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Wang H, Ouyang Y, Chen Y, Zeng L. Clinical application of tranexamic acid in arthroscopic rotator cuff repair surgery: A randomized controlled trial. Medicine (Baltimore) 2024; 103:e38515. [PMID: 38941391 DOI: 10.1097/md.0000000000038515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND To investigate whether intravenous administration of tranexamic acid (TXA) prior to arthroscopic rotator cuff repair improves operative blood loss, postoperative fibrinolytic index, inflammatory response, and postoperative pain. METHODS This was a prospective, double-blind, randomized controlled study. From January 2023 to February 2024, 64 patients who required arthroscopic rotator cuff repair were included and divided into tranexamic acid group (T group) group and control group (C group) according to the random number table method. In T group, 1000 mg TXA was administered intravenously 10 minutes before surgery, and an equivalent dose of normal saline was administered intravenously 10 minutes before surgery in C group. Intraoperative bleeding, postoperative fibrinolytic indexes, inflammatory indexes, pain scores, and occurrence of adverse effects were compared between the 2 groups. RESULTS Intraoperative bleeding in T group was lower than that in C group (P < .05); D-D and FDP in T group were significantly lower than those in C group (P < .05); postoperative TNF-α and IL-6 in 2 groups was higher than that before operation and T group was lower than C group (P < .05); The pain scores of the 2 groups after operation were lower than those before operation (P < .05), and there was no difference between the 2 groups (P > .05). CONCLUSION SUBSECTIONS TXA is able to reduce blood loss and inflammatory reactions, modulate fibrinolytic function, and promote postoperative recovery in patients undergoing arthroscopic rotator cuff repair, with no elevated risk of complications.
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Affiliation(s)
- Huihu Wang
- Department of Anesthesiology, Shifang People's Hospital, Shifang, Sichuan Province, China
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Kanhangad MP, Ramachandra Theja V, Bhat SN. Role of tranexamic acid in reducing peri-operative blood loss in open spine surgeries. Musculoskelet Surg 2024:10.1007/s12306-024-00826-0. [PMID: 38819771 DOI: 10.1007/s12306-024-00826-0] [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: 01/22/2024] [Accepted: 05/15/2024] [Indexed: 06/01/2024]
Abstract
Spine surgeries are associated with significant blood loss due to the extensive soft tissue dissection, bony decompression, and prolonged surgical time. Excessive bleeding may require blood transfusions and thereby increase the risk of adverse transfusion reactions. Therefore, minimizing peri-operative bleeding is important for spine surgeons to reduce post-operative morbidity. Tranexamic acid (TXA) is a synthetic anti-fibrinolytic drug, which helps in reducing perioperative blood loss in major surgeries. The evidence on the efficacy of this agent in all manner of spine surgeries is not sufficient. Hence this study was conducted to determine the efficacy of TXA on perioperative blood loss in major spinal surgeries. In a prospective study, two groups of patients with similar surgical profiles who were posted for all manner of open spine surgeries were included. One group received one gram of intravenous TXA while the others did not. Intra- and post-operative assessments included noting levels of surgery, duration of surgery, assessment of blood loss, intra- and/or post- operative blood transfusion, and blood collected in surgical drain at the end of 24 h. The intra-operative blood loss, frequency of intra-operative blood transfusion, post-operative Hemoglobin drop, and surgical drain output were found to be significantly lower in patients who received TXA. In spine surgeries, TXA was found to be effective in reducing intra-operative blood loss, need for intra-operative blood transfusion and post-operative Hb drop. Also, TXA had reduced surgical drain output significantly between the two groups.
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Affiliation(s)
- Madhava Pai Kanhangad
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - V Ramachandra Theja
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Shyamasunder N Bhat
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
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Fouche PF, Stein C, Nichols M, Meadley B, Bendall JC, Smith K, Anderson D, Doi SA. Tranexamic Acid for Traumatic Injury in the Emergency Setting: A Systematic Review and Bias-Adjusted Meta-Analysis of Randomized Controlled Trials. Ann Emerg Med 2024; 83:435-445. [PMID: 37999653 DOI: 10.1016/j.annemergmed.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/14/2023] [Accepted: 10/06/2023] [Indexed: 11/25/2023]
Abstract
STUDY OBJECTIVE Traumatic injury causes a significant number of deaths due to bleeding. Tranexamic acid (TXA), an antifibrinolytic agent, can reduce bleeding in traumatic injuries and potentially enhance outcomes. Previous reviews suggested potential TXA benefits but did not consider the latest trials. METHODS A systematic review and bias-adjusted meta-analysis were performed to assess TXA's effectiveness in emergency traumatic injury settings by pooling estimates from randomized controlled trials. Researchers searched Medline, Embase, and Cochrane Central for randomized controlled trials comparing TXA's effects to a placebo in emergency trauma cases. The primary endpoint was 1-month mortality. The methodological quality of the trials underwent assessment using the MASTER scale, and the meta-analysis applied the quality-effects method to adjust for methodological quality. RESULTS Seven randomized controlled trials met the set criteria. This meta-analysis indicated an 11% decrease in the death risk at 1 month after TXA use (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.84 to 0.95) with a number needed to treat of 61 to avoid 1 additional death. The meta-analysis also revealed reduced 24-hour mortality (OR 0.76, 95% CI 0.65 to 0.88) for TXA. No compelling evidence of increased vascular occlusive events emerged (OR 0.96, 95% CI 0.73 to 1.27). Subgroup analyses highlighted TXA's effectiveness in general trauma versus traumatic brain injury and survival advantages when administered out-of-hospital versus inhospital. CONCLUSIONS This synthesis demonstrates that TXA use for trauma in emergencies leads to a reduction in 1-month mortality, with no significant evidence of problematic vascular occlusive events. Administering TXA in the out-of-hospital setting is associated with reduced mortality compared to inhospital administration, and less mortality with TXA in systemic trauma is noted compared with traumatic brain injury specifically.
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Affiliation(s)
| | - Christopher Stein
- Department of Emergency Medical Care, University of Johannesburg, Johannesburg, Gauteng, South Africa
| | - Martin Nichols
- Clinical Systems, New South Wales Ambulance, Rozelle, NSW, Australia
| | - Benjamin Meadley
- Department of Paramedicine, Monash University, Mulgrave, Victoria, Australia
| | - Jason C Bendall
- Clinical Systems, New South Wales Ambulance, Rozelle, NSW, Australia
| | | | | | - Suhail A Doi
- College of Medicine, Qatar University, Doha, Qatar
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Yu H, Liu M, Zhang X, Ma T, Yang J, Wu Y, Wang J, Li M, Wang J, Zeng M, Zhang L, Jin H, Liu X, Li S, Peng Y. The effect of tranexamic acid on intraoperative blood loss in patients undergoing brain meningioma resections: Study protocol for a randomized controlled trial. PLoS One 2023; 18:e0290725. [PMID: 37651373 PMCID: PMC10470952 DOI: 10.1371/journal.pone.0290725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 06/18/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) has been proven to prevent thrombolysis and reduce bleeding and blood transfusion requirements in various surgical settings. However, the optimal dose of TXA that effectively reduce intraoperative bleeding and blood product infusion in patients undergoing neurosurgical resection of meningioma with a diameter ≥ 5 cm remains unclear. METHODS This is a single-center, randomized, double-blinded, paralleled-group controlled trial. Patients scheduled to receive elective tumor resection with meningioma diameter ≥ 5 cm will be randomly assigned the high-dose TXA group, the low-dose group, and the placebo. Patients in the high-dose TXA group will be administered with a loading dose of 20 mg/kg TXA followed by continuous infusion TXA at a rate of 5 mg/kg/h. In the low-dose group, patients will receive the same loading dose of TXA followed by a continuous infusion of normal saline. In the control group, patients will receive an identical volume of normal saline. The primary outcome is the estimated intraoperative blood loss calculated using the following formula: collected blood volume in the suction canister (mL)-the volume of flushing (mL) + the volume from the gauze tampon (mL). Secondary outcomes include calculated intraoperative blood loss, intraoperative coagulation function assessed using thromboelastogram (TEG), intraoperative cell salvage use, blood product infusion, and other safety outcomes. DISCUSSION Preclinical studies suggest that TXA could reduce intraoperative blood loss, yet the optimal dose was controversial. This study is one of the early studies to evaluate the impact of intraoperative different doses infusion of TXA on reducing blood loss in neurological meningioma patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT05230381. Registered on February 8, 2022.
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Affiliation(s)
- Haojie Yu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Minying Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingyue Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingting Ma
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jingchao Yang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yaru Wu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jie Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Muhan Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Juan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liyong Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hailong Jin
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyuan Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Shakur-Still H, Roberts I. Tranexamic Acid for Trauma Patients - More Lives to Save and Outcomes to Consider. N Engl J Med 2023; 389:181-183. [PMID: 37314242 DOI: 10.1056/nejme2305075] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Haleema Shakur-Still
- From the Global Health Trials Group, Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London
| | - Ian Roberts
- From the Global Health Trials Group, Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London
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Hmidan Simsam M, Delorme L, Grimm D, Priestap F, Bohnert S, Descoteaux M, Hilsden R, Laverty C, Mickler J, Parry N, Rochwerg B, Sherman C, Smith S, Toole J, Vogt K, Wilson S, Ball I. Efficacy of high dose tranexamic acid (TXA) for hemorrhage: A systematic review and meta-analysis. Injury 2023; 54:857-870. [PMID: 36746710 DOI: 10.1016/j.injury.2022.12.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Standard dose (≤ 1 g) tranexamic acid (TXA) has established mortality benefit in trauma patients. The role of high dose IV TXA (≥2 g or ≥30 mg/kg as a single bolus) has been evaluated in the surgical setting, however, it has not been studied in trauma. We reviewed the available evidence of high dose IV TXA in any setting with the goal of informing its use in the adult trauma population. METHODS We searched MEDLINE, EMBASE and unpublished sources from inception until July 27, 2022 for studies that compared standard dose with high dose IV TXA in adults (≥ 16 years of age) with hemorrhage. Screening and data abstraction was done independently and in duplicate. We pooled trial data using a random effects model and considered randomized controlled trials (RCTs) and observational cohort studies separately. We assessed the individual study risk of bias using the Cochrane Risk of Bias for RCTs and the Newcastle-Ottawa Scale for observational cohort studies. The overall certainty of evidence was assessed using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation). RESULTS We included 20 studies with a combined total of 12,523 patients. Based on pooled RCT data, and as compared to standard dose TXA, high dose IV TXA probably decreases transfusion requirements (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.76 to 0.97, moderate certainty) but with possibly no effect on blood loss (mean difference [MD] 43.31 ml less, 95% CI 135.53 to 48.90 ml less, low certainty), and an uncertain effect on thromboembolic events (OR 1.33, 95% CI 0.86 to 2.04, very low certainty) and mortality (OR 0.70, 95% CI 0.37 to 1.32, very low certainty). CONCLUSION When compared to standard dose, high dose IV TXA probably reduces transfusion requirements with an uncertain effect on thromboembolic events and mortality. LEVEL OF EVIDENCE Systematic review and meta-analysis, level IV.
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Affiliation(s)
- Mohammad Hmidan Simsam
- Schulich School of Medicine and Dentistry, Western University, 1397 Medway Park Dr, London, Ontario N6G 0Z6, Canada.
| | - Laurence Delorme
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Dylan Grimm
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Fran Priestap
- London Health Sciences Centre Trauma Program, London, Ontario, Canada
| | | | | | - Rich Hilsden
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Royal Canadian Medical Service, Canada; Department of Surgery, Western University, London, Ontario, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada
| | | | | | - Neil Parry
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada
| | - Bram Rochwerg
- Department of Medicine, MacMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Shane Smith
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Royal Canadian Medical Service, Canada; Department of Surgery, Western University, London, Ontario, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada
| | | | - Kelly Vogt
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada
| | | | - Ian Ball
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Royal Canadian Medical Service, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Roberts I, Brenner A, Shakur-Still H. Tranexamic acid for bleeding: Much more than a treatment for postpartum hemorrhage. Am J Obstet Gynecol MFM 2023; 5:100722. [PMID: 35988879 DOI: 10.1016/j.ajogmf.2022.100722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/01/2022] [Accepted: 08/13/2022] [Indexed: 10/15/2022]
Abstract
The evidence that early tranexamic acid treatment reduces postpartum hemorrhage deaths has major implications for obstetrical care worldwide. Tranexamic acid may also have a role in the prevention of postpartum hemorrhage, but more evidence is needed on the balance of risks and benefits. Most deaths from postpartum hemorrhage are in low- and middle-income countries where tranexamic acid treatment is often unavailable. Several maternal health organizations including the Reproductive Health Supplies Coalition, Clinton Health Access Initiative, Concept Foundation, International Federation of Gynecology and Obstetrics, and Unitaid are working to increase access. However, a wider view of the evidence on tranexamic acid and bleeding shows that it can improve maternal health in many other ways. An appreciation of these other health benefits could facilitate efforts to increase access. By reducing heavy menstrual bleeding, tranexamic acid could reduce the prevalence of maternal anemia, a common and important risk factor for postpartum hemorrhage and other maternal and neonatal outcomes. Further clinical trials of tranexamic acid for the treatment of menstrual bleeding are needed. By reducing surgical bleeding and the need for blood transfusion, tranexamic acid would increase the availability of blood in countries where there is blood shortage so that more blood is available for use in life-threatening bleeding including postpartum hemorrhage. In countries where there is no blood shortage, tranexamic acid use would reduce healthcare costs and prevent transfusion-transmitted infections and reactions. Trauma affects women and men, and violence is a leading cause of death in pregnancy. Increased use of tranexamic acid in trauma would significantly reduce trauma deaths. Efforts to increase the availability and use of tranexamic acid for obstetrical hemorrhage should acknowledge its other health benefits and aim to increase its use across health services more generally.
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Affiliation(s)
- Ian Roberts
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | - Amy Brenner
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Haleema Shakur-Still
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Bivens MJ, Fritz CL, Burke RC, Schoenfeld DW, Pope JV. State-by-state estimates of avoidable trauma mortality with early and liberal versus delayed or restricted administration of tranexamic acid. BMC Emerg Med 2022; 22:191. [PMID: 36463125 PMCID: PMC9719138 DOI: 10.1186/s12873-022-00741-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 11/03/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE Early administration of tranexamic acid (TXA) has been shown to save lives in trauma patients, and some U.S. emergency medical systems (EMS) have begun providing this therapy prehospital. Treatment protocols vary from state to state: Some offer TXA broadly to major trauma patients, others reserve it for patients meeting vital sign criteria, and still others defer TXA entirely pending a hospital evaluation. The purpose of this study is to compare the avoidable mortality achievable under each of these strategies, and to report on the various approaches used by EMS. METHODS We used the National Center for Health Statistics Underlying Cause of Death data to identify a TXA-naïve population of trauma patients who died from 2007 to 2012 due to hemorrhage. We estimated the proportion of deaths where the patient was hypotensive or tachycardic using the National Trauma Data Bank. We used avoidable mortality risk ratios from the landmark CRASH 2 study to calculate lives saved had TXA been given within one hour of injury based on a clinician's gestalt the patient was at risk for significant hemorrhage; had it been reserved only for hypotensive or tachycardic patients; or had it been given between hours one to three of injury, considered here as a surrogate for deferring the question to the receiving hospital. RESULTS Had TXA been given within 1 hour of injury, an average of 3409 deaths per year could have been averted nationally. Had TXA been given between one and three hours after injury, 2236 deaths per year could have been averted. Had TXA only been given to either tachycardic or hypotensive trauma patients, 1371 deaths per year could have been averted. Had TXA only been given to hypotensive trauma patients, 616 deaths per year could have been averted. Similar trends are seen at the individual state level. A review of EMS practices found 15 statewide protocols that allow EMS providers to administer TXA for trauma. CONCLUSION Providing early TXA to persons at risk of significant hemorrhage has the potential to prevent many deaths from trauma, yet most states do not offer it in statewide prehospital treatment protocols.
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Affiliation(s)
- Matthew J. Bivens
- grid.239395.70000 0000 9011 8547Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, MA Boston, USA
| | - Christie L. Fritz
- grid.239395.70000 0000 9011 8547Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, MA Boston, USA
| | - Ryan C. Burke
- grid.239395.70000 0000 9011 8547Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - David W. Schoenfeld
- grid.239395.70000 0000 9011 8547Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, MA Boston, USA
| | - Jennifer V. Pope
- grid.413480.a0000 0004 0440 749XDepartment of Emergency Medicine, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH USA
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Gettig K, Maxson RT. International needs in pediatric trauma. Semin Pediatr Surg 2022; 31:151223. [PMID: 36379159 DOI: 10.1016/j.sempedsurg.2022.151223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Kelly Gettig
- Lead Pediatric Nurse Practitioner, Physical Medicine and Rehabilitation; Director, Traumatic Brain Injury/Concussion Clinic Dell Children's Medical Center, Austin, TX, United States.
| | - R Todd Maxson
- Pediatric Surgery - UAMS Surgeon-in-Chief Rachel Fuller Endowed Chair Associate Trauma Medical Director Arkansas Children's Hospital, United States
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Roberts I, Shakur-Still H. Decolonising knowledge production: our experience researching tranexamic acid for trauma victims. BMJ 2022; 377:o1338. [PMID: 35623649 DOI: 10.1136/bmj.o1338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Ian Roberts
- London School of Hygiene and Tropical Medicine
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Roberts I, Shakur-Still H. Tranexamic acid for trauma in the USA: is prejudice a barrier to saving lives? Lancet 2022; 399:1675-1677. [PMID: 35429441 DOI: 10.1016/s0140-6736(22)00664-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.
| | - Haleema Shakur-Still
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
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12
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Thota B, Marinica A, Oh MW, Cripps MW, Moon TS. The Use of Tranexamic Acid in Trauma. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00509-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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White NJ, Reitzel SL, Doyle-Baker D, Sabo MT, Mattiello B, Samuel TL. Management of patients with hip fracture receiving anticoagulation: What are we doing in Canada? Can J Surg 2021; 64:E510-E515. [PMID: 34598928 PMCID: PMC8526126 DOI: 10.1503/cjs.018520] [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] [Accepted: 10/28/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Direct oral anticoagulants (DOACs) are rapidly replacing warfarin for therapeutic anticoagulation; however, many DOACs are irreversible and may complicate bleeding in emergent situations such as hip fracture. In this setting, there is a lack of clear guidelines for the timing of surgery. The purpose of this study was to evaluate the current practices of Canadian orthopedic surgeons who manage patients with hip fracture receiving anticoagulation. Methods: In January–March 2018, we administered a purpose-specific cross-sectional survey to all currently practising orthopedic surgeons in Canada who had performed hip fracture surgery in 2017. The survey evaluated approaches to decision-making and timing of surgery in patients with hip fracture receiving anticoagulation. Results: A total of 280 surgeons representing a mix of academic and community practice, seniority and fellowship training responded. Nearly one-quarter of respondents (66 [23.4%]) were members of the Canadian Orthopaedic Trauma Society (COTS). Almost three-quarters (206 [73.6%]) felt that adequate clinical guidelines for patients with hip fracture receiving anticoagulation did not exist, and 177 (61.9%) indicated that anesthesiology or internal medicine had a greater influence on the timing of surgery than the attending surgeon. A total of 117/273 respondents (42.9%) indicated that patients taking warfarin should have immediate surgery (with or without reversal), compared to 63/270 (23.3%) for patients taking a DOAC (p < 0.001). Members of COTS were more likely than nonmembers to advocate for immediate surgery in all patients (p < 0.05). Conclusion: There is wide variability in Canada in the management of patients with hip fracture receiving anticoagulation. Improved multidisciplinary communication, prospectively evaluated treatment guidelines and focus on knowledge translation may add clarity to this issue. Level of evidence: IV.
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Affiliation(s)
- Neil J White
- From the Division of Orthopaedic Trauma, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (White, Reitzel, Doyle-Baker, Sabo, Samuel); the McCaig Institute of Bone and Joint Health, Calgary, Alta. (White, Sabo); and the South Campus Research Unit for Bone and Soft Tissue, University of Calgary, Calgary, Alta. (Mattiello)
| | - Sarah L Reitzel
- From the Division of Orthopaedic Trauma, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (White, Reitzel, Doyle-Baker, Sabo, Samuel); the McCaig Institute of Bone and Joint Health, Calgary, Alta. (White, Sabo); and the South Campus Research Unit for Bone and Soft Tissue, University of Calgary, Calgary, Alta. (Mattiello)
| | - Douglas Doyle-Baker
- From the Division of Orthopaedic Trauma, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (White, Reitzel, Doyle-Baker, Sabo, Samuel); the McCaig Institute of Bone and Joint Health, Calgary, Alta. (White, Sabo); and the South Campus Research Unit for Bone and Soft Tissue, University of Calgary, Calgary, Alta. (Mattiello)
| | - Marlis T Sabo
- From the Division of Orthopaedic Trauma, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (White, Reitzel, Doyle-Baker, Sabo, Samuel); the McCaig Institute of Bone and Joint Health, Calgary, Alta. (White, Sabo); and the South Campus Research Unit for Bone and Soft Tissue, University of Calgary, Calgary, Alta. (Mattiello)
| | - Brenna Mattiello
- From the Division of Orthopaedic Trauma, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (White, Reitzel, Doyle-Baker, Sabo, Samuel); the McCaig Institute of Bone and Joint Health, Calgary, Alta. (White, Sabo); and the South Campus Research Unit for Bone and Soft Tissue, University of Calgary, Calgary, Alta. (Mattiello)
| | - Tina L Samuel
- From the Division of Orthopaedic Trauma, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (White, Reitzel, Doyle-Baker, Sabo, Samuel); the McCaig Institute of Bone and Joint Health, Calgary, Alta. (White, Sabo); and the South Campus Research Unit for Bone and Soft Tissue, University of Calgary, Calgary, Alta. (Mattiello)
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Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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15
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Kantyka ME, Meira C, Bettschart-Wolfensberger R, Hartnack S, Kutter APN. Prospective, controlled, blinded, randomized crossover trial evaluating the effect of maropitant versus ondansetron on inhibiting tranexamic acid-evoked emesis. J Vet Emerg Crit Care (San Antonio) 2020; 30:436-441. [PMID: 32515910 DOI: 10.1111/vec.12954] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 09/07/2018] [Accepted: 09/19/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the incidence of tranexamic acid (TXA)-induced nausea and vomiting after the prophylactic use of 2 antiemetics, ondansetron and maropitant, compared with saline. DESIGN Prospective, blinded, placebo-controlled, randomized, crossover study. SETTING University research facility. ANIMALS Eight adult, purpose-bred Beagles. INTERVENTION Dogs received 3 treatments on 3 occasions with a 3-week washout period. Either maropitant (1 mg/kg), ondansetron (0.2 mg/kg), or saline solution was given intravenously in equal volumes, followed 10 minutes later by 50 mg/kg IV TXA. A blinded observer evaluated the dogs for signs of vomiting and nausea for 30 minutes. The severity of nausea was assessed with a visual analog scale (VAS) and recorded at baseline before TXA, and at the end of 3 observational periods: 0-5, 5-15, and 15-30 minutes after TXA. A generalized linear mixed effect model was used to assess for group and period effects. Statistical significance was set at P < 0.05 . MEASUREMENTS AND MAIN RESULTS None of the dogs vomited after maropitant. Emesis occurred in 5 out of 8 dogs (62.5%), a median (range) of 1 time (1-2) after ondansetron and 1 time (1-3) after saline. There was a significant effect on vomiting of maropitant against saline (P < 0.0001) but not for ondansetron against saline (P = 0.53). The highest nausea VASs were recorded during the first 5 minutes after TXA with a significant reduction of VAS variability in the maropitant group (P = 0.003). The effect of maropitant and ondansetron against saline on the severity of nausea was not statistically significant (P = 0.069). CONCLUSION The neurokinin 1 receptor antagonist maropitant at the dose used, administered IV 10 minutes before 50 mg/kg TXA, was effective in preventing vomiting compared with ondansetron and placebo. Our results support the prophylactic IV administration of maropitant in dogs that are scheduled to receive TXA.
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Affiliation(s)
- Marta E Kantyka
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, Vetsuisse Faculty of the University of Zurich, Zurich, Switzerland
| | - Carolina Meira
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, Vetsuisse Faculty of the University of Zurich, Zurich, Switzerland
| | - Regula Bettschart-Wolfensberger
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, Vetsuisse Faculty of the University of Zurich, Zurich, Switzerland
| | - Sonja Hartnack
- Section of Epidemiology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Annette P N Kutter
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, Vetsuisse Faculty of the University of Zurich, Zurich, Switzerland
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Erramouspe PJ, García‐Pintos MF, Benipal S, Manoukian MAC, Santamarina J, Shawagga HG, Vo LL, Galante JM, Nishijima D. Mortality and Complication Rates in Adult Trauma Patients Receiving Tranexamic Acid: A Single-center Experience in the Post-CRASH-2 Era. Acad Emerg Med 2020; 27:358-365. [PMID: 32189440 DOI: 10.1111/acem.13883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/01/2019] [Accepted: 10/03/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The CRASH-2 trial demonstrated that tranexamic acid (TXA) in adults with significant traumatic hemorrhage safely reduces mortality. Given that the CRASH-2 trial did not include U.S. sites, our objective was to evaluate patient characteristics, TXA dosing strategies, and the incidence of mortality and adverse events in adult trauma patients receiving TXA at a U.S. Level I trauma center in the post-CRASH-2 era. METHODS We conducted a retrospective study that included patients aged 18 years or older who received TXA after an acute injury from July 2014 to June 2017. We excluded patients who received TXA orally, patients who received TXA for elective surgical procedures or nontrauma indications, patients who received it 8 hours or longer after the time of injury, and patients with cardiac arrest at time of emergency department arrival. Trained abstractors collected data from the trauma registry and hospital electronic medical records. Our primary outcome measures were in-hospital death and acute thromboembolic events within 28 days from injury. RESULTS We included 273 patients with a mean (±SD) age of 43.8 (±18.7) years. The mean (±SD) time of administration of TXA from time of injury was 1.55 (±1.2) hours with 229 patients (83.9%) receiving TXA within 3 hours. The overall mortality within 28 days from injury was 12.8% (95% confidence interval [CI] = 8.9% to 16.7%), which was similar compared to that in the CRASH-2 trial (14.5%, 95% CI = 13.9% to 15.2%). The incidence of acute thromboembolic events was 6.6% (95% CI = 3.7% to 9.5%), which was higher than that in the CRASH-2 trial (2.0%, 95% CI = 1.73% to 2.27%). Patients in our cohort also received surgery (64.8% vs. 47.9%) and blood transfusions (74.0% vs. 50.4%) more frequently than those in the CRASH-2 cohort. CONCLUSIONS Adult trauma patients receiving TXA had similar incidences of death but higher incidences of thromboembolic events compared to the CRASH-2 trial. Variation in patient characteristics, injury severity, TXA dosing, and surgery and transfusion rates could explain these observed differences. Further research is necessary to provide additional insight into the incidence and risk factors of thromboembolic events in TXA use.
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Affiliation(s)
- Pablo Joaquin Erramouspe
- Department of Emergency Medicine UC Davis School of Medicine Sacramento CA
- Faculty of Health Queensland University of Technology Translational Research Institute Brisbane QLD Australia
| | | | - Simranjeet Benipal
- Department of Emergency Medicine UC Davis School of Medicine Sacramento CA
| | | | | | - Hiwote G. Shawagga
- Department of Emergency Medicine UC Davis School of Medicine Sacramento CA
| | - Linda L. Vo
- Department of Emergency Medicine UC Davis School of Medicine Sacramento CA
| | | | - Daniel Nishijima
- Department of Emergency Medicine UC Davis School of Medicine Sacramento CA
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Assessment of primary outcome measures for a clinical trial of pediatric hemorrhagic injuries. Am J Emerg Med 2020; 43:210-216. [PMID: 32278572 DOI: 10.1016/j.ajem.2020.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/28/2020] [Accepted: 03/03/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE We evaluated the acceptability of the Pediatric Quality of Life Inventory (PedsQL) and other outcomes as the primary outcomes for a pediatric hemorrhagic trauma trial (TIC-TOC) among clinicians. METHODS We conducted a mixed-methods study that included an electronic questionnaire followed by teleconference discussions. Participants confirmed or rejected the PedsQL as the primary outcome for the TIC-TOC trial and evaluated and proposed alternative primary outcomes. Responses were compiled and a list of themes and representative quotes was generated. RESULTS 73 of 91 (80%) participants completed the questionnaire. 61 (84%) participants agreed that the PedsQL is an appropriate primary outcome for children with hemorrhagic brain injuries. 32 (44%) participants agreed that the PedsQL is an acceptable primary outcome for children with hemorrhagic torso injuries, 27 (38%) participants were neutral, and 13 (18%) participants disagreed. Several themes were identified from responses, including that the PedsQL is an important and patient-centered outcome but may be affected by other factors, and that intracranial hemorrhage progression assessed by brain imaging (among patients with brain injuries) or blood product transfusion requirements (among patients with torso injuries) may be more objective outcomes than the PedsQL. CONCLUSIONS The PedsQL was a well-accepted proposed primary outcome for children with hemorrhagic brain injuries. Traumatic intracranial hemorrhage progression was favored by a subset of clinicians. A plurality of participants also considered the PedsQL an acceptable outcome for children with hemorrhagic torso injuries. Blood product transfusion requirement was favored by fewer participants.
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Wu XD, Tian M, He Y, Chen Y, Tao YZ, Shao L, Luo C, Xiao PC, Zhu ZL, Liu JC, Huang W, Qiu GX. Efficacy of a three-day prolonged-course of multiple-dose versus a single-dose of tranexamic acid in total hip and knee arthroplasty. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:307. [PMID: 32355751 PMCID: PMC7186724 DOI: 10.21037/atm.2020.02.99] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background The application of tranexamic acid (TXA) in total hip arthroplasty (THA) and total knee arthroplasty (TKA) has brought momentous changes in blood management. However, the optimal regimen of TXA has not yet been identified. This study aimed to compare the efficacy of a three-day prolonged-course of multiple-dose of TXA with a single pre-operative dose of TXA in patients who undergo THA and TKA. Method We retrospectively analyzed two groups of consecutive patients who received primary unilateral THA and TKA from 2015 to 2017. One group received a three-day prolonged-course of multiple-dose of TXA, while another group received a single-dose of TXA. The primary outcomes included the changes in hemoglobin (Hb), estimated total blood loss (TBL), and transfusion rate; the secondary outcomes included the platelet (PLT) counts, inflammatory markers, and fibrinolysis parameters. Results A total of 193 THA and 166 TKA procedures were included for comparison. Compared with the patients who received a single-dose of TXA, the patients who received a three-day prolonged-course of multiple-dose of TXA had smaller post-operative drops in Hb levels, which led to consistently significantly higher Hb levels in both THA and TKA. Therefore, the use of multiple-dose of TXA was associated with significantly lower maximum Hb drops and estimated TBL in both THA (24.58±11.43 vs. 30.38±11.33 g/L, P=0.001; 685.88±412.02 vs. 968.94±479.9 mL, P<0.0001) and TKA (18.04±9.75 vs. 27.24±10.99 g/L, P<0.0001; 497.35±291.03 vs. 816.51±354.38 mL, P<0.0001), and marginally reduced transfusion requirements (THA: 1/65 vs. 10/128; TKA: 0/70 vs. 2/96). The multiple-dose group also showed higher PLT counts, continuously reduced inflammatory responses, and significantly and durably attenuated fibrinolytic responses. Conclusions A three-day prolonged-course of multiple-dose of TXA was consistently effective in reducing post-operative Hb drops, estimated TBL, inflammatory responses, and fibrinolytic responses, which could be recommended for clinical practice. However, these findings need to be confirmed by prospective studies.
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Affiliation(s)
- Xiang-Dong Wu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China.,Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Mian Tian
- Department of Orthopaedic Surgery, Dianjiang People's Hospital, Chongqing 408300, China
| | - Yao He
- Department of Orthopaedic Surgery, Banan People's Hospital of Chongqing, Chongqing 400320, China
| | - Yu Chen
- Department of Orthopaedic Surgery, Chongqing Orthopedic Hospital of Traditional Chinese Medicine, Chongqing 400012, China
| | - Yu-Zhang Tao
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Long Shao
- Department of Orthopaedic Surgery, Ningbo No. 6 Hospital, Ningbo 315040, China
| | - Changqi Luo
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Peng-Cheng Xiao
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Zheng-Lin Zhu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Jia-Cheng Liu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Wei Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Gui-Xing Qiu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
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The Use of Tranexamic Acid (TXA) for the Management of Hemorrhage in Trauma Patients in the Prehospital Environment: Literature Review and Descriptive Analysis of Principal Themes. Shock 2020; 53:277-283. [DOI: 10.1097/shk.0000000000001389] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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20
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Maegele M. Challenges to improving patient outcome following massive transfusion in severe trauma. Expert Rev Hematol 2020; 13:323-330. [PMID: 32075445 DOI: 10.1080/17474086.2020.1733404] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Uncontrolled hemorrhage with trauma-induced coagulopathy (TIC) still represents the most common cause of preventable death after trauma. Timely diagnosis and treatment including bleeding control and hemostatic resuscitation to correct TIC are important, as death from exsanguination occurs rapidly. Recognizing who requires an early massive transfusion together with the initiation of corresponding massive transfusion protocols (MTPs) is key to outcome.Areas covered: This expert review summarizes the current state of MT including the activation and termination of MTPs, complications of MT, and strategies for refinement in the administration of blood products in order to avoid harmful over-transfusion.Expert opinion: MTPs should be initiated and continued until normal physiologic parameters are reached and definitive control of bleeding is achieved. Hospitals should develop their own MTPs, guided by evidence, and according to local infrastructure, logistics, needs and patient populations. Massive transfusion, defined as > 10 units of packed red blood cell concentrates (pRBCs) within the first 24 hours of hospital admission, can be life-saving, but is not without complications. MTPs are currently being refined through targeted and early goal-directed approaches which include functional coagulation testing assays to better guide the administration of blood products and hemostatic agents once the patient is stabilized.
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Affiliation(s)
- Marc Maegele
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC) Institute for Research in Operative Medicine (IFOM), University Witten-Herdecke, Cologne, Germany
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21
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Zhang H. The Effects of Hemocoagulase on Coagulation Factors in an Elderly Patient with Upper Gastrointestinal Hemorrhage: A Case Report. Curr Drug Saf 2020; 14:230-232. [PMID: 31124425 PMCID: PMC6865287 DOI: 10.2174/1574886314666190524093711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 04/28/2019] [Accepted: 05/01/2019] [Indexed: 11/22/2022]
Abstract
Background: Hemocoagulase agkistrodon has been widely used for visceral bleeding, however, its adverse reaction has not been fully recognized. Case Report: A 65-year-old female with upper gastrointestinal hemorrhage occurred severe coagulation disorder during her hospitalization. Transfusion of blood products can not improve coagulation function. Coagulation parameters returned to normal two days after discontinuation of hemocoagulase agkistrodon. Conclusion: So intravenous administration of hemocoagulase should be cautiously used for the treatment of gastrointestinal bleeding.
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Affiliation(s)
- Haiyan Zhang
- Department of General Practice, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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22
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Blutungsmanagement: Tranexamsäure in der Präklinik. Pro und Kontra. Notf Rett Med 2019. [DOI: 10.1007/s10049-018-0471-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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23
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Lier H, Maegele M, Shander A. Tranexamic Acid for Acute Hemorrhage: A Narrative Review of Landmark Studies and a Critical Reappraisal of Its Use Over the Last Decade. Anesth Analg 2019; 129:1574-1584. [PMID: 31743178 DOI: 10.1213/ane.0000000000004389] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The publication of the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage-2 (CRASH-2) study and its intense dissemination prompted a renaissance for the use of the antifibrinolytic agent tranexamic acid (TXA) in acute trauma hemorrhage. Subsequent studies led to its widespread use as a therapeutic as well as prophylactic agent across different clinical scenarios involving bleeding, such as trauma, postpartum, and orthopedic surgery. However, results from the existing studies are confounded by methodological and statistical ambiguities and are open to varied interpretations. Substantial knowledge gaps remain on dosing, pharmacokinetics, mechanism of action, and clinical applications for TXA. The risk for potential thromboembolic complications with the use of TXA must be balanced against its clinical benefits. The present article aims to provide a critical reappraisal of TXA use over the last decade and a "thought exercise" in the potential downsides of TXA. A more selective and individualized use of TXA, guided by extended and functional coagulation assays, is advocated in the context of the evolving concept of precision medicine.
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Affiliation(s)
- Heiko Lier
- From the Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Marc Maegele
- Department for Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Campus Cologne-Merheim, Cologne, Germany
| | - Aryeh Shander
- Department of Anesthesiology, Critical Care Medicine, Hyperbaric Medicine, Englewood Health, TeamHealth Research Institute, Englewood, New Jersey
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Baylis JR, Lee MM, St John AE, Wang X, Simonson E, Cau M, Kazerooni A, Gusti V, Statz ML, Yoon JSJ, Liggins RT, White NJ, Kastrup CJ. Topical tranexamic acid inhibits fibrinolysis more effectively when formulated with self-propelling particles. J Thromb Haemost 2019; 17:1645-1654. [PMID: 31145837 DOI: 10.1111/jth.14526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 05/10/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Endogenous fibrinolytic activation contributes to coagulopathy and mortality after trauma. Administering tranexamic acid (TXA), an antifibrinolytic agent, is one strategy to reduce bleeding; however, it must be given soon after injury to be effective and minimize adverse effects. Administering TXA topically to a wound site would decrease the time to treatment and could enable both local and systemic delivery if a suitable formulation existed to deliver the drug deep into wounds adequately. OBJECTIVES To determine whether self-propelling particles could increase the efficacy of TXA. METHODS Using previously developed self-propelling particles, which consist of calcium carbonate and generate CO2 gas, TXA was formulated to disperse in blood and wounds. The antifibrinolytic properties were assessed in vitro and in a murine tail bleeding assay. Self-propelled TXA was also tested in a swine model of junctional hemorrhage consisting of femoral arteriotomy without compression. RESULTS Self-propelled TXA was more effective than non-propelled formulations in stabilizing clots from lysis in vitro and reducing blood loss in mice. It was well tolerated when administered subcutaneously in mice up to 300 to 1000 mg/kg. When it was incorporated in gauze, four of six pigs treated after a femoral arteriotomy and without compression survived, and systemic concentrations of TXA reached approximately 6 mg/L within the first hour. CONCLUSIONS A formulation of TXA that disperses the drug in blood and wounds was effective in several models. It may have several advantages, including supporting local clot stabilization, reducing blood loss from wounds, and providing systemic delivery of TXA. This approach could both improve and simplify prehospital trauma care for penetrating injury.
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Affiliation(s)
- James R Baylis
- Michael Smith Laboratories, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael M Lee
- Michael Smith Laboratories, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexander E St John
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Xu Wang
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Eric Simonson
- Centre for Drug Research and Development, Vancouver, British Columbia, Canada
| | - Massimo Cau
- Michael Smith Laboratories, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amir Kazerooni
- Michael Smith Laboratories, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vionarica Gusti
- Centre for Drug Research and Development, Vancouver, British Columbia, Canada
| | - Matthew L Statz
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Jeff S J Yoon
- Michael Smith Laboratories, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard T Liggins
- Centre for Drug Research and Development, Vancouver, British Columbia, Canada
| | - Nathan J White
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Christian J Kastrup
- Michael Smith Laboratories, University of British Columbia, Vancouver, British Columbia, Canada
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Benipal S, Santamarina JL, Vo L, Nishijima DK. Mortality and Thrombosis in Injured Adults Receiving Tranexamic Acid in the Post-CRASH-2 Era. West J Emerg Med 2019; 20:443-453. [PMID: 31123544 PMCID: PMC6526890 DOI: 10.5811/westjem.2019.4.41698] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/10/2019] [Accepted: 04/08/2019] [Indexed: 12/13/2022] Open
Abstract
Introduction The CRASH-2 trial demonstrated that tranexamic acid (TXA) reduced mortality with no increase in adverse events in severely injured adults. TXA has since been widely used in injured adults worldwide. Our objective was to estimate mortality and adverse events in adults with trauma receiving TXA in studies published after the CRASH-2 trial. Methods We systematically searched PubMed, Embase, MicroMedex, and ClinicalTrials.gov for studies that included injured adults who received TXA and reported mortality and/or adverse events. Two reviewers independently assessed study eligibility, abstracted data, and assessed the risk of bias. We conducted meta-analyses using random effects models to estimate the incidence of mortality at 28 or 30 days and in-hospital thrombotic events. Results We included 19 studies and 13 studies in the systematic review and meta-analyses, respectively. The pooled incidence of mortality at 28 or 30 days (five studies, 1538 patients) was 10.1% (95% confidence interval [CI], 7.8–12.4%) (vs 14.5% [95% CI, 13.9–15.2%] in the CRASH-2 trial), and the pooled incidence of in-hospital thrombotic events (nine studies, 1656 patients) was 5.9% (95% CI, 3.3–8.5%) (vs 2.0% [95% CI, 1.8–2.3%] in the CRASH-2 trial). Conclusion Compared to the CRASH-2 trial, adult trauma patients receiving TXA identified in our systematic review had a lower incidence of mortality at 28 or 30 days, but a higher incidence of in-hospital thrombotic events. Our findings neither support nor refute the findings of the CRASH-2 trial but suggest that incidence rates in adults with trauma in settings outside of the CRASH-2 trial may be different than those observed in the CRASH-2 trial.
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Affiliation(s)
- Simranjeet Benipal
- Universtiy of California, Davis Medical Center, Department of Emergency Medicine, Sacramento, California
| | - John-Lloyd Santamarina
- Universtiy of California, Davis Medical Center, Department of Emergency Medicine, Sacramento, California
| | - Linda Vo
- Universtiy of California, Davis Medical Center, Department of Emergency Medicine, Sacramento, California
| | - Daniel K Nishijima
- Universtiy of California, Davis Medical Center, Department of Emergency Medicine, Sacramento, California
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Development of a nurse-led tranexamic acid administration protocol for trauma patients in rural South Africa. Afr J Emerg Med 2019; 9:S52-S55. [PMID: 30976502 PMCID: PMC6440919 DOI: 10.1016/j.afjem.2018.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 10/03/2018] [Indexed: 11/24/2022] Open
Abstract
Introduction Administration of tranexamic acid (TXA) has been shown to effectively reduce all-cause mortality in trauma patients when given within three hours of injury. We found that many trauma patients in our hospital were not receiving TXA. This was due to a variety of factors, including late presentation to hospital, lack of staff awareness, short staffing, and unavailable drugs or equipment. Our aim was to develop a protocol for safe, nurse-led administration of TXA in the emergency centre in order to increase the number of eligible patients treated. Methods We developed a protocol based on the inclusion criteria of the CRASH-2 study, opting to use physiological observations along with criteria from the South African Triage Scale to allow nursing staff to identify patients with, or at risk of, significant haemorrhage. We tailored the protocol to the equipment and training available in our poorly resourced rural healthcare setting. Results In a two-month period, 14 patients were given TXA by nurses before the arrival of a doctor. 13/14 (92.9%) were deemed appropriate, with 1/14 (7.1%) deemed inappropriate due to the time since injury. 12/13 (92.3%) patients received the correct infusion dose, with 1/13 (7.7%) only receiving the infusion once the doctor arrived. No adverse events were reported. Conclusions Nursing staff in resource poor rural settings can use a protocol based on the South African Triage Scale and the CRASH-2 study to safely administer TXA to trauma patients. We believe this to be the first published literature on nurse-led administration of TXA. Mortality from trauma may be reduced in rural settings by the timely administration of TXA in the prehospital and rural primary healthcare settings.
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Greenaway M. Prophylactic uterotonics in the prevention of primary postpartum haemorrhage for unplanned out-of-hospital births: a literature review. Br Paramed J 2019; 3:15-22. [PMID: 33328812 PMCID: PMC7706747 DOI: 10.29045/14784726.2019.03.3.4.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Introduction: Postpartum haemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide. Protocols for the use of prophylactic uterotonics in strategy to prevent PPH have been implemented for in-hospital births following recommendation from the National Institute for Health and Care Excellence (NICE). There are currently no guidelines for prophylactic uterotonic use in out-of-hospital (OOH) births by ambulance crews despite inappropriate birthing conditions and difficulties in obtaining a timely response from community midwives. The aim of this article is to review the use of uterotonic drugs used for the prevention of PPH which could be administered in OOH births. Methods: The PubMed and ScienceDirect databases were searched for papers discussing the use of prophylactic uterotonics in the third stage of labour, utilising the MeSH keywords: third stage labour, prophylactic, uterotonic. Primary studies, meta-analyses and systematic reviews published between 1998 and 2018 were eligible for inclusion. A review of the full text of the included papers was undertaken using the Critical Appraisal Skills Programme (CASP) checklists. Results: Of the published articles, 392 were returned, 25 of which met the inclusion criteria. Following assessment of the full text, 11 papers were included for discussion, including a large randomised control trial (WOMAN trial) on the use of tranexamic acid (TXA), which while not a uterotonic drug, was considered a significant drug in the context of PPH management. Conclusions: PPH is a low incidence, but high risk complication of childbirth. While it is possible for paramedics to administer uterotonics during the third stage of labour, there have been no OOH trials with paramedics to explore whether prophylactic use is safe and effective in the OOH births before arrival (BBA) scenario. Further research is required to determine the efficacy of prophylactic uterotonics in reducing PPH within pre-hospital care.
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Increased resistance to tissue plasminogen activator-induced fibrinolysis in healthy subjects from Thailand. Blood Coagul Fibrinolysis 2018; 29:356-360. [PMID: 29337700 DOI: 10.1097/mbc.0000000000000695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: There is significant variability in blood coagulation among world populations. In particular, there may exist important differences in regulation of the fibrinolytic system in Asian populations that contribute to diseases of thrombosis and hemostasis. To investigate this issue, we compared fibrinogen concentration, plasma clot formation, and fibrinolytic resistance of healthy Asian subjects from Hat Yai, Songkhla, Thailand (Thai) vs. healthy North American subjects from Seattle, Washington, USA (SEA). Citrated plasma samples were obtained from healthy adult volunteers. Fibrinogen concentration was measured in plasma by the method of Clauss to examine for baseline differences of fibrinogen concentration. Samples were then standardized to 2.8 mg/ml fibrinogen using physiological buffer for each sample prior to fibrinolytic testing using rotational thromboelastometry (ROTEM) to examine for differences of clot lysis not attributable to fibrinogen concentration alone. Clot lysis was examined with ROTEM extrinsic pathway activation in the presence of 0, 0.5, and 1.0 μg/ml of tissue plasminogen activator (tPA). Two-way repeated measures analysis of variance was used to determine the effects of tPA and study group on ROTEM parameters. N = 49 Thai samples were compared with N = 58 SEA samples. Mean (SD) fibrinogen concentration was significantly increased for the Thai group at 4.03 (0.79) mg/ml vs. the SEA group at 3.66 (0.70) mg/ml (t test P = 0.014). After standardization of all samples to equivalent fibrinogen concentration, there were no differences in clot formation between groups without tPA. There was a significant effect of increasing tPA concentration on all ROTEM parameters except for clotting time. There were significant individual differences for amplitude at 10 min and lysis onset time, where amplitude at 10 min was significantly increased and lysis onset time was significantly prolonged for Thai vs. SEA at tPA concentrations of 0.5 and 1.0 μg/ml. Variability in thrombosis and hemostasis in Asians vs. other populations is likely to involve differences of fibrinogen concentration and regulation of clot lysis.
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Grassin-Delyle S, Theusinger OM, Albrecht R, Mueller S, Spahn DR, Urien S, Stein P. Optimisation of the dosage of tranexamic acid in trauma patients with population pharmacokinetic analysis. Anaesthesia 2018; 73:719-729. [DOI: 10.1111/anae.14184] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2017] [Indexed: 01/14/2023]
Affiliation(s)
- S. Grassin-Delyle
- Plateforme de spectrométrie de masse MasSpecLab; INSERM; UMR 1173; UFR des Sciences de la Santé Simone Veil; Université Versailles Saint Quentin; Université Paris Saclay; Montigny le Bretonneux France
- Département des maladies respiratoires; Hôpital Foch; Suresnes France
| | - O. M. Theusinger
- Department of Anaesthesiology; University Hospital Balgrist and University Hospital of Zurich; Zurich Switzerland
| | - R. Albrecht
- Swiss Air-Ambulance Rega (Rettungsflugwacht/Garde Aérienne); Zurich Switzerland
| | - S. Mueller
- Schutz und Rettung Zurich; Zurich Switzerland
| | - D. R. Spahn
- Institute of Anesthesiology; University and University Hospital of Zurich; Zurich Switzerland
| | - S. Urien
- CIC-0901 Inserm Necker-Cochin; URC Paris Centre; AP-HP; Paris France
- EA-3620 Université Paris Descartes; Sorbonne Paris Cité France
| | - P. Stein
- Swiss Air-Ambulance Rega (Rettungsflugwacht/Garde Aérienne); Zurich Switzerland
- Institute of Anesthesiology; University and University Hospital of Zurich; Zurich Switzerland
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Gerstein NS, Brierley JK, Windsor J, Panikkath PV, Ram H, Gelfenbeyn KM, Jinkins LJ, Nguyen LC, Gerstein WH. Antifibrinolytic Agents in Cardiac and Noncardiac Surgery: A Comprehensive Overview and Update. J Cardiothorac Vasc Anesth 2017; 31:2183-2205. [DOI: 10.1053/j.jvca.2017.02.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Indexed: 12/19/2022]
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31
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Bardes JM, Palmer A, Con J, Wilson A, Schaefer G. Antifibrinolytics in a rural trauma state: assessing the opportunities. Trauma Surg Acute Care Open 2017; 2:e000107. [PMID: 29766102 PMCID: PMC5877915 DOI: 10.1136/tsaco-2017-000107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 09/12/2017] [Accepted: 09/13/2017] [Indexed: 12/03/2022] Open
Abstract
Background Tranexamic acid (TXA) has demonstrated improved mortality among trauma patients. However, recent evidence from urban US trauma centers has failed to show a benefit among the civilian population. TXA in rural states has not been evaluated. This study aimed to evaluate the current use of TXA in the rural trauma population. Methods A retrospective observational review at a level 1 trauma center based in a rural environment. Records were reviewed for TXA indications. TXA indication was defined as: systolic blood pressure <90 mm Hg, blood transfusion, or with a clinical concern for ongoing bleeding. Patients were ineligible if the time since injury was >3 hours. Results 400 patients were evaluated. 54% of patients met indications for TXA. 14% of these received TXA. 30.4% with an indication for TXA were ineligible due to arrival beyond 3 hours from time of injury. 135 patients arrived as transfers, 265 from the scene. There was no difference in TXA indications between scene and transfers (73 vs 144, p=1). Transfers were more likely to arrive beyond the 3-hour window (59 vs 7, p=0.001). Mortality for patients treated with TXA was 12.5%. This was not significantly different from patients not treated with TXA (19%). Discussion In a rural system, long transfers exclude most patients from treatment with TXA. A multicenter rural trauma center study will be needed to better define the optimal use of TXA in rural populations. Level of evidence Level IV data: therapeutic/care management.
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Affiliation(s)
- James M Bardes
- Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Amanda Palmer
- Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Jorge Con
- Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Alison Wilson
- Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Gregory Schaefer
- Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
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32
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Bommiasamy AK, Schreiber MA. Damage control resuscitation: how to use blood products and manage major bleeding in trauma. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- A. K. Bommiasamy
- Department of Surgery; Oregon Health & Science University; Portland OR USA
| | - M. A. Schreiber
- Department of Surgery; Oregon Health & Science University; Portland OR USA
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Zekcer A, Del Priori R, Tieppo C, Silva RSD, Severino NR. Estudo comparativo com uso do ácido tranexâmico tópico e intravenoso em relação à perda sanguínea na artroplastia total do joelho. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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34
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Comparative study of topical vs. intravenous tranexamic acid regarding blood loss in total knee arthroplasty. Rev Bras Ortop 2017; 52:589-595. [PMID: 29062824 PMCID: PMC5643894 DOI: 10.1016/j.rboe.2017.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 09/20/2016] [Indexed: 12/02/2022] Open
Abstract
Objective To compare topical vs. intravenous tranexamic acid (TA) in total knee arthroplasty regarding blood loss and transfusion. Methods Ninety patients were randomized to receive TA intravenously (20 mg/kg in 100 mL of saline; group IV), topically (1.5 g in 50 mL of saline, sprayed over the operated site, before release of the tourniquet; topical group), or intravenous saline (100 mL with anesthesia; control group). The volume of drained blood in 48 h, the amount of transfused blood, and the serum levels of hemoglobin and hematocrit before and after surgery were evaluated. Results The groups were similar for gender, age, weight, laterality, and preoperative hemoglobin and hematocrit levels (p > 0.2). The hemoglobin level dropped in all groups when comparing the preoperative and the 48-h evaluations: the control group decreased 3.8 mg/dL on average, while the IV group had a decrease of 3.0, and the topical group, of 3.2 (p = 0.019). The difference between the control and IV groups was confirmed by Bonferroni test (p = 0.020). The difference between the control group and the topical group was not significant (p = 0.130), although there was less reduction in hemoglobin in the topical group; the comparison between the IV group and the topical group was also not significant (p = 1.000). Conclusion Using topic and IV tranexamic acid decreased blood loss and the need for transfusion in total knee arthroplasty. Topical application showed results similar to IV use regarding the need for blood transfusion, but without the possible side effects of IV administration.
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35
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La Rochelle P. Prehospital transfer strategies and tranexamic acid during major trauma. Lancet 2017; 389:1604-1605. [PMID: 28443547 DOI: 10.1016/s0140-6736(17)31012-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/25/2017] [Indexed: 12/25/2022]
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36
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Abstract
Following results from the CRASH-2 trial, tranexamic acid (TXA) gained considerable interest for the treatment of hemorrhage in trauma patients. Although TXA is effective at reducing mortality in patients presenting within 3 hours of injury, optimal dosing, timing of administration, mechanism, and pharmacokinetics require further elucidation. The concept of fibrinolysis shutdown in hemorrhagic trauma patients has prompted discussion of real-time viscoelastic testing and its potential role for appropriate patient selection. The results of ongoing clinical trials will help establish high-quality evidence for optimal incorporation of TXA in mature trauma networks in the United States and abroad.
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Affiliation(s)
- Ricardo J Ramirez
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Philip C Spinella
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Grant V Bochicchio
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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Fredericks C, Kubasiak JC, Mentzer CJ, Yon JR. Massive transfusion: An update for the anesthesiologist. World J Anesthesiol 2017; 6:14-21. [DOI: 10.5313/wja.v6.i1.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/04/2016] [Accepted: 12/19/2016] [Indexed: 02/06/2023] Open
Abstract
Exsanguination from trauma, gastrointestinal bleeding, and obstetric hemorrhage remains a major source of mortality across the planet. Continued research into resuscitation strategies and evolving technology and blood product storage has allowed for patient to undergo very large volume transfusions, even to the point of replacing a patient’s blood volume several times over. As massive transfusions have become more common, more studies have been performed delineating the exact patient population that would benefit, start- and stop-points of transfusions, complications and avoidance of the same. We discuss these points and provide information and strategies for massive transfusion.
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Pinto MA, Silva JGD, Chedid AD, Chedid MF. USE OF TRANEXAMIC ACID IN TRAUMA PATIENTS: AN ANALYSIS OF COST-EFFECTIVENESS FOR USE IN BRAZIL. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 29:282-286. [PMID: 28076488 PMCID: PMC5225873 DOI: 10.1590/0102-6720201600040017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 08/16/2016] [Indexed: 11/30/2022]
Abstract
Introduction: Use of tranexamic acid (TXA) in trauma has been the subject of growing interest by researchers and health professionals. However, there are still several open questions regarding its use. In some aspects medical literature is controversial. The points of disagreement among experts include questions such as: Which patients should receive TXA in trauma? Should treatment be performed in the pre-hospital environment? Is there any need for laboratory parameters before starting TXA treatment? What is the drug safety profile? The main issue on which there is still no basis in literature is: What is the indication for treatment within massive transfusion protocols? Objective: Answer the questions proposed based on critical evaluation of the evidence gathered so far and carry out a study of cost-effectiveness of TXA use in trauma adapted to the Brazilian reality. Methods: A literature review was performed through searching Pubmed.com, Embase and Cab Abstract by headings "tranexamic AND trauma", in all languages, yielding 426 articles. Manuscripts reporting on TXA utilization for elective procedures were excluded, remaining 79 articles. Fifty-five articles were selected, and critically evaluated in order to answer study questions. The evaluation of cost effectiveness was performed using CRASH-2 trial data and Brazilian official population data. Results: TXA is effective and efficient, and should be administered to a wide range of patients, including those with indication evaluated in research protocols and current indication criteria for TXA should be expanded. As for the cost-effectiveness, the TXA proved to be cost-effective with an average cost of R$ 61.35 (currently US$16) per year of life saved. Conclusion: The use of TXA in trauma setting seems to be effective, efficient and cost-effective in the various groups of polytrauma patients. Its use in massive transfusion protocols should be the subject of further investigations.
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Affiliation(s)
- Marcelo A Pinto
- Division of General and Trauma Surgery, Hospital de Pronto Socorro Municipal de Porto Alegre.,Division of Gastrointestinal Surgery and Liver and Pancreas Transplantation, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul
| | - Jair G da Silva
- Division of General and Trauma Surgery, Hospital de Pronto Socorro Municipal de Porto Alegre.,Kidney Transplantation Group, Hospital Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Aljamir D Chedid
- Division of Gastrointestinal Surgery and Liver and Pancreas Transplantation, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul
| | - Marcio F Chedid
- Division of Gastrointestinal Surgery and Liver and Pancreas Transplantation, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul
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Tranexamic Acid (TXA) in Trauma Patients: Barriers to Use among Trauma Surgeons and Emergency Physicians. Emerg Med Int 2017; 2017:4235785. [PMID: 28316839 PMCID: PMC5338310 DOI: 10.1155/2017/4235785] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 12/01/2016] [Accepted: 01/22/2017] [Indexed: 01/11/2023] Open
Abstract
Objective. Tranexamic Acid (TXA) is currently the only drug with prospective clinical evidence supporting its use in bleeding trauma patients. We sought to better understand the barriers preventing its use and elicit suggestions to further its use in trauma patients in the state of Maryland. Methods. This is a cross-sectional study. Results. The overall response rate was 38%. Half of all participants reported being familiar with the CRASH-2 trial and MATTERs study. Half reported being aware of TXA as part of their institution's massive transfusion protocol. The majority of participants felt that TXA would have a significant positive impact on the survival of trauma patients. A majority also felt that the use of TXA would increase if its administration was the responsibility of both trauma surgeons and emergency physicians. Conclusion. Only half of responders reported being aware of TXA as being part of their institution's massive transfusion protocol. Lack of awareness of the clinical data supporting its use is a major barrier. However, most trauma providers and emergency physicians do have a favorable view of TXA and support its incorporation into massive transfusion protocols. We believe that more studies of this kind on both state and national level are needed.
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40
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Vorhaltung von Tranexamsäure im deutschen Rettungsdienst. Anaesthesist 2017; 66:249-255. [DOI: 10.1007/s00101-017-0277-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 01/12/2017] [Accepted: 01/15/2017] [Indexed: 10/20/2022]
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41
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Energy metabolism regulated by HDAC inhibitor attenuates cardiac injury in hemorrhagic rat model. Sci Rep 2016; 6:38219. [PMID: 27910887 PMCID: PMC5133557 DOI: 10.1038/srep38219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 11/07/2016] [Indexed: 12/11/2022] Open
Abstract
A disturbance of energy metabolism reduces cardiac function in acute severe hemorrhagic patients. Alternatively, adequate energy supply reduces heart failure and increases survival. However, the approach to regulating energy metabolism conductive to vital organs is limited, and the underlying molecular mechanism remains unknown. This study assesses the ability of histone deacetylase inhibitors (HDACIs) to preserve cardiac energy metabolism during lethal hemorrhagic injury. In the lethally hemorrhagic rat and hypoxic myocardial cells, energy metabolism and heart function were well maintained following HDACI treatment, as evident by continuous ATP production with normal cardiac contraction. Valproic acid (VPA) regulated the energy metabolism of hemorrhagic heart by reducing lactate synthesis and protecting the mitochondrial ultrastructure and respiration, which were attributable to the inhibition of lactate dehydrogenase A activity and the increased myeloid cell leukemia-1 (mcl-1) gene expression, ultimately facilitating ATP production and consumption. MCL-1, the key target of VPA, mediated this cardioprotective effect under acute severe hemorrhage conditions. Our results suggest that HDACIs promote cardioprotection by improving energy metabolism during hemorrhagic injury and could therefore be an effective strategy to counteract this process in the clinical setting.
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Jawa RS, Singer A, Mccormack JE, Huang EC, Rutigliano DN, Vosswinkel JA. Tranexamic Acid Use in United States Trauma Centers: A National Survey. Am Surg 2016. [DOI: 10.1177/000313481608200520] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic agent that is listed as an essential medication by the World Health Organization for traumatic hemorrhage. We determined United States–based surgeons’ familiarity with TXA and their use of TXA. An online survey was sent to the 1291 attending surgeon members of a national trauma organization. The survey was organized into three general parts: respondent demographics, perceptions of TXA, and experience with TXA. The survey was completed by 35 per cent of members. TXA was available at 89.1 per cent of centers. Experience with TXA was variable: 38.0 per cent use regularly, 24.9 per cent use it 1 to 2 times per year, 12.3 per cent use it rarely, and 24.7 per cent had never used it. Among surgeons who had used TXA, 77.1 per cent noted that TXA had reduced bleeding, but 22.9 per cent indicated that it had not. Reasons for not routinely using TXA included uncertain clinical benefit (47.7%) and unfamiliarity (31.5%). Finally, 90.5 per cent of respondents indicated that are looking toward national organizations to develop practice guidelines. TXA is widely available in civilian United States trauma centers. Although a majority of surveyed surgeons had used TXA, only 38 per cent use TXA regularly for significant traumatic hemorrhage; principal reasons for this are uncertainty regarding clinical benefit and unfamiliarity with the drug. National guidelines are sought.
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Affiliation(s)
- Randeep S. Jawa
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine and Stony Brook University Medical Center, Stony Brook, New York
| | - Adam Singer
- Department of Emergency Medicine, Stony Brook University School of Medicine, Stony Brook, New York
| | - Jane E. Mccormack
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine and Stony Brook University Medical Center, Stony Brook, New York
| | - Emily C. Huang
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine and Stony Brook University Medical Center, Stony Brook, New York
| | - Daniel N. Rutigliano
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine and Stony Brook University Medical Center, Stony Brook, New York
| | - James A. Vosswinkel
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine and Stony Brook University Medical Center, Stony Brook, New York
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Valproic acid–mediated myocardial protection of acute hemorrhagic rat via the BCL-2 pathway. J Trauma Acute Care Surg 2016; 80:812-8. [DOI: 10.1097/ta.0000000000000987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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44
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Roberts I. Fibrinolytic shutdown: fascinating theory but randomized controlled trial data are needed. Transfusion 2016; 56 Suppl 2:S115-8. [DOI: 10.1111/trf.13490] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/05/2015] [Accepted: 11/05/2015] [Indexed: 02/05/2023]
Affiliation(s)
- Ian Roberts
- Clinical Trials Unit; London School of Hygiene & Tropical Medicine; London UK
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45
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Panteli M, Pountos I, Giannoudis PV. Pharmacological adjuncts to stop bleeding: options and effectiveness. Eur J Trauma Emerg Surg 2015; 42:303-10. [PMID: 26660675 PMCID: PMC4886148 DOI: 10.1007/s00068-015-0613-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 11/29/2022]
Abstract
Severe trauma and massive haemorrhage represent the leading cause of death and disability in patients under the age of 45 years in the developed world. Even though much advancement has been made in our understanding of the pathophysiology and management of trauma, outcomes from massive haemorrhage remain poor. This can be partially explained by the development of coagulopathy, acidosis and hypothermia, a pathological process collectively known as the “lethal triad” of trauma. A number of pharmacological adjuncts have been utilised to stop bleeding, with a wide variation in the safety and efficacy profiles. Antifibrinolytic agents in particular, act by inhibiting the conversion of plasminogen to plasmin, therefore decreasing the degree of fibrinolysis. Tranexamic acid, the most commonly used antifibrinolytic agent, has been successfully incorporated into most trauma management protocols effectively reducing mortality and morbidity following trauma. In this review, we discuss the current literature with regard to the management of haemorrhage following trauma, with a special reference to the use of pharmacological adjuncts. Novel insights, concepts and treatment modalities are also discussed.
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Affiliation(s)
- M Panteli
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK.
| | - I Pountos
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK
| | - P V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK.,NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
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Hilbert-Carius P, Hofmann G, Stuttmann R. [Hemoglobin-oriented and coagulation factor-based algorithm : Effect on transfusion needs and standardized mortality rate in massively transfused trauma patients]. Anaesthesist 2015; 64:828-38. [PMID: 26453580 DOI: 10.1007/s00101-015-0093-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 08/14/2015] [Accepted: 08/23/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Bleeding and trauma-induced coagulopathy (TIC) are major contributors to death related to trauma in the first 24 h and the major preventable contributors. Early surgical therapy and aggressive correction of TIC are key steps to prevent death in patients suffering from hemorrhage. Therefore, a standard operating procedure (SOP) using a hemoglobin (Hb)-oriented and coagulation factor-based algorithm for early correction of TIC was introduced in this level 1 trauma center. This SOP uses the correlation of the Hb values measured in the trauma bay and standard coagulation tests as the basis for various aggressive coagulation therapies. OBJECTIVE The aim was to investigate the effectiveness of the SOP in trauma patients requiring massive transfusions. The main objective was the effect on the transfusion requirements and the standardized mortality ratio (SMR), the ratio of observed deaths to expected/predicted deaths, in the cohort of massively transfused trauma patients after introduction of the SOP compared with a historical cohort. METHOD A retrospective, single center study was carried out at a supraregional trauma center between 2005 and 2014. After introduction of the Hb-oriented, coagulation factor-based SOP for correction of TIC in 2011 a before/after comparison of all trauma patients requiring massive transfusions during trauma bay resuscitation and intensive care unit (ICU) admission was carried out. Main outcome parameters were the transfusion requirement and the SMR. The historical cohort of massively transfused trauma patients before introduction of the SOP (group 1) was compared with the cohort after introduction of the SOP (group 2). Furthermore, the two cohorts were compared regarding injury severity, expected death calculated with the revised injury severity classification (RISC), hemostatic results on trauma bay and ICU admission, clotting therapy and outcome. RESULTS Of the 952 patients investigated 86 (9%) required massive transfusion (45 in group 1 and 41 in group 2). Both groups were comparable regarding injury severity but showed slight differences in hemostatic results on trauma bay admission, with a trend to worse results in group 2. Differences were recorded for platelet count on trauma bay admission with significantly lower values in group 2. The RISC predicted a significant difference in the mortality rate (46.5% group 1 and 65.3% group 2) but no significant differences in the observed mortality (44.4% group 1 and 47% group 2) were recorded. The SMR decreased from 0.95 in group 1 to 0.72 in group 2, meaning that in group 1 from 21 predicated trauma deaths 20 occurred and in group 2 from 27 predicated trauma deaths 19 occurred. This difference is not statistically significant (p = 0.16) due to the small sample size but is clinically relevant. A significant reduction in the requirement of red blood cell transfusions (22.8 ± 8.1 units vs 17.6 ± 7.6 units) was achieved (p = 0.003). Significant differences between the groups were observed regarding frequency and quantity of the coagulation-promoting drugs. Compared with group 1 the SOP used in group 2 achieved significantly better hemostatic results on ICU admission for fibrinogen and Quick's value and a clear trend to better results for international normalized ratio (INR) and PTT. CONCLUSION The SOP based on coagulation factor values and standardized clotting therapy showed a clear trend to reduction of the SMR in massively transfused trauma patients. On the other hand the SOP achieved a significant reduction in the transfusion requirements and a significant improvement in the hemostatic results in the most severely injured patients. This can be interpreted as an effective use of coagulation factors in the early hospital treatment of trauma patients with ongoing bleeding.
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Affiliation(s)
- P Hilbert-Carius
- Klinik für Anästhesiologie, Intensiv- u. Notfallmedizin, BG-Kliniken Bergmannstrost Halle (Saale), Merseburgerstr. 165, 06112, Halle (Saale), Deutschland.
| | - G Hofmann
- Klinik für Unfall- u. Wiederherstellungschirurgie, BG-Kliniken Bergmannstrost Halle (Saale), Halle (Saale), Deutschland.,Klinik für Unfall-, Hand- u. Wiederherstellungschirurgie, Friedrich-Schiller-Universität Jena, Jena, Deutschland
| | - R Stuttmann
- Klinik für Anästhesiologie, Intensiv- u. Notfallmedizin, BG-Kliniken Bergmannstrost Halle (Saale), Merseburgerstr. 165, 06112, Halle (Saale), Deutschland
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Stengel D, Rademacher G, Ekkernkamp A, Güthoff C, Mutze S. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database Syst Rev 2015; 2015:CD004446. [PMID: 26368505 PMCID: PMC6464800 DOI: 10.1002/14651858.cd004446.pub4] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ultrasonography (performed by means of a four-quadrant, focused assessment of sonography for trauma (FAST)) is regarded as a key instrument for the initial assessment of patients with suspected blunt abdominal and thoraco-abdominal trauma in the emergency department setting. FAST has a high specificity but low sensitivity in detecting and excluding visceral injuries. Proponents of FAST argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of unnecessary multi-detector computed tomography (MDCT) scans, and enable quicker triage to surgical and non-surgical care. Given the proven accuracy, increasing availability of, and indication for, MDCT among patients with blunt abdominal and multiple injuries, we aimed to compile the best available evidence of the use of FAST-based assessment compared with other primary trauma assessment protocols. OBJECTIVES To assess the effects of diagnostic algorithms using ultrasonography including in FAST examinations in the emergency department in relation to the early, late, and overall mortality of patients with suspected blunt abdominal trauma. SEARCH METHODS The most recent search was run on 30th June 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, MEDLINE (OvidSP), EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), clinical trials registers, and screened reference lists. Trial authors were contacted for further information and individual patient data. SELECTION CRITERIA We included randomised controlled trials (RCTs). Participants were patients with blunt torso, abdominal, or multiple trauma undergoing diagnostic investigations for abdominal organ injury. The intervention was diagnostic algorithms comprising emergency ultrasonography (US). The control was diagnostic algorithms without US examinations (for example, primary computed tomography (CT) or diagnostic peritoneal lavage (DPL)). Outcomes were mortality, use of CT or invasive procedures (DPL, laparoscopy, laparotomy), and cost-effectiveness. DATA COLLECTION AND ANALYSIS Two authors (DS and CG) independently selected trials for inclusion, assessed methodological quality, and extracted data. Methodological quality was assessed using the Cochrane Collaboration risk of bias tool. Where possible, data were pooled and relative risks (RRs), risk differences (RDs), and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed-effect or random-effects models as appropriate. MAIN RESULTS We identified four studies meeting our inclusion criteria. Overall, trials were of poor to moderate methodological quality. Few trial authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. Strong heterogeneity amongst the trials prompted discussion between the review authors as to whether the data should or should not be pooled; we decided in favour of a quantitative synthesis to provide a rough impression about the effect sizes achievable with US-based triage algorithms. We pooled mortality data from three trials involving 1254 patients; the RR in favour of the FAST arm was 1.00 (95% CI 0.50 to 2.00). FAST-based pathways reduced the number of CT scans (random-effects model RD -0.52, 95% CI -0.83 to -0.21), but the meaning of this result was unclear. AUTHORS' CONCLUSIONS The experimental evidence justifying FAST-based clinical pathways in diagnosing patients with suspected abdominal or multiple blunt trauma remains poor. Because of strong heterogeneity between the trial results, the quantitative information provided by this review may only be used in an exploratory fashion. It is unlikely that FAST will ever be investigated by means of a confirmatory, large-scale RCT in the future. Thus, this Cochrane Review may be regarded as a review which provides the best available evidence for clinical practice guidelines and management recommendations. It can only be concluded from the few head-to-head studies that negative US scans are likely to reduce the incidence of MDCT scans which, given the low sensitivity of FAST (or reliability of negative results), may adversely affect the diagnostic yield of the trauma survey. At best, US has no negative impact on mortality or morbidity. Assuming that major blunt abdominal or multiple trauma is associated with 15% mortality and a CT-based diagnostic work-up is considered the current standard of care, 874, 3495, or 21,838 patients are needed per intervention group to demonstrate non-inferiority of FAST to CT-based algorithms with non-inferiority margins of 5%, 2.5%, and 1%, power of 90%, and a type-I error alpha of 5%.
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Affiliation(s)
- Dirk Stengel
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryWarener Str 7BerlinGermany12683
| | - Grit Rademacher
- Unfallkrankenhaus BerlinDepartment of Diagnostic and Interventional RadiologyWarener Str 7BerlinGermany12683
| | - Axel Ekkernkamp
- University HospitalDepartment of Trauma and Reconstructive SurgeryFerdinand‐Sauerbruch‐StraßeGreifswaldGermany17475
| | - Claas Güthoff
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryWarener Str 7BerlinGermany12683
| | - Sven Mutze
- Unfallkrankenhaus BerlinDepartment of Diagnostic and Interventional RadiologyWarener Str 7BerlinGermany12683
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Binz S, McCollester J, Thomas S, Miller J, Pohlman T, Waxman D, Shariff F, Tracy R, Walsh M. CRASH-2 Study of Tranexamic Acid to Treat Bleeding in Trauma Patients: A Controversy Fueled by Science and Social Media. JOURNAL OF BLOOD TRANSFUSION 2015; 2015:874920. [PMID: 26448897 PMCID: PMC4576020 DOI: 10.1155/2015/874920] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/14/2015] [Indexed: 12/14/2022]
Abstract
This paper reviews the application of tranexamic acid, an antifibrinolytic, to trauma. CRASH-2, a large randomized controlled trial, was the first to show a reduction in mortality and recommend tranexamic acid use in bleeding trauma patients. However, this paper was not without controversy. Its patient recruitment, methodology, and conductance in moderate-to-low income countries cast doubt on its ability to be applied to trauma protocols in countries with mature trauma networks. In addition to traditional vetting in scientific, peer-reviewed journals, CRASH-2 came about at a time when advances in communication technology allowed debate and influence to be leveraged in new forms, specifically through the use of multimedia campaigns, social media, and Internet blogs. This paper presents a comprehensive view of tranexamic acid utilization in trauma from peer-reviewed evidence to novel multimedia influences.
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Affiliation(s)
- Sophia Binz
- Department of Emergency and Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Jonathon McCollester
- College of Osteopathic Medicine, Des Moines University, Des Moines, IA 50312, USA
| | - Scott Thomas
- Trauma Center, Memorial Hospital, South Bend, IN 46601, USA
| | - Joseph Miller
- Department of Emergency and Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Timothy Pohlman
- Section of Trauma and Critical Care, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Dan Waxman
- Indiana Blood Center, Indianapolis, IN 46227, USA
| | - Faisal Shariff
- Trauma Center, Memorial Hospital, South Bend, IN 46601, USA
- University of Notre Dame, Notre Dame, IN 46556, USA
| | - Rebecca Tracy
- Trauma Center, Memorial Hospital, South Bend, IN 46601, USA
| | - Mark Walsh
- Trauma Center, Memorial Hospital, South Bend, IN 46601, USA
- Indiana University School of Medicine, Notre Dame Campus, South Bend, IN 46556, USA
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Ker K, Roberts I. Exploring redundant research into the effect of tranexamic acid on surgical bleeding: further analysis of a systematic review of randomised controlled trials. BMJ Open 2015; 5:e009460. [PMID: 26303335 PMCID: PMC4550739 DOI: 10.1136/bmjopen-2015-009460] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 07/29/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES We examined whether apparent redundancy in a cumulative meta-analysis of trials is justified by concern about bias, random error or generalisability of the results. DESIGN Cumulative meta-analysis, risk of bias assessment, trial sequential analysis, description of study participants over time and a review of rationales for conducting trials. DATA SOURCE 126 randomised trials included in a systematic review assessing of tranexamic acid on blood transfusion in surgery. RESULTS The cumulative meta-analysis including all trials shows that the pooled estimate first reached statistical significance after the second trial in 1993. When the analysis was limited to the 38 high-quality trials and adjusted to account for potential systematic and random errors, the uncertainty was resolved after the 22nd trial in 2008. When the analysis was restricted to the two high-quality, prospectively registered trials, the cumulative z-curve crossed p=0.05 but not the monitoring boundary, suggesting an early potentially spurious statistically significant result. As precision of the pooled estimate increased, the number of trials initiated increased, although trial activity appeared to move to other surgery types. Most (62%) reports cited at least one systematic review. Of 118 reports examined, concern about generalisability was the reason for initiating the trial in 60%. Other reasons were to address a question other than the effect on bleeding (26%) and to confirm previously observed results (4%). Unawareness of previous research was apparent in 4% trials, while the rationale was unclear in 3%. CONCLUSIONS Our results indicate that poor quality is a more important cause of redundant research than the failure to review existing evidence. Concerns about generalisability of results is the main motivation for new trials. Contrary to previous claims, our results suggest that systematic reviews showing treatment effects can stimulate an increase in trial activity rather than reduce it.
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Affiliation(s)
- Katharine Ker
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
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Abstract
BACKGROUND Data on time-based trauma mortality (TTM) patterns in developing countries are lacking. OBJECTIVE Our objective was to analyze the TTM in a newly established trauma center. METHODS A retrospective analysis of all trauma-related mortality between 2010 and 2012 was conducted in Qatar. Based on the time of injury, deceased cases were categorized into immediate (pre-hospital), early (first 24 h), and late (>24 h) groups. TTM was analyzed and compared. RESULTS A total of 4,966 trauma patients were admitted to the trauma center over 3 years; of them, 333 trauma-related deaths (6.8 %) were documented and reviewed. The death pattern peaked immediately post-trauma (n = 142), followed by 96 deaths within the first 24 h, 19 deaths within the time period >24 to 48 h, 50 deaths within the 3rd and 7th day (second peak), and 26 deaths after the 1st week. The majority of the deceased were males, with a mean age of 36 ± 17 years. Motor vehicle crashes (43.5 %) were the commonest mechanism of injury. At presentation, median injury severity score (ISS) was 32 (range 9-75). Bleeding, abdominal, and pelvic injuries were higher in the early group, whereas head injuries were observed more in the late mortality group. Co-morbidities and in-hospital complications were predominantly encountered in the late group. Head injury (odds ratio [OR] 3.760; 95 % confidence interval [CI] 1.311-10.797) was an independent predictor for late death, whereas the need for blood transfusion was a predictor for early death (OR 3.233; 95 % CI 1.125-9.345). CONCLUSION The distribution of mortality shows a bimodal pattern. The high rate of death at the scene highlights the importance of pre-hospital care and the need for injury prevention programs.
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