Wozniak MJ, Murphy GJ. Effects of interventions targeting the systemic inflammatory response to cardiac surgery on clinical outcomes in adults. Cochrane Database Syst Rev 2023; 10:CD013584. [PMID: 37873947 PMCID: PMC10594589 DOI: 10.1002/14651858.cd013584.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Organ injury is a common and severe complication of cardiac surgery that contributes to the majority of deaths. There are no effective treatment or prevention strategies. It has been suggested that innate immune system activation may have a causal role in organ injury. A wide range of organ protection interventions targeting the innate immune response have been evaluated in randomised controlled trials (RCTs) in adult cardiac surgery patients, with inconsistent results in terms of effectiveness. OBJECTIVES The aim of the review was to summarise the results of RCTs of organ protection interventions targeting the innate immune response in adult cardiac surgery. The review considered whether the interventions had a treatment effect on inflammation, important clinical outcomes, or both. SEARCH METHODS CENTRAL, MEDLINE, Embase, conference proceedings and two trial registers were searched on October 2022 together with reference checking to identify additional studies. SELECTION CRITERIA RCTs comparing organ protection interventions targeting the innate immune response versus placebo or no treatment in adult patients undergoing cardiac surgery where the treatment effect on innate immune activation and on clinical outcomes of interest were reported. DATA COLLECTION AND ANALYSIS Searches, study selection, quality assessment, and data extractions were performed independently by pairs of authors. The primary inflammation outcomes were peak IL-6 and IL-8 concentrations in blood post-surgery. The primary clinical outcome was in-hospital or 30-day mortality. Treatment effects were expressed as risk ratios (RR) and standardised mean difference (SMD) with 95% confidence intervals (CI). Meta-analyses were performed using random effects models, and heterogeneity was assessed using I2. MAIN RESULTS A total of 40,255 participants from 328 RCTs were included in the synthesis. The effects of treatments on IL-6 (SMD -0.77, 95% CI -0.97 to -0.58, I2 = 92%) and IL-8 (SMD -0.92, 95% CI -1.20 to -0.65, I2 = 91%) were unclear due to heterogeneity. Heterogeneity for inflammation outcomes persisted across multiple sensitivity and moderator analyses. The pooled treatment effect for in-hospital or 30-day mortality was RR 0.78, 95% CI 0.68 to 0.91, I2 = 0%, suggesting a significant clinical benefit. There was little or no treatment effect on mortality when analyses were restricted to studies at low risk of bias. Post hoc analyses failed to demonstrate consistent treatment effects on inflammation and clinical outcomes. Levels of certainty for pooled treatment effects on the primary outcomes were very low. AUTHORS' CONCLUSIONS A systematic review of RCTs of organ protection interventions targeting innate immune system activation did not resolve uncertainty as to the effectiveness of these treatments, or the role of innate immunity in organ injury following cardiac surgery.
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Affiliation(s)
| | | | - Marius A Roman
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Angelica Rizzello
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Suraj Pathak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Joussi Ramzi
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Carla Lucarelli
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | - Georgia Layton
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ayesha Butt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Florence Lai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Marcin J Wozniak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Lam T, Medcalf RL, Cloud GC, Myles PS, Keragala CB. Tranexamic acid for haemostasis and beyond: does dose matter? Thromb J 2023; 21:94. [PMID: 37700271 PMCID: PMC10496216 DOI: 10.1186/s12959-023-00540-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023] Open
Abstract
Tranexamic acid (TXA) is a widely used antifibrinolytic agent that has been used since the 1960's to reduce blood loss in various conditions. TXA is a lysine analogue that competes for the lysine binding sites in plasminogen and tissue-type plasminogen activator impairing its interaction with the exposed lysine residues on the fibrin surface. The presence of TXA therefore, impairs the plasminogen and tPA engagement and subsequent plasmin generation on the fibrin surface, protecting fibrin clot from proteolytic degradation. However, critical lysine binding sites for plasmin(ogen) also exist on other proteins and on various cell-surface receptors allowing plasmin to exert potent effects on other targets that are unrelated to classical fibrinolysis, notably in relation to immunity and inflammation. Indeed, TXA was reported to significantly reduce post-surgical infection rates in patients after cardiac surgery unrelated to its haemostatic effects. This has provided an impetus to consider TXA in other indications beyond inhibition of fibrinolysis. While there is extensive literature on the optimal dosage of TXA to reduce bleeding rates and transfusion needs, it remains to be determined if these dosages also apply to blocking the non-canonical effects of plasmin.
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Affiliation(s)
- Tammy Lam
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia
| | - Geoffrey C Cloud
- Department of Clinical Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne VIC, Australia
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne VIC, Australia
| | - Charithani B Keragala
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia.
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Dong W, Liang Y, Li D, Ma Z, Cheng M, Zhang X, Shen J, Zhou N, Hao J, Jiang W, Hu Z. The effect of sequential perioperative intravenous tranexamic acid in reducing postoperative blood loss and hidden blood loss after posterior lumbar interbody fusion: a randomized controlled trial. Front Med (Lausanne) 2023; 10:1192971. [PMID: 37601774 PMCID: PMC10436300 DOI: 10.3389/fmed.2023.1192971] [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: 03/24/2023] [Accepted: 07/17/2023] [Indexed: 08/22/2023] Open
Abstract
Background Tranexamic acid (TXA) has previously been shown to be effective in reducing intraoperative blood loss (IBL) and transfusion requirements in spine surgery. A conventional TXA regimen is a simple preoperative or intraoperative administration. However, the hyperfibrinolysis caused by surgical trauma lasts at least 24 h, and a single dose of TXA cannot cover the whole process of hyperfibrinolysis. Moreover, its ability to control postoperative blood loss (PBL) may be insufficient. Therefore, this study aimed to explore the effects and safety of sequential perioperative intravenous TXA for reducing bleeding after posterior lumbar interbody fusion (PLIF). Methods Patients requiring PLIF were randomly divided into two groups. All patients were intravenously injected with 1 g of TXA 15 min before skin resection. Every day after the surgery, 200 ml saline was intravenously injected for 1-3 days in Group A, while Group B received 1 g of TXA instead of saline. The total blood loss (TBL), IBL, PBL, HCT, Hb, blood transfusion volume, inflammation-related indicators, and complications were recorded. Results TBL, PBL, and hidden blood loss (HBL) in Group B were significantly lower than those in Group A (P < 0.05). The maximum decreases in HCT and Hb in Group B were also significantly lower than those in Group A (P < 0.05), and the drainage removal time (DRT) was sooner in Group B than in Group A (P = 0.003). On the 3rd and 5th days after surgery, the level of CRP in Group B was significantly lower than that in Group A (P < 0.05). Similarly, IL-6 levels were significantly lower in Group B for the first 5 days postoperatively (P < 0.001). Sex, operation time, level of decompression, length of incision, and change in HCT were significant predictors of both TBL and HBL. TBL was also significantly associated with BMI and preoperative fibrinogen, while postoperative TXA was a significant predictor of HBL only. Conclusion Intravenous injection of 1 g of TXA 15 min before skin resection combined with continuous intravenous injection of 1 g of TXA 1 to 3 days after PLIF can reduce postoperative bleeding and shorten the time to drainage tube removal. In addition, it can also inhibit the postoperative inflammatory response. Clinical trial registration ChiCTR2200056210.
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Affiliation(s)
- Wei Dong
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Yi Liang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dongxu Li
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Zhaoxin Ma
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Minghuang Cheng
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Xiaojun Zhang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Jieliang Shen
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Nian Zhou
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Jie Hao
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Wei Jiang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Zhenming Hu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
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Liu Z, McCutcheon FM, Ho H, Chia J, Xiao Y, Tippett I, Keragala CB, Cloud GC, Medcalf RL. Tranexamic acid in a mouse model of cerebral amyloid angiopathy: setting the stage for a novel stroke treatment approach. Res Pract Thromb Haemost 2023; 7:102166. [PMID: 37694270 PMCID: PMC10483050 DOI: 10.1016/j.rpth.2023.102166] [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: 04/10/2023] [Revised: 06/22/2023] [Accepted: 07/04/2023] [Indexed: 09/12/2023] Open
Abstract
Background Symptomatic intracerebral hemorrhage (sICH) commonly occurs in patients with cerebral amyloid angiopathy (CAA). Amyloid also initiates plasminogen activation and might promote sICH. Objectives As amyloid-driven plasmin formation can be blocked by tranexamic acid (TXA), we aimed to evaluate the biodistribution and long-term consequences of TXA on brain amyloid-beta (Aβ) levels, inflammation, and neurologic function in APP/PS1 mice. Methods APP/PS1 mice overexpressing the mutant human amyloid precursor protein and wild-type littermates were randomized to TXA (20 mg/mL) or placebo in the drinking water for 6 months. TXA in plasma and various organs was determined by liquid chromatography-mass spectrometry. Plasmin activity assays were performed to evaluate changes in fibrinolytic activity. Neurologic function was evaluated by Y-maze and parallel rod floor testing. Proximity ligation-based immunoassays were used to quantitate changes of 92 biomarkers of inflammation. Brain Aβ levels were assessed by immunohistochemistry. Results Long-term oral TXA administration inhibited fibrinolysis. TXA accumulated in the kidney (19.4 ± 11.2 μg/g) with 2- to 5-fold lower levels seen in the lung, spleen, and liver. TXA levels were lowest in the brain (0.28 ± 0.01 μg/g). Over 6 months, TXA had no discernible effect on motor coordination, novelty preference, or brain Aβ levels. TXA reduced plasma levels of epithelial cell adhesion molecule and increased CCL20. Conclusion Long-term TXA treatment does not alter brain Aβ levels or impact neurologic behavior in mice predisposed to amyloid deposition and had minor effects on the levels of inflammatory mediators. This finding supports the safety of TXA and lays the foundation for TXA as a novel treatment to reduce sICH in patients with CAA.
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Affiliation(s)
- Zikou Liu
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Fiona M. McCutcheon
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Heidi Ho
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Joanne Chia
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Yunxin Xiao
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Isabel Tippett
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | | | - Geoffrey C. Cloud
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Robert L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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21
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Whyte CS. All tangled up: interactions of the fibrinolytic and innate immune systems. Front Med (Lausanne) 2023; 10:1212201. [PMID: 37332750 PMCID: PMC10272372 DOI: 10.3389/fmed.2023.1212201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/17/2023] [Indexed: 06/20/2023] Open
Abstract
The hemostatic and innate immune system are intertwined processes. Inflammation within the vasculature promotes thrombus development, whilst fibrin forms part of the innate immune response to trap invading pathogens. The awareness of these interlinked process has resulted in the coining of the terms "thromboinflammation" and "immunothrombosis." Once a thrombus is formed it is up to the fibrinolytic system to resolve these clots and remove them from the vasculature. Immune cells contain an arsenal of fibrinolytic regulators and plasmin, the central fibrinolytic enzyme. The fibrinolytic proteins in turn have diverse roles in immunoregulation. Here, the intricate relationship between the fibrinolytic and innate immune system will be discussed.
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Bønnelykke-Behrndtz ML, Kristensen KB, Hölmich LR, Pottegård A. Tranexamic acid use is not associated with the risk of melanoma in Danish women: A nested case-control study using Danish health registries. Cancer Epidemiol 2023; 84:102356. [PMID: 36996688 DOI: 10.1016/j.canep.2023.102356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Repurposing already approved drugs in a cancer setting has gained increasing interest in recent years. Tranexamic acid is an anti-fibrinolytic drug that has recently been suggested as an anti-cancer drug due to its anti-inflammatory and anti-carcinogenic effects in animal studies. In this study, we aimed to investigate the possible melanoma-preventive role of tranexamic acid in Danish women. METHOD In this nested case-control study, we identified female cases 18-60 years with first-time melanoma during 2000-2015 and age-matched them with 10 female controls. The odds ratio (OR) of melanoma with tranexamic acid ever- or high use (≥ 100,000 mg) was estimated using conditional logistic regression. RESULTS A total of 7986 women with incident melanoma were eligible for study inclusion and were matched to 79,860 controls. Most exposed cases and controls were exposed to low cumulative doses of tranexamic acid corresponding to around 5 days of continuous treatment (1000 mg 3 times daily) for the presumed main indication, i.e., menorrhagia. The crude OR associating tranexamic ever use with melanoma was 1.04 (95% CI 0.98-1.11, p = 0.20), and the adjusted OR was 1.03 (0.97-1.10, p = 0.32). We found no dose-response pattern or effect measure modification by age, histologic type, localization, or clinical stage. However, prolonged use with cumulative doses of tranexamic acid (≥ 100,000 mg) was associated with an increased risk of melanoma (adjusted OR 1.23,95 %, CI 0.96-1.56), compared with non-use. CONCLUSION We found no association between tranexamic acid use and the risk of melanoma in Danish women. This could be explained by underlying dose- or biological factors, and sporadic use patterns. A higher risk of melanoma was seen among prolonged users which could be due to surveillance bias.
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23
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Nichols G, Andrade E, Gregoski M, Herrera FA, Armstrong MB. Local Infiltration of Tranexamic Acid in Breast Reduction for Symptomatic Macromastia. Ann Plast Surg 2023; 90:S366-S370. [PMID: 36856723 PMCID: PMC11166195 DOI: 10.1097/sap.0000000000003456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND With a surge of tranexamic acid (TXA) use in the plastic surgery community and a constant demand for breast reduction for symptomatic macromastia, questions about the benefits and risks emerge. The aims of this study are to evaluate and compare outcomes of patients undergoing breast reduction while receiving local TXA as opposed to standard procedure without TXA and to assess intraoperative bleeding and operative time. METHODS A retrospective review of breast reductions at a single institution from June 2020 to December 2021 was performed. The breast was infiltrated with tumescent solution at the time of surgery, with or without TXA. The population was divided into 2 groups: the TXA receiving group and tumescent only group. Demographics, intraoperative bleeding, operative time, complications, and drain duration were compared between groups. T test and χ 2 test analyses were performed on IBM SPSS.TM. RESULTS A total of 81 patients and 162 breasts were included. Mean age among patients was 30 ± 13.44 years. Mean SN-N distance was 32.80 ± 3.62 cm. Average resected breast specimen weight was 903.21 ± 336.50 g. Mean operating room time was 159 minutes. Intraoperative blood loss and operative time were not statistically different between groups ( P = 0.583 and P = 0.549, respectively). T-junction dehiscence was lower in the TXA group ( P = 0.016). Incidence of suture granulomas was lower in the TXA group ( P = 0.05). Drain duration was statistically significantly higher in the TXA group ( P = 0.033). CONCLUSIONS No decreases in intraoperative blood loss, operative time, or hematoma were seen after local administration of TXA during breast reduction. The rate of overall complications was not increased by using TXA, and incidence of T-junction dehiscence was lower in the TXA group lending to TXA's relatively safe profile. More research is necessary to further elucidate the TXA-related benefits in standard breast reductions.
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Affiliation(s)
- Georgina Nichols
- Division of Plastic and Reconstructive Surgery, Medical University of South Carolina
| | - Erika Andrade
- College of Medicine, Medical University of South Carolina
| | - Mathew Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Fernando A. Herrera
- Division of Plastic and Reconstructive Surgery, Medical University of South Carolina
- College of Medicine, Medical University of South Carolina
| | - Milton B. Armstrong
- Division of Plastic and Reconstructive Surgery, Medical University of South Carolina
- College of Medicine, Medical University of South Carolina
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Fu Y, Xue H, Wang T, Ding Y, Cui Y, Nie H. Fibrinolytic system and COVID-19: From an innovative view of epithelial ion transport. Biomed Pharmacother 2023; 163:114863. [PMID: 37172333 PMCID: PMC10169260 DOI: 10.1016/j.biopha.2023.114863] [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: 03/13/2023] [Revised: 05/05/2023] [Accepted: 05/06/2023] [Indexed: 05/14/2023] Open
Abstract
Lifeways of worldwide people have changed dramatically amid the coronavirus disease 2019 (COVID-19) pandemic, and public health is at stake currently. In the early stage of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, fibrinolytic system is mostly inhibited, which is responsible for the development of hypofibrinolysis, promoting disseminated intravascular coagulation, hyaline membrane formation, and pulmonary edema. Whereas the common feature and risk factor at advanced stage is a large amount of fibrin degradation products, including D-dimer, the characteristic of hyperfibrinolysis. Plasmin can cleave both SARS-CoV-2 spike protein and γ subunit of epithelial sodium channel (ENaC), a critical element to edematous fluid clearance. In this review, we aim to sort out the role of fibrinolytic system in the pathogenesis of COVID-19, as well as provide the possible guidance in current treating methods. In addition, the abnormal regulation of ENaC in the occurrence of SARS-CoV-2 mediated hypofibrinolysis and hyperfibrinolysis are summarized, with the view of proposing an innovative view of epithelial ion transport in preventing the dysfunction of fibrinolytic system during the progress of COVID-19.
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Affiliation(s)
- Yunmei Fu
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Hao Xue
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Tingyu Wang
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Yan Ding
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Yong Cui
- Department of Anesthesiology, the First Hospital of China Medical University, Shenyang 110001, China.
| | - Hongguang Nie
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China.
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Leverett GD, Marriott A. Intravenous tranexamic acid and thromboembolic events in hip fracture surgery: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2023; 109:103337. [PMID: 35643364 DOI: 10.1016/j.otsr.2022.103337] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Osteoporotic hip fractures are a major health problem in developed countries. Surgical management is the mainstay of treatment for these injuries, and historically presents an increased risk of thromboembolism, blood loss and blood transfusion. Despite the demonstrated safety of tranexamic acid (TXA) in elective hip arthroplasty, there is uncertainty regarding the risk of thromboembolism with the administration of TXA during hip fracture surgery. This study aims to address the following questions regarding patients undergoing traumatic hip fracture surgery: 1. Does intravenous TXA increase the risk of thromboembolic events? 2. Does intravenous TXA reduce peri-operative blood loss? 3. Does intravenous TXA increase the risk of non-thromboembolic complications or post-operative mortality? METHODS A literature search of Ovid MEDLINE, Embase, PubMed, the Cochrane Register of Controlled Trials and CINAHL was conducted, assessing results from database inception until the 11th May, 2021. We included randomised controlled trials that investigated perioperative administration of intravenous TXA in patients undergoing hip fracture surgery, compared to a control cohort. We excluded articles published in a language other than English, evaluated elective hip arthroplasty, or did not report thromboembolic events. Included trials were analysed using RevMan v5.3. RESULTS Sixteen articles encompassing 1491 patients met inclusion criteria. The risk difference of thromboembolic events in the TXA group was 0.02 (95%C.I. -0.01-0.04; p=0.17). TXA reduced post-operative transfusion rates by 42% (range: 28-54%, p<0.0001). The mean haemoglobin was higher in the TXA group on post-operative day one (0.77g/dL, p<0.0001), day two (0.56g/dL, p<0.0001) and day three (0.42g/dL, p<0.0001). There was no statistically significant difference in non-thromboembolic complications or post-operative mortality across the two cohorts. DISCUSSION There is no conclusive evidence from the current published literature that peri-operative intravenous TXA administration increases the risk of thromboembolic events after hip fracture surgery. This meta-analysis reinforces that TXA is effective in reducing post-operative transfusions and haemoglobin decline after hip fracture surgery. This study found that TXA did not increase non-thromboembolic complications or post-operative mortality. Further large-scale studies evaluating thromboembolic complications as a primary outcome are required to definitively establish the safety of TXA in hip fracture surgery. LEVEL OF EVIDENCE I; meta-analysis of randomised controlled trials.
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Affiliation(s)
- Gregory D Leverett
- Department of Anaesthesia and Perioperative Medicine, Eastern Health, Victoria, Australia; Department of Medicine and Veterinary Science, University of Edinburgh, Edinburgh, Scotland.
| | - Andrew Marriott
- Department of Anaesthetics, Perioperative and Pain Medicine, Barwon Health, Victoria, Australia; Clinical Associate Professor, School of Medicine, IMPACT SRC, Deakin University, Victoria, Australia
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Tanaka KA, Pontikes AE, Van D, Vandyck K, Butt A, Mazzeffi MA, Thakral R, Stewart KE. Relationships Between Body Mass Index, Allogeneic Transfusion, and Surgical Site Infection After Knee and Hip Arthroplasty Surgery. Anesth Analg 2023; 136:123-129. [PMID: 35389377 DOI: 10.1213/ane.0000000000006036] [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
BACKGROUND Increased body mass index (BMI) is considered as an important factor that affects the need for total knee and hip arthroplasty (TKA/THA) and the rate of perioperative complications. Previous investigations have not fully established the relationship of BMI and perioperative transfusion with surgical site infection (SSI) or the relationship of BMI and perioperative transfusion after TKA or THA. METHODS The National Surgical Quality Improvement Program database was used to perform a retrospective cohort study involving 333,223 TKA and 41,157 THA cases between 2011 and 2018. Multivariable regression assessed the associations of BMI (5 standard categories) and transfusion with SSI. Odds ratio (OR) of SSI was calculated relative to a normal BMI (18.5-24.9 kg/m 2 ) after adjustment of potential confounding factors. RESULTS Perioperative transfusion decreased significantly over time for both TKA and THA; however, SSI rates remained steady at just under 1% for TKA and 3% for THA. In TKA, a higher OR for SSI was associated only with a BMI of 40+ (OR, 1.86; 95% confidence interval [CI], 1.60-2.18) compared to a referent BMI. In THA, increased ORs of SSI were seen for all BMI levels above normal and were highest for a BMI 40+ (OR, 3.08; 95% CI, 2.47-3.83). In TKA, ORs of transfusion decreased with increasing BMI and were lowest for a BMI 40+ (OR, 0.51; 95% CI, 0.47-0.54). In THA, ORs of transfusion began to increase slightly in overweight patients, reaching an OR of 1.36 (95% CI, 1.21-1.54) for a BMI 40+. CONCLUSIONS SSI incidence remained unchanged despite continuous reductions in blood transfusion in TKA and THA patients over 8 years. In TKA, ORs for SSI increased, but ORs for transfusion decreased with increasing BMI above normal. Conversely, in THA, ORs for SSI and transfusion both increased for a BMI 40+, but only OR for transfusion increased in underweight patients. These findings suggest the importance of controlling obesity in reducing SSI following TKA and THA.
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Affiliation(s)
- Kenichi A Tanaka
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Andrew E Pontikes
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - David Van
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Kofi Vandyck
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Amir Butt
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Michael A Mazzeffi
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences
| | - Rishi Thakral
- Departments of Orthopedic Surgery and Rehabilitation
| | - Kenneth E Stewart
- Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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A Propensity-Matched Analysis of Tranexamic Acid and Acute Respiratory Distress Syndrome in Trauma Patients. J Surg Res 2022; 280:469-474. [PMID: 36058012 PMCID: PMC9575143 DOI: 10.1016/j.jss.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/23/2022] [Accepted: 06/09/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Tranexamic acid (TXA) protects the vasculature endothelium after hemorrhage, resulting in a decreased capillary leak. These properties may protect patients receiving TXA from acute respiratory distress syndrome (ARDS), however, clinical studies have yet to examine this topic. We hypothesized that trauma patients receiving TXA would have lower incidence of ARDS. METHODS This was a retrospective review of adult (18+ y) patients who presented to a large Level I trauma center with an injury severity score ≥ 16 from admit years 2012-2020. Propensity matching was employed to examine how TXA administration is associated with ARDS. RESULTS There were a total of 2751 patients meeting study criteria, with 162 (5.9%) received TXA. Of the 162 patients that received TXA, only 12 (7.4%) received pre-hospital TXA, while 4 (2.5%) received TXA both pre-hospital and in hospital. Of the 63 patients developing ARDS, 62 (98.4%) did not receive TXA. After propensity matching, 304 patients remained, with 152 in each cohort. The incidence of ARDS (P = 0.08), pneumonia (P = 0.68), any pulmonary complication (P = 0.33), and mortality (P = 0.37) were not different in patients receiving TXA on propensity matching. CONCLUSIONS TXA did not protect trauma patients from pulmonary complications; however, nearly all patients developing ARDS did not receive TXA. Larger studies should examine this relationship to improve understanding of therapies that may prevent ARDS.
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Xie CM, Yao YT, He LX, Yang K. Anti-inflammatory effect of tranexamic acid on adult cardiac surgical patients: A PRISMA-compliant systematic review and meta-analysis. Front Surg 2022; 9:951835. [PMID: 36263090 PMCID: PMC9574557 DOI: 10.3389/fsurg.2022.951835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/02/2022] [Indexed: 11/21/2022] Open
Abstract
Objective This study aims to evaluate the anti-inflammatory effect of tranexamic acid (TXA) on adult cardiac surgical patients. Methods PubMed, Embase, Ovid, Web of Science, CNKI, VIP, and WANFANG databases were systematically searched using the related keywords for cardiac surgical randomized controlled trials (RCTs) published from their inception to February 1, 2022. The primary outcomes were postoperative inflammatory biomarkers levels. The secondary outcomes were postoperative systemic inflammatory response syndrome and other major postoperative outcomes. The odds ratios and/or the weighted mean difference (WMD) with a 95% confidence interval (CI) were used to pool the data. Results Ten RCTs with 770 adult cardiac surgical patients were included. Compared with placebo, TXA achieved statistically significant inhibition of the postoperative interleukin (IL)-6 level (postoperative 6 h: n = 6 trials; WMD -31.66; 95% CI: -45.90, -17.42; p < 0.0001; I 2 = 93%; postoperative 24 h: n = 8 trials; WMD, -44.06; 95% CI: -69.21, -18.91; p = 0.006; I 2 = 100%); IL-8 level postoperative 24 h, TNF-α level postoperative 24 h, NE level postoperative 6 h: n = 3 trials; WMD, -36.83; 95% CI: -68.84, -4.83; p = 0.02; I 2 = 95%); tissue necrosis factor alpha (TNF-α) level (postoperative 6 h: n = 3 trials; WMD, -7.21; 95% CI: -12.41, -2.01; p = 0.007; I 2 = 47%; postoperative 24 h: n = 5 trials; WMD, -10.02; 95% CI: -14.93, -5.12; p < 0.0001; I 2 = 94%); and neutrophil elastase (NE) level (postoperative 6 h: n = 3 trials; WMD, -66.93; 95% CI: -111.94, -21.92; p = 0.004; I 2 = 86%). However, TXA achieved no statistically significant influence on the postoperative 24 h NE level. Conclusions TXA had a significant anti-inflammatory effect in adult cardiac surgical patients, as evidenced by the reduction of multiple postoperative proinflammatory biomarkers levels, but these results should be interpreted carefully and cautiously, as only a limited number of studies were included and there was high heterogeneity between them. Systematic Review Registration https://www.crd.york.ac.uk/prospero/#recordDetails, identifier: CRD42022312919.
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Affiliation(s)
- Chun-Mei Xie
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, China
| | - Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China,Correspondence: Yun-Tai Yao
| | - Li-Xian He
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, China
| | - Ke Yang
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, China
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Tranexamic Acid Associated With Less Wound Complications in Ankle and Hindfoot Surgery: Level III, Retrospective Cohort Study. J Am Acad Orthop Surg 2022; 30:789-797. [PMID: 35858253 DOI: 10.5435/jaaos-d-21-01064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 05/21/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The purpose of this study was to determine whether total ankle arthroplasty (TAA) and ankle/hindfoot fusion patients receiving tranexamic acid (TXA) exhibit fewer wound complications. METHODS A retrospective review was conducted of 212 patients (217 feet) undergoing TAA (n = 72), ankle (n = 36), tibiotalocalcaneal (n = 20), pantalar (n = 1), or hindfoot fusion (ie, subtalar = 47, double = 33, and triple = 8) between 2015 and 2020 by a fellowship-trained foot and ankle surgeon at an academic medical center. Demographics, medical history, complications, and union status were compared between TXA (n = 101) and non-TXA (n = 116) cohorts. The mean follow-up was 1.24 years (range, 0.25 to 4.68). RESULTS The TXA group had significantly less postoperative infections (5.9% versus 15.5%, P = 0.025). Within a subgroup analysis of ankle/hindfoot fusions, the TXA group exhibited significantly more Charcot neuroarthropathy (20.7% versus 5.7%, P = 0.006) and shorter follow-up duration (0.96 versus 1.30 years, P = 0.030); however, TXA was associated with shorter time to fusion (146 versus 202 days, P = 0.049) and fewer revision surgeries (8.6% versus 21.8%, P = 0.036). Subgroup analysis excluding feet with Charcot also demonstrated less postoperative infections (4.5% versus 14.4%, P = 0.020). Subgroup analysis of TAAs showed fewer cases of superficial infections (2.3% versus 27.6%, P = 0.002) and delayed wound healing (25.6% versus 48.3%, P = 0.047) in the TXA cohort. DISCUSSION TXA use in ankle/hindfoot surgery was correlated with a reduction in superficial infections and radiographic time to union. The use of TXA in TAA correlated with fewer superficial infections and cases of delayed wound healing. Thus, in addition to other areas of orthopaedics, TXA seems to be beneficial in hindfoot and ankle surgery. DATA AVAILABILITY AND TRIAL REGISTRATION NUMBERS All data were obtained from our institution's medical records. This study is not associated with a clinical trial.
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Gando S, Shiraishi A, Wada T, Yamakawa K, Fujishima S, Saitoh D, Kushimoto S, Ogura H, Abe T, Mayumi T, Sasaki J, Kotani J, Takeyama N, Tsuruta R, Takuma K, Shiraishi SI, Shiino Y, Nakada TA, Okamoto K, Sakamoto Y, Hagiwara A, Fujimi S, Umemura Y, Otomo Y. Effects of tranexamic acid on coagulofibrinolytic markers during the early stage of severe trauma: A propensity score-matched analysis. Medicine (Baltimore) 2022; 101:e29711. [PMID: 35960088 PMCID: PMC9371565 DOI: 10.1097/md.0000000000029711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Tranexamic acid (TXA) reduces the risk of bleeding trauma death without altering the need for blood transfusion. We examined the effects of TXA on coagulation and fibrinolysis dynamics and the volume of transfusion during the early stage of trauma. This subanalysis of a prospective multicenter study of severe trauma included 276 patients divided into propensity score-matched groups with and without TXA administration. The effects of TXA on coagulation and fibrinolysis markers immediately at (time point 0) and 3 hours after (time point 3) arrival at the emergency department were investigated. The transfusion volume was determined at 24 hours after admission. TXA was administered to the patients within 3 hours (median, 64 minutes) after injury. Significant reductions in fibrin/fibrinogen degradation products and D-dimer levels from time points 0 to 3 in the TXA group compared with the non-TXA group were confirmed, with no marked differences noted in the 24-hour transfusion volumes between the 2 groups. Continuously increased levels of soluble fibrin, a marker of thrombin generation, from time points 0 to 3 and high levels of plasminogen activator inhibitor-1, a marker of inhibition of fibrinolysis, at time point 3 were observed in both groups. TXA inhibited fibrin(ogen)olysis during the early stage of severe trauma, although this was not associated with a reduction in the transfusion volume. Other confounders affecting the dynamics of fibrinolysis and transfusion requirement need to be clarified.
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Affiliation(s)
- Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Japan
- *Correspondence: Satoshi Gando, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, N33E14, Higashi-ku 065-0033, Japan (e-mail: )
| | | | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical College, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
- Health Services Research and Development Center, University of Tsukuba, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Kiyotsugu Takuma
- Emergency and Critical Care Center, Kawasaki Municipal Hospital, Japan
| | | | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Japan
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Japan
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Prudovsky I, Kacer D, Zucco VV, Palmeri M, Falank C, Kramer R, Carter D, Rappold J. Tranexamic acid: Beyond antifibrinolysis. Transfusion 2022; 62 Suppl 1:S301-S312. [PMID: 35834488 DOI: 10.1111/trf.16976] [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: 11/30/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 11/30/2022]
Abstract
Tranexamic acid (TXA) is a popular antifibrinolytic drug widely used in hemorrhagic trauma patients and cardiovascular, orthopedic, and gynecological surgical patients. TXA binds plasminogen and prevents its maturation to the fibrinolytic enzyme plasmin. A number of studies have demonstrated the broad life-saving effects of TXA in trauma, superior to those of other antifibrinolytic agents. Besides preventing fibrinolysis and blood loss, TXA has been reported to suppress posttraumatic inflammation and edema. Although the efficiency of TXA transcends simple inhibition of fibrinolysis, little is known about its mechanisms of action besides the suppression of plasmin maturation. Understanding the broader effects of TXA at the cell, organ, and organism levels are required to elucidate its potential mechanisms of action transcending antifibrinolytic activity. In this article, we provide a brief review of the current clinical use of TXA and then focus on the effects of TXA beyond antifibrinolytics such as its anti-inflammatory activity, protection of the endothelial and epithelial monolayers, stimulation of mitochondrial respiration, and suppression of melanogenesis.
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Affiliation(s)
- Igor Prudovsky
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, USA
| | - Doreen Kacer
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, USA
| | - Victoria Vieira Zucco
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, USA
| | - Monica Palmeri
- Maine Medical Center Cardiovascular Institute, Maine Medical Center, Portland, Maine, USA
| | - Carolyne Falank
- Department of Trauma, Maine Medical Center, Maine Medical Center, Portland, Maine, USA
| | - Robert Kramer
- Maine Medical Center Cardiovascular Institute, Maine Medical Center, Portland, Maine, USA
| | - Damien Carter
- Department of Trauma, Maine Medical Center, Maine Medical Center, Portland, Maine, USA
| | - Joseph Rappold
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, USA.,Department of Trauma, Maine Medical Center, Maine Medical Center, Portland, Maine, USA
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Gibson BHY, Duvernay MT, McKeithan LJ, Benvenuti TA, Warhoover TA, Martus JE, Mencio GA, Emerson BR, Moore-Lotridge SN, Borst AJ, Schoenecker JG. Variable Response to Antifibrinolytics Correlates with Blood-loss and Transfusion in Posterior Spinal Fusion. Spine Deform 2022; 10:841-851. [PMID: 35247191 PMCID: PMC9891390 DOI: 10.1007/s43390-022-00489-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 02/19/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE Posterior spinal fusion (PSF) activates the fibrinolytic protease plasmin, which is implicated in blood loss and transfusion. While antifibrinolytic drugs have improved blood loss and reduced transfusion, variable blood loss has been observed in similar PSF procedures treated with the same dose of antifibrinolytics. However, both the cause of this and the appropriate measures to determine antifibrinolytic efficacy during high-blood-loss spine surgery are unknown, making clinical trials to optimize antifibrinolytic dosing in PSF difficult. We hypothesized that patients undergoing PSF respond differently to antifibrinolytic dosing, resulting in variable blood loss, and that specific diagnostic markers of plasmin activity will accurately measure the efficacy of antifibrinolytics in PSF. METHODS A prospective study of 17 patients undergoing elective PSF with the same dosing regimen of TXA was conducted. Surgery-induced plasmin activity was exhaustively analyzed in perioperative blood samples and correlated to measures of inflammation, bleeding, and transfusion. RESULTS While markers of in vivo plasmin activation (PAP and D-dimer) suggested significant breakthrough plasmin activation and fibrinolysis (P < 0.01), in vitro plasmin assays, including TEG, did not detect plasmin activation. In vivo measures of breakthrough plasmin activation correlated with blood loss (R2 = 0.400, 0.264; P < 0.01), transfusions (R2 = 0.388; P < 0.01), and complement activation (R2 = 0.346, P < 0.05). CONCLUSIONS Despite all patients receiving a high dose of TXA, its efficacy among patients was variable, indicated by notable intra-operative plasmin activity. Markers of in vivo plasmin activation best correlated with clinical outcomes. These findings suggest that the efficacy of antifibrinolytic therapy to inhibit plasmin in PSF surgery should be determined by markers of in vivo plasmin activation in future studies. LEVEL OF EVIDENCE Level II-diagnostic.
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Affiliation(s)
| | - Matthew T Duvernay
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Teresa A Benvenuti
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tracy A Warhoover
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey E Martus
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pediatrics, Vanderbilt University Medical Center, 1155 MRBIV, 2215B Garland Ave, Nashville, TN, 37232, USA
| | - Gregory A Mencio
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pediatrics, Vanderbilt University Medical Center, 1155 MRBIV, 2215B Garland Ave, Nashville, TN, 37232, USA
| | - Brian R Emerson
- Department of Pediatric Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephanie N Moore-Lotridge
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexandra J Borst
- Department of Pediatrics, Vanderbilt University Medical Center, 1155 MRBIV, 2215B Garland Ave, Nashville, TN, 37232, USA
- Department of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan G Schoenecker
- Department of Pharmacology, Vanderbilt University, Nashville, TN, USA.
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Pediatrics, Vanderbilt University Medical Center, 1155 MRBIV, 2215B Garland Ave, Nashville, TN, 37232, USA.
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Wallen TE, Singer KE, Baucom MR, England LG, Schuster RM, Pritts TA, Goodman MD. Effects of antifibrinolytics on systemic and cerebral inflammation after traumatic brain injury. J Trauma Acute Care Surg 2022; 93:30-37. [PMID: 35319541 PMCID: PMC9232970 DOI: 10.1097/ta.0000000000003607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Administration of antifibrinolytic medications, including tranexamic acid (TXA), may reduce head injury-related mortality. The effect of these medications on post-traumatic brain injury (TBI) inflammatory response is unknown. The goal of this study was to investigate the role of available antifibrinolytic medications on both systemic and cerebral inflammation after TBI. METHODS An established murine weight drop model was used to induce a moderate TBI. Mice were administered 1, 10, or 100 mg/kg of TXA, 400 mg/kg of aminocaproic acid (Amicar, Hospira, Lake Forest, IL), 100 kIU/kg of aprotonin, or equivalent volume of normal saline (NS) 10 minutes after recovery. Mice were euthanized at 1, 6, or 24 hours. Serum and cerebral tissue were analyzed for neuron-specific enolase and inflammatory cytokines. Hippocampal histology was evaluated at 30 days for phosphorylated tau accumulation. RESULTS One hour after TBI, mice given TXA displayed decreased cerebral cytokine concentrations of tumor necrosis factor α (TNF-α) and, by 24 hours, displayed decreased concentrations of cerebral TNF-α, interleukin (IL)-6, and monocyte chemoattractant protein 1 compared with TBI-NS. However, serum concentrations of TNF-α and macrophage inflammatory protein 1α (MIP-1α) were significantly elevated from 1 to 24 hours in TBI-TXA groups compared with TBI-NS. The concentration of phosphorylated tau was significantly decreased in a dose-dependent manner in TBI-TXA groups compared with TBI-NS. By contrast, Amicar administration increased cerebral cytokine levels of IL-6 1 hour after TBI, with serum elevations noted in TNF-α, MIP-1α, and monocyte chemoattractant protein 1 at 24 hours compared with TBI-NS. Aprotonin administration increased serum TNF-α, IL-6, and MIP-1α from 1 to 24 hours without differences in cerebral cytokines compared with TBI-NS. CONCLUSION Tranexamic acid administration may provide acute neuroinflammatory protection in a dose-dependent manner. Amicar administration may be detrimental after TBI with increased cerebral and systemic inflammatory effects. Aprotonin administration may increase systemic inflammation without significant contributions to neuroinflammation. While no antifibrinolytic medication improved systemic inflammation, these data suggest that TXA may provide the most beneficial inflammatory modulation after TBI.
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Affiliation(s)
- Taylor E Wallen
- From the Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Benjumea A, Díaz-Navarro M, Hafian R, Cercenado E, Sánchez-Somolinos M, Vaquero J, Chana F, Muñoz P, Guembe M. Tranexamic Acid in Combination With Vancomycin or Gentamicin Has a Synergistic Effect Against Staphylococci. Front Microbiol 2022; 13:935646. [PMID: 35847081 PMCID: PMC9280180 DOI: 10.3389/fmicb.2022.935646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic agent applied in orthopedic surgery and has been proven to reduce post-surgery infection rates. We previously showed that TXA also had an additional direct antimicrobial effect against planktonic bacteria. Therefore, we aimed to evaluate whether it has a synergistic effect if in combination with antibiotics. Materials and Methods Three ATCC and seven clinical strains of staphylococci were tested against serial dilutions of vancomycin and gentamicin alone and in combination with TXA at 10 and 50 mg/ml. The standardized microtiter plate method was used. Minimal inhibitory concentrations (MICs) were calculated by standard visualization of well turbidity (the lowest concentration at which complete absence of well bacterial growth was observed by the researcher) and using the automated method (the lowest concentration at which ≥80% reduction in well bacterial growth was measured using a spectrophotometer). Results Tranexamic acid-10 mg/ml reduced the MIC of vancomycin and gentamicin with both the standard method (V: 1-fold dilution, G: 4-fold dilutions) and the automated turbidity method (vancomycin: 8-fold dilutions, gentamicin: 8-fold dilutions). TXA-50 mg/ml reduced the MIC of gentamicin with both the standard turbidity method (6-fold dilutions) and the automated turbidity method (1-fold dilutions). In contrast, for vancomycin, the MIC remained the same using the standard method, and only a 1-fold dilution was reduced using the automated method. Conclusion Ours was a proof-of-concept study in which we suggest that TXA may have a synergistic effect when combined with both vancomycin and gentamicin, especially at 10 mg/ml, which is the concentration generally used in clinical practice.
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Affiliation(s)
- Antonio Benjumea
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marta Díaz-Navarro
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Rama Hafian
- School of Biology, Universidad Complutense de Madrid, Madrid, Spain
| | - Emilia Cercenado
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Mar Sánchez-Somolinos
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Vaquero
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Francisco Chana
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - María Guembe
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Tranexamic acid – A narrative review for the emergency medicine clinician. Am J Emerg Med 2022; 56:33-44. [DOI: 10.1016/j.ajem.2022.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/07/2022] [Accepted: 03/14/2022] [Indexed: 02/06/2023] Open
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Tranexamic Acid and Its Potential Anti-Inflammatory Effect: A Systematic Review. Semin Thromb Hemost 2022; 48:568-595. [PMID: 35636449 DOI: 10.1055/s-0042-1742741] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic drug primarily used for reducing blood loss in patients with major bleedings. Animal and cell studies have shown that TXA might modulate the inflammatory response by either enhancing or inhibiting cytokine levels. Furthermore, recent human studies have found altered inflammatory biomarkers in patients receiving TXA when compared with patients who did not receive TXA. In this systematic review we investigated the effect of TXA on inflammatory biomarkers in different patient groups. A systematic literature search was conducted on the databases PubMed and Embase to identify all original articles that investigated inflammatory biomarkers in patients receiving TXA and compared them to a relevant control group. The review was performed according to the PRISMA guidelines, and the literature search was performed on November 29, 2021. Thirty-three studies were included, among which 14 studies compared patients receiving TXA with patients getting no medication, another 14 studies investigated different dosing regimens of TXA, and finally five studies examined the administration form of TXA. The present review suggests that TXA has an anti-inflammatory effect in patients undergoing orthopaedic surgery illustrated by decreased levels of C-reactive protein and interleukin-6 in patients receiving TXA compared with patients receiving no or lower doses of TXA. However, the anti-inflammatory effect was not found in patients undergoing cardiac surgery, pediatric craniosynostosis patients, or in rheumatoid arthritis patients. The inflammatory response was not affected by administration form of TXA (oral, intravenous, or topical). In conclusion, an anti-inflammatory effect of TXA was consistently found among orthopaedic patients only.
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Draxler DF, Hanafi G, Zahra S, McCutcheon F, Ho H, Keragala CB, Liu Z, Daly D, Painter T, Wallace S, Plebanski M, Myles PS, Medcalf RL. Tranexamic acid alters the immunophenotype of phagocytes after lower limb surgery. Thromb J 2022; 20:17. [PMID: 35410340 PMCID: PMC8996554 DOI: 10.1186/s12959-022-00373-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic agent frequently used in elective surgery to reduce blood loss. We recently found it also acts as a potent immune-modulator in patients undergoing cardiac surgery. Methods Patients undergoing lower limb surgery were enrolled into the “Tranexamic Acid in Lower Limb Arthroplasty” (TALLAS) pilot study. The cellular immune response was characterised longitudinally pre- and post-operatively using full blood examination (FBE) and comprehensive immune cell phenotyping by flowcytometry. Red blood cells and platelets were determined in the FBE and levels of T cell cytokines and the plasmin-antiplasmin complex determined using ELISA. Results TXA administration increased the proportion of circulating CD141+ conventional dendritic cells (cDC) on post-operative day (POD) 3. It also reduced the expression of CD83 and TNFR2 on classical monocytes and levels of circulating IL-10 at the end of surgery (EOS) time point, whilst increasing the expression of CCR4 on natural killer (NK) cells at EOS, and reducing TNFR2 on POD-3 on NK cells. Red blood cells and platelets were decreased to a lower extent at POD-1 in the TXA group, representing reduced blood loss. Conclusion In this investigation we have extended our examination on the immunomodulatory effects of TXA in surgery by also characterising the end of surgery time point and including B cells and neutrophils in our immune analysis, elucidating new immunophenotypic changes in phagocytes as well as NK cells. This study enhances our understanding of TXA-mediated effects on the haemostatic and immune response in surgery, validating changes in important functional immune cell subsets in orthopaedic patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00373-3.
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Effect of Tranexamic Acid against Staphylococcus spp. and Cutibacterium acnes Associated with Peri-Implant Infection: Results from an In Vitro Study. Microbiol Spectr 2022; 10:e0161221. [PMID: 35171021 PMCID: PMC8849059 DOI: 10.1128/spectrum.01612-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Tranexamic acid (TXA) is extensively used in orthopedic surgery and traumatology as an antifibrinolytic agent to control intra- and postoperative bleeding and, therefore, indirectly, to reduce postsurgery infection rates. The hypothesis of an additional antibiotic effect against microorganisms associated with periprosthetic joint infection needs to be further evaluated. We aimed to assess whether TXA could reduce bacterial growth using an in vitro model. ATCC and clinical strains of staphylococci and Cutibacterium acnes were tested against TXA in both planktonic and sessile forms. We recorded the percent reduction in the following variables: log CFU/mL by microbiological culture, percentage of live cells by confocal laser scanning microscopy, and, additionally in sessile cells, metabolic activity by the 2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide salt (XTT) assay. Variables were compared between groups using the Kruskal-Wallis test, and the results were reported as median (interquartile range [IQR]). Statistical significance was set at a P value of <0.05. Clinical significance was defined as a reduction of ≥25%. TXA at 50 mg/mL led to a slight reduction in CFU counts (4.5%). However, it was at 10 mg/mL that the reduction reached 27.2% and 33.0% for log CFU/mL counts and percentage of live cells, respectively. TXA was not efficacious for reducing preformed 24-h mature staphylococci and 48-h mature C. acnes biofilms, regardless of its concentration. TXA did not exert an antimicrobial effect against bacterial biofilms. However, when bacteria were in the planktonic form, it led to a clinically and statistically significant reduction in bacterial growth at 10 mg/mL. IMPORTANCE The possible use of TXA as an antibiotic agent in addition to its antifibrinolytic effect may play an important role in the prevention of prosthetic joint infection.
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Kornelsen E, Kuppermann N, Nishijima D, Ren LY, Rumantir M, Gill PJ, Finkelstein Y. Effectiveness and safety of tranexamic acid in pediatric trauma: A systematic review and meta-analysis. Am J Emerg Med 2022; 55:103-110. [DOI: 10.1016/j.ajem.2022.01.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/25/2022] [Accepted: 01/31/2022] [Indexed: 12/27/2022] Open
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Gibson BHY, Wollenman CC, Moore-Lotridge SN, Keller PR, Summitt JB, Revenko AR, Flick MJ, Blackwell TS, Schoenecker JG. Plasmin drives burn-induced systemic inflammatory response syndrome. JCI Insight 2021; 6:154439. [PMID: 34877937 PMCID: PMC8675186 DOI: 10.1172/jci.insight.154439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 10/27/2021] [Indexed: 12/12/2022] Open
Abstract
Severe injuries, such as burns, provoke a systemic inflammatory response syndrome (SIRS) that imposes pathology on all organs. Simultaneously, severe injury also elicits activation of the fibrinolytic protease plasmin. While the principal adverse outcome of plasmin activation in severe injury is compromised hemostasis, plasmin also possesses proinflammatory properties. We hypothesized that, following a severe injury, early activation of plasmin drives SIRS. Plasmin activation was measured and related to injury severity, SIRS, coagulopathy, and outcomes prospectively in burn patients who are not at risk of hemorrhage. Patients exhibited early, significant activation of plasmin that correlated with burn severity, cytokines, coagulopathy, and death. Burn with a concomitant, remote muscle injury was employed in mice to determine the role of plasmin in the cytokine storm and inflammatory cascades in injured tissue distant from the burn injury. Genetic and pharmacologic inhibition of plasmin reduced the burn-induced cytokine storm and inflammatory signaling in injured tissue. These findings demonstrate (a) that severe injury-induced plasmin activation is a key pathologic component of the SIRS-driven cytokine storm and SIRS-activated inflammatory cascades in tissues distant from the inciting injury and (b) that targeted inhibition of plasmin activation may be effective for limiting both hemorrhage and tissue-damaging inflammation following injury.
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Affiliation(s)
| | - Colby C Wollenman
- School of Medicine.,Department of Orthopaedic Surgery, Vanderbilt University Medical Center
| | - Stephanie N Moore-Lotridge
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center.,Vanderbilt Center for Bone Biology
| | | | - J Blair Summitt
- Department of Plastic Surgery, Vanderbilt University Medical Center; and.,Vanderbilt University Medical Center Burn Center, Vanderbilt University, Nashville, Tennessee, USA
| | - Alexey R Revenko
- IONIS Pharmaceuticals Pulmonary and Oncology Drug Discovery, Carlsbad, California, USA
| | - Matthew J Flick
- Department of Pathology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA.,University of North Carolina Blood Research Center, Chapel Hill, North Carolina, USA
| | - Timothy S Blackwell
- Department of Cancer Biology, Vanderbilt University, Nashville, Tennessee, USA.,Division of Pulmonary and Critical Care
| | - Jonathan G Schoenecker
- Department of Pharmacology.,Department of Orthopaedic Surgery, Vanderbilt University Medical Center.,Vanderbilt Center for Bone Biology.,Department of Pathology, Microbiology, and Immunology; and.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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41
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Peña Borras JJ, Pajares Moncho A, Puig J, Mateo Rodríguez E, López Forte C, Peña Pérez L, Moreno Pachón J, Gabaldón Conejos T, Pérez Artacho J, Ferrer Gómez C, Férez Martí A, López Cantero M, de Andrés Ibáñez J. Tranexamic acid in cardiac surgery: Are low doses enough? REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:576-583. [PMID: 34857506 DOI: 10.1016/j.redare.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 02/09/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Tranexamic acid is used to prevent hyperfibrinolysis and reduce postoperative bleeding and blood transfusions in on-pump cardiac surgery. We evaluate the efficacy of low or high dose tranexamic acid in a prospective cohort study conducted in Valencia. MATERIALS AND METHODS A total of 427 patients were recruited between January 2019 and January 2020, 207 in the Hospital General Universitario (low dose [LD]) and 220 in the Hospital Universitario y Politécnico La Fe (high dose [HD] and intermediate dose [ID]). We recorded the presence of hyperfibrinolysis on rotational thromboelastometry, intra- and postoperative administration of blood products, chest tube output within the first 12 h, and incidence of convulsions. Univariate and multivariate comparisons were performed. Univariate analysis of all categories was performed after propensity score matching between LD and HD and between LD and ID. RESULTS There were no statistically significant differences in: appearance of hyperfibrinolysis, administration of blood products, postoperative chest tube output within the first 12 h, or occurrence of convulsions. Group LD received less fibrinogen than group HD (P = .014) and ID (P = .040) but more fresh frozen plasma than group ID (P = .0002). CONCLUSIONS Administration of low-dose tranexamic acid is as effective as higher doses in hyperfibrinolysis prophylaxis and the prevention of postoperative bleeding in cardiac surgery.
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Affiliation(s)
- J J Peña Borras
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - A Pajares Moncho
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - J Puig
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain; Departamento de Cirugía, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, Spain.
| | - E Mateo Rodríguez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - C López Forte
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - L Peña Pérez
- Centre for Haematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - J Moreno Pachón
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - T Gabaldón Conejos
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - J Pérez Artacho
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - C Ferrer Gómez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - A Férez Martí
- Servicio de Análisis Clínicos, Hospital General Universitario de Valencia, Valencia, Spain
| | - M López Cantero
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - J de Andrés Ibáñez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain; Departamento de Cirugía, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, Spain
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42
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Strauss ER, Li S, Henderson R, Carpenter R, Guo D, Thangaraju K, Katneni U, Buehler PW, Gobburu JV, Tanaka KA. A pharmacokinetic and plasmin generation pharmacodynamic assessment of a tranexamic acid regimen designed for cardiac surgery with cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2021; 36:2473-2482. [DOI: 10.1053/j.jvca.2021.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/16/2021] [Accepted: 12/23/2021] [Indexed: 11/11/2022]
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43
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Peña Borras JJ, Pajares Moncho A, Puig J, Mateo Rodríguez E, López Forte C, Peña Pérez L, Moreno Pachón J, Gabaldón Conejos T, Pérez Artacho J, Ferrer Gómez C, Férez Martí A, López Cantero M, de Andrés Ibáñez J. Tranexamic acid in cardiac surgery: Are low doses enough? REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:S0034-9356(21)00105-5. [PMID: 34538453 DOI: 10.1016/j.redar.2021.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/04/2020] [Accepted: 02/09/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Tranexamic acid is used to prevent hyperfibrinolysis and reduce postoperative bleeding and blood transfusions in on-pump cardiac surgery. We evaluate the efficacy of low or high dose tranexamic acid in a prospective cohort study conducted in Valencia. MATERIALS AND METHODS A total of 427 patients were recruited between January 2019 and January 2020, 207 in the Hospital General Universitario (low dose [LD]) and 220 in the Hospital Universitario y Politécnico La Fe (high dose [HD] and intermediate dose [ID]). We recorded the presence of hyperfibrinolysis on rotational thromboelastometry, intra- and postoperative administration of blood products, chest tube output within the first 12h, and incidence of convulsions. Univariate and multivariate comparisons were performed. Univariate analysis of all categories was performed after propensity score matching between LD and HD and between LD and ID. RESULTS There were no statistically significant differences in: appearance of hyperfibrinolysis, administration of blood products, postoperative chest tube output within the first 12h, or occurrence of convulsions. Group LD received less fibrinogen than group HD (P=.014) and ID (P=.040) but more fresh frozen plasma than group ID (P=.0002). CONCLUSIONS Administration of low-dose tranexamic acid is as effective as higher doses in hyperfibrinolysis prophylaxis and the prevention of postoperative bleeding in cardiac surgery.
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Affiliation(s)
- J J Peña Borras
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - A Pajares Moncho
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - J Puig
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España; Departamento de Cirugía, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, España.
| | - E Mateo Rodríguez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - C López Forte
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - L Peña Pérez
- Centre for Haematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Suecia
| | - J Moreno Pachón
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón Conejos
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - J Pérez Artacho
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - C Ferrer Gómez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - A Férez Martí
- Servicio de Análisis Clínicos, Hospital General Universitario de Valencia, Valencia, España
| | - M López Cantero
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - J de Andrés Ibáñez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España; Departamento de Cirugía, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, España
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44
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Tranexamic acid rapidly inhibits fibrinolysis, yet transiently enhances plasmin generation in vivo. Blood Coagul Fibrinolysis 2021; 32:172-179. [PMID: 33443933 DOI: 10.1097/mbc.0000000000001008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tranexamic acid (TXA) is a lysine analogue that inhibits plasmin generation and has been used for decades as an antifibrinolytic agent to reduce bleeding. Recent reports have indicated that TXA can paradoxically promote plasmin generation. Blood was obtained from 41 cardiac surgical patients randomly assigned to TXA or placebo before start of surgery (preOP), at the end of surgery (EOS), then again on postoperative day 1 (POD-1) as well as POD-3. Plasma levels of tissue-type plasminogen activator (t-PA), urokinase (u-PA), the plasmin-antiplasmin (PAP) complex, as well as t-PA and u-PA-induced clot lysis assays were then determined. Clot lysis and PAP complex levels were also assessed in healthy volunteers before and at various time points after taking 1 g TXA orally. Surgery induced an increase in circulating t-PA, yet not u-PA at EOS. t-PA levels were unaffected by TXA; however, u-PA levels were significantly reduced in patients on POD-3. t-PA and u-PA-induced clot lysis were both inhibited in plasma from TXA-treated patients. In contrast, PAP complex formation, representing plasmin generation, was unexpectedly enhanced in the plasma of patients administered TXA at the EOS time point. In healthy volunteers, oral TXA effectively blocked fibrinolysis within 30 min and blockade was sustained for 8 h. However, TXA also increased PAP levels in volunteers 4 h after administration. Our findings demonstrate that TXA can actually augment PAP complex formation, consistent with an increase in plasmin generation in vivo despite the fact that it blocks fibrinolysis within 30 min. This may have unanticipated consequences in vivo.
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45
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Abstract
The deposition and removal of fibrin has been the primary role of coagulation and fibrinolysis, respectively. There is also little doubt that these 2 enzyme cascades influence each other given they share the same serine protease family ancestry and changes to 1 arm of the hemostatic pathway would influence the other. The fibrinolytic system in particular has also been known for its capacity to clear various non-fibrin proteins and to activate other enzyme systems, including complement and the contact pathway. Furthermore, it can also convert a number of growth factors into their mature, active forms. More recent findings have extended the reach of this system even further. Here we will review some of these developments and also provide an account of the influence of individual players of the fibrinolytic (plasminogen activating) pathway in relation to physiological and pathophysiological events, including aging and metabolism.
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46
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Abstract
Plasminogen is an abundant plasma protein that exists in various zymogenic forms. Plasmin, the proteolytically active form of plasminogen, is known for its essential role in fibrinolysis. To date, therapeutic targeting of the fibrinolytic system has been for 2 purposes: to promote plasmin generation for thromboembolic conditions or to stop plasmin to reduce bleeding. However, plasmin and plasminogen serve other important functions, some of which are unrelated to fibrin removal. Indeed, for >40 years, the antifibrinolytic agent tranexamic acid has been administered for its serendipitously discovered skin-whitening properties. Plasmin also plays an important role in the removal of misfolded/aggregated proteins and can trigger other enzymatic cascades, including complement. In addition, plasminogen, via binding to one of its dozen cell surface receptors, can modulate cell behavior and further influence immune and inflammatory processes. Plasminogen administration itself has been reported to improve thrombolysis and to accelerate wound repair. Although many of these more recent findings have been derived from in vitro or animal studies, the use of antifibrinolytic agents to reduce bleeding in humans has revealed additional clinically relevant consequences, particularly in relation to reducing infection risk that is independent of its hemostatic effects. The finding that many viruses harness the host plasminogen to aid infectivity has suggested that antifibrinolytic agents may have antiviral benefits. Here, we review the broadening role of the plasminogen-activating system in physiology and pathophysiology and how manipulation of this system may be harnessed for benefits unrelated to its conventional application in thrombosis and hemostasis.
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47
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Briggs GD, Balogh ZJ. Tranexamic acid and inflammation in trauma. ANZ J Surg 2021; 90:426-428. [PMID: 32339431 DOI: 10.1111/ans.15755] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Gabrielle D Briggs
- Discipline of Surgery, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Zsolt J Balogh
- Discipline of Surgery, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Department of Traumatology, John Hunter Hospital, Newcastle, New South Wales, Australia
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48
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Hastings S, Myles PS, Medcalf RL. Plasmin, Immunity, and Surgical Site Infection. J Clin Med 2021; 10:2070. [PMID: 34065949 PMCID: PMC8150767 DOI: 10.3390/jcm10102070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/05/2021] [Accepted: 05/10/2021] [Indexed: 12/20/2022] Open
Abstract
SSI are a universal economic burden and increase individual patient morbidity and mortality. While antibiotic prophylaxis is the primary preventative intervention, these agents are not themselves benign and may be less effective in the context of emerging antibiotic resistant organisms. Exploration of novel therapies as an adjunct to antimicrobials is warranted. Plasmin and the plasminogen activating system has a complex role in immune function. The immunothrombotic role of plasmin is densely interwoven with the coagulation system and has a multitude of effects on the immune system constituents, which may not always be beneficial. Tranexamic acid is an antifibrinolytic agent which inhibits the conversion of plasminogen to plasmin. Clinical trials have demonstrated a reduction in surgical site infection in TXA exposed patients, however the mechanism and magnitude of this benefit is incompletely understood. This effect may be through the reduction of local wound haematoma, decreased allogenic blood transfusion or a direct immunomodulatory effect. Large scale randomised clinical trial are currently being undertaken to better explain this association. Importantly, TXA is a safe and widely available pharmacological agent which may have a role in the reduction of SSI.
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Affiliation(s)
- Stuart Hastings
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC 3004, Australia;
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Paul S. Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC 3004, Australia;
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Robert L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC 3004, Australia;
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49
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Draxler DF, Medcalf RL. Fibrinolysis and tranexamic acid: mechanistic principles. ANZ J Surg 2021; 90:410-411. [PMID: 32339417 DOI: 10.1111/ans.15541] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 01/11/2023]
Affiliation(s)
- Dominik F Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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50
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Kolev K, Medcalf RL. Editorial: Fibrinolysis in Immunity. Front Immunol 2021; 11:582. [PMID: 32296445 PMCID: PMC7137896 DOI: 10.3389/fimmu.2020.00582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/13/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Krasimir Kolev
- Department of Medical Biochemistry, Semmelweis University, Budapest, Hungary
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
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