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Culkin MC, Bele P, Georges AP, Santos P, Niziolek G, Kaplan LJ, Smith DH, Pascual JL. Dose-Dependent Tranexamic Acid Blunting of Penumbral Leukocyte Mobilization and Blood-Brain Barrier Permeability Following Traumatic Brain Injury: An In Vivo Murine Study. Neurocrit Care 2024; 41:469-478. [PMID: 38443709 DOI: 10.1007/s12028-024-01952-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/29/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Early posttraumatic brain injury (TBI) tranexamic acid (TXA) may reduce blood-brain barrier (BBB) permeability, but it is unclear if this effect is fixed regardless of dose. We hypothesized that post-TBI TXA demonstrates a dose-dependent reduction of in vivo penumbral leukocyte mobilization, BBB microvascular permeability, and enhancement of neuroclinical recovery. METHODS CD1 male mice (n = 40) were randomly assigned to TBI by controlled cortical impact (injury [I]) or sham TBI (S), followed by intravenous bolus of either saline (placebo [P]) or TXA (15, 30, or 60 mg/kg). At 48 h, in vivo pial intravital microscopy visualized live penumbral BBB microvascular leukocytes and albumin leakage. Neuroclinical recovery was assessed by Garcia Neurological Test scores and animal weight changes at 24 h and 48 h after injury. RESULTS I + TXA60 reduced live penumbral leukocyte rolling compared with I + P (p < 0.001) and both lower TXA doses (p = 0.017 vs. I + TXA15, p = 0.012 vs. I + TXA30). Leukocyte adhesion was infrequent and similar across groups. Only I + TXA60 significantly reduced BBB permeability compared with that in the I + P (p = 0.004) group. All TXA doses improved Garcia Test scores relative to I + P at both 24 h and 48 h (p < 0.001 vs. I + P for all at both time points). Mean 24-h body weight loss was greatest in the I + P (- 8.7 ± 1.3%) group and lowest in the I + TXA15 (- 4.4 ± 1.0%, p = 0.051 vs. I + P) group. CONCLUSIONS Only higher TXA dosing definitively abrogates penumbral leukocyte mobilization, preserving BBB integrity post TBI. Some neuroclinical recovery is observed, even with lower TXA dosing. Better outcomes with higher dose TXA after TBI may occur secondary to blunting of leukocyte-mediated penumbral cerebrovascular inflammation.
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Affiliation(s)
- Matthew C Culkin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, SICU Administration Office - 5 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Priyanka Bele
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, SICU Administration Office - 5 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anastasia P Georges
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, USA
| | - Patricia Santos
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, SICU Administration Office - 5 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Grace Niziolek
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, SICU Administration Office - 5 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Lewis J Kaplan
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, SICU Administration Office - 5 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Douglas H Smith
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jose L Pascual
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, SICU Administration Office - 5 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Liu X, Ma Z, Wang H, Zhang X, Li S, Zhang M, An J, Luo Z. Effectiveness and Safety of High-Dose Tranexamic Acid in Adolescent Idiopathic Scoliosis Surgery: A Meta-Analysis and Systematic Review. World Neurosurg 2024; 191:39-48. [PMID: 39111654 DOI: 10.1016/j.wneu.2024.07.203] [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: 07/14/2024] [Accepted: 07/29/2024] [Indexed: 09/02/2024]
Abstract
OBJECTIVE This systematic review and meta-analysis of randomized controlled trials and retrospective controlled studies aims to evaluate the efficacy and safety of high-dose tranexamic acid (TXA) in spinal correction surgery for adolescent idiopathic scoliosis patients. METHODS In March 2024, a comprehensive search was conducted in PubMed, Web of Science, Embase, and Cochrane databases to identify randomized controlled trials and retrospective controlled studies comparing the effects of high-dose TXA on blood loss and transfusion requirements during spinal correction surgery. RESULTS This meta-analysis included 10 studies encompassing a total of 741 patients. The pooled results indicated that the use of high-dose TXA significantly reduced intraoperative blood loss [weighted mean difference (WMD) = -519.83, 95% CI (-724.74, -314.92), P < 0.00001], transfusion rate [RR = 0.28, 95% CI (0.17, 0.45), P < 0.00001], total blood loss [WMD = -891.09, 95% CI (-1623.92, -158.26), P = 0.02], and postoperative blood loss [WMD = -105.91, 95% CI (-141.29, -70.52), P < 0.00001]. There was no significant difference in operative time [WMD = -18.96, 95% CI (-40.20, 2.28), P = 0.08] and blood loss per segment [WMD = -50.51, 95% CI (-102.19, 1.17), P = 0.06]. Both groups had a comparable incidence of thromboembolic events. CONCLUSIONS Our meta-analysis suggests that the use of high-dose TXA reduces intraoperative blood loss, transfusion rate, total blood loss, and postoperative blood loss in spinal correction surgery for adolescent idiopathic scoliosis patients. However, there were no significant differences in operative time and blood loss per segment.
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Affiliation(s)
- Xin Liu
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China; Key Laboratory of Bone and Joint Disease Research of Gansu Provincial, Lanzhou, China
| | - Zhong Ma
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China; Key Laboratory of Bone and Joint Disease Research of Gansu Provincial, Lanzhou, China
| | - Hao Wang
- Gansu University of Chinese Medicine, Lanzhou, China
| | - Xianxu Zhang
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China; Key Laboratory of Bone and Joint Disease Research of Gansu Provincial, Lanzhou, China
| | - Shicheng Li
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China; Key Laboratory of Bone and Joint Disease Research of Gansu Provincial, Lanzhou, China
| | - Mingtao Zhang
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China; Key Laboratory of Bone and Joint Disease Research of Gansu Provincial, Lanzhou, China
| | - Jiangdong An
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China
| | - Zhiqiang Luo
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China.
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Meretsky CR, Polychronis A, Schiuma AT. Use of Intravenous Tranexamic Acid in Patients Undergoing Plastic Surgery: Implications and Recommendations per a Systematic Review and Meta-Analysis. Cureus 2024; 16:e62482. [PMID: 39015854 PMCID: PMC11251670 DOI: 10.7759/cureus.62482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2024] [Indexed: 07/18/2024] Open
Abstract
With increasing interest in aesthetic plastic procedures, the event of blood loss has compromised patients' safety and satisfaction. Tranexamic acid (TXA) is a drug used for the reduction of blood loss during surgical procedures. This systematic review aims to evaluate the clinical efficacy and safety of TXA in aesthetic plastic surgery for the reduction of bleeding and related complications. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Electronic databases PubMed, EMBASE, Cochrane Library, and Google Scholar were searched. The medical subject headings (MeSH) keywords used for data extraction were ("TXA," OR "tranexamic acid,") AND ("plastic surgery," OR "aesthetic surgery," OR "rhinoplasty," OR "blepharoplasty,") AND ("blood loss" OR "bleeding" OR "TBL") AND ("Edema" OR "ecchymosis"). A combination of these MeSH terms was used in the literature search. The timeline of research was set from 2015 to January 2024. A total of 7380 research articles were identified from the above-mentioned databases, and only 13 research articles met the inclusion criteria. There was a significant difference in total blood loss (TBL) among patients who had undergone plastic surgery procedures while on TXA as compared to a placebo (mean difference = -6.02; Cl: -1.07 to -0.16; p > 0.00001), and heterogeneity was found (degrees of freedom (df) = 9; I2 = 97%). Only two studies reported the average ecchymosis scores after TXA among interventions in comparison to the placebo group. This review provides evidence that TXA lowers TBL, ecchymosis, edema, and anemia during cosmetic surgery without significantly increasing thromboembolic consequences.
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Faraoni D, Fenger-Eriksen C. Dosing of tranexamic acid in trauma. Curr Opin Anaesthesiol 2024; 37:125-130. [PMID: 38390911 DOI: 10.1097/aco.0000000000001357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW Tranexamic acid is routinely used as part of the management of traumatic bleeding. The dose recommendation in trauma was extrapolated from other clinical settings and the results of pragmatic randomized trials rather than pharmaco-kinetic and -dynamic evaluations. The review addresses current evidence on dosing of tranexamic acid in traumatized patients with a focus on efficacy, safety and risk-benefit profile. RECENT FINDINGS A majority, but not all, of existing randomized clinical trials reports a reduction in mortality and/or blood loss with tranexamic acid administration. Increasing dose above the general recommendation (1 g bolus + 1 g infusion/8 h intravenously) has not been shown to further increase efficacy and could potentially increase side effects. SUMMARY The benefit of tranexamic acid as adjuvant therapy in the management of bleeding trauma patients on mortality and transfusion requirements is clear and well documented, being most effective if given early and to patients with clinical signs of hemorrhagic shock. Recent reports suggest that in some patients presenting with a shutdown of their fibrinolytic pathway the administration of tranexamic acid could be associated with an increased risk of thromboembolic events and poor outcomes. A more personalized approach based on bedside assessment of fibrinolytic activation and pharmacokinetic-based dose regimen should be developed moving forward.
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Affiliation(s)
- David Faraoni
- Arthur S. Keats Division of Pediatric. Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Christian Fenger-Eriksen
- Department of Anesthesiology and Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Piette N, Beck F, Carella M, Hans G, Maesen D, Kurth W, Lecoq JP, Bonhomme VL. Oral as compared to intravenous tranexamic acid to limit peri-operative blood loss associated with primary total hip arthroplasty: A randomised noninferiority trial. Eur J Anaesthesiol 2024; 41:217-225. [PMID: 38214552 DOI: 10.1097/eja.0000000000001950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND Oral as compared to intravenous tranexamic acid (TXA) is an attractive option, in terms of cost and safety, to reduce blood loss and transfusion in total hip arthroplasty. Exclusion criteria applied in the most recent randomised trials may have limited the generalisability of oral tranexamic acid in this indication. Larger and more inclusive studies are needed to definitively establish oral administration as a credible alternative to intravenous administration. OBJECTIVES To assess the noninferiority of oral to intravenous TXA at reducing intra-operative and postoperative total blood loss (TBL) in primary posterolateral approached total hip arthroplasty (PLTHA). DESIGN Noninferiority, single centre, randomised, double-blind controlled study. SETTING Patients scheduled for primary PLTHA. Data acquisition occurred between May 2021 and November 2022 at the University Hospital of Liège, Belgium. PATIENTS Two hundred and twenty-eight patients, randomised in a 1 : 1 ratio from a computer-generated list, completed the trial. INTERVENTIONS Administration of 2 g of oral TXA 2 h before total hip arthroplasty and 4 h after incision (Group oral) was compared to the intravenous administration of 1 g of TXA 30 min before surgery and 4 h after incision (Group i.v.). MAIN OUTCOME MEASURES TBL (measured intra-operative and drainage blood loss up to 48 h after surgery, primary outcome), decrease in haemoglobin concentration, D-Dimer at day 1 and day 3, transfusion rate (secondary outcomes). RESULTS Analyses were performed on 108 out of 114 participants (Group i.v.) and 104 out of 114 participants (Group oral). Group oral was noninferior to Group i.v. with regard to TBL, with a difference between medians (95% CI) of 35 ml (-103.77 to 33.77) within the noninferiority margins. Median [IQR] of estimated TBL was 480 ml [350 to 565] and 445 ml [323 to 558], respectively. No significant interaction between group and time was observed regarding the evolution of TBL and haemoglobin over time. CONCLUSIONS TXA as an oral premedication before PLTHA is noninferior to its intravenous administration regarding peri-operative TBL. TRIAL REGISTRATION European Clinical Trial Register under EudraCT-number 2020-004167-29 ( https://www.clinicaltrialsregister.eu/ctr-search/trial/2020-004167-29/BE ).
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Affiliation(s)
- Nicolas Piette
- From the Department of Anaesthesia and Intensive Care Medicine (NP, FB, MC, GH, J-PL, VLB), Department of Clinical Pharmacy (DM), Department of Locomotor System Surgery, Liege University Hospital (WK), Inflammation and Enhanced Rehabilitation Laboratory (Regional Anaesthesia and Analgesia), GIGA-I3 Thematic Unit (NP, MC, J-PL), Anaesthesia and Perioperative Neuroscience Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium (FB, VLB)
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Franchini M, Focosi D, Zaffanello M, Mannucci PM. Efficacy and safety of tranexamic acid in acute haemorrhage. BMJ 2024; 384:e075720. [PMID: 38176733 DOI: 10.1136/bmj-2023-075720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy
| | - Marco Zaffanello
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Kim K, Jinno C, Li X, Bravo D, Cox E, Ji P, Liu Y. Impact of an oligosaccharide-based polymer on the metabolic profiles and microbial ecology of weanling pigs experimentally infected with a pathogenic E. coli. J Anim Sci Biotechnol 2024; 15:1. [PMID: 38169416 PMCID: PMC10759389 DOI: 10.1186/s40104-023-00956-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/29/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Our previous study has reported that supplementation of oligosaccharide-based polymer enhances gut health and disease resistance of pigs infected with enterotoxigenic E. coli (ETEC) F18 in a manner similar to carbadox. The objective of this study was to investigate the impacts of oligosaccharide-based polymer or antibiotic on the host metabolic profiles and colon microbiota of weaned pigs experimentally infected with ETEC F18. RESULTS Multivariate analysis highlighted the differences in the metabolic profiles of serum and colon digesta which were predominantly found between pigs supplemented with oligosaccharide-based polymer and antibiotic. The relative abundance of metabolic markers of immune responses and nutrient metabolisms, such as amino acids and carbohydrates, were significantly differentiated between the oligosaccharide-based polymer and antibiotic groups (q < 0.2 and fold change > 2.0). In addition, pigs in antibiotic had a reduced (P < 0.05) relative abundance of Lachnospiraceae and Lactobacillaceae, whereas had greater (P < 0.05) Clostridiaceae and Streptococcaceae in the colon digesta on d 11 post-inoculation (PI) compared with d 5 PI. CONCLUSIONS The impact of oligosaccharide-based polymer on the metabolic and microbial profiles of pigs is not fully understood, and further exploration is needed. However, current research suggest that various mechanisms are involved in the enhanced disease resistance and performance in ETEC-challenged pigs by supplementing this polymer.
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Affiliation(s)
- Kwangwook Kim
- Department of Animal Science, University of California, Davis, CA, 95616, USA
- Present Affiliation: Department of Animal Science, Michigan State University, East Lansing, MI, 48824, USA
| | - Cynthia Jinno
- Department of Animal Science, University of California, Davis, CA, 95616, USA
- Present Affiliation: Cedars-Sinai Medical Center, Los Angeles, CA, 90084, USA
| | - Xunde Li
- School of Veterinary Medicine, University of California, Davis, CA, 95616, USA
| | - David Bravo
- Pancosma|ADM, 1180, Rolle, Switzerland
- Present Affiliation: Nutreco Exploration, Nutreco, The Netherlands
| | - Eric Cox
- Department of Virology, Parasitology and Immunology, Ghent University, 9000, Ghent, Belgium
| | - Peng Ji
- Department of Nutrition, University of California, Davis, CA, 95616, USA
| | - Yanhong Liu
- Department of Animal Science, University of California, Davis, CA, 95616, USA.
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Culkin MC, Coons M, Bele P, Thaploo A, Georges AP, Anderson E, Browne KD, Jacovides C, Santos P, Kaplan LJ, Meaney DF, Smith DH, Pascual JL. Delayed tranexamic acid after traumatic brain injury impedes learning and memory: Early tranexamic acid is favorable but not in sham animals. J Trauma Acute Care Surg 2024; 96:26-34. [PMID: 37853567 DOI: 10.1097/ta.0000000000004155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
BACKGROUND Early but not late tranexamic acid (TXA) after TBI preserves blood-brain-barrier integrity, but it is unclear if and how dose timing affects cognitive recovery beyond hours postinjury. We hypothesized that early (1 hour post-TBI) but not late (24 hours post-TBI) TXA administration improves cognitive recovery for 14 days. METHODS CD1 male mice (n = 25) were randomized to severe TBI (injury [I], by controlled cortical impact) or sham craniotomy (S) followed by intravenous saline at 1 hour (placebo [P1]) or 30 mg/kg TXA at 1 hour (TXA1) or 24 hours (TXA24). Daily body weights, Garcia Neurological Test scores, brain/lung water content, and Morris water maze exercises quantifying swimming traffic in the platform quadrant (zone [Z] 1) and platform area (Z5) were recorded for up to 14 days. RESULTS Among injured groups, I-TXA1 demonstrated fastest weight gain for 14 days and only I-TXA1 showed rapid (day 1) normalization of Garcia Neurological Test ( p = 0.01 vs. I-P1, I-TXA24). In cumulative spatial trials, compared with I-TXA1, I-TXA24 hindered learning (distance to Z5 and % time in Z1, p < 0.05). Compared with I-TXA1, I-TXA24 showed poorer memory with less Z5 time (0.51 vs. 0.16 seconds, p < 0.01) and Z5 crossing frequency. Unexpectedly, TXA in uninjured animals (S-TXA1) displayed faster weight gain but inferior learning and memory. CONCLUSION Early TXA appears beneficial for cognitive and behavioral outcomes following TBI, although administration 24 hours postinjury consistently impairs cognitive recovery. Tranexamic acid in sham animals may lead to adverse effects on cognition.
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Affiliation(s)
- Matthew C Culkin
- From the Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery (M.C.C., M.C., P.B., A.T., C.J., P.S., L.J.K., J.L.P.), and Center for Brain Injury and Repair, Department of Neurosurgery (M.C.C., M.C., P.B., A.T., A.P.G., E.A., K.D.B., C.J., P.S., L.J.K., D.F.M., D.H.S., J.L.P.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Al-Dardery NM, Abdelwahab OA, Abouzid M, Albakri K, Elkhadragy A, Katamesh BE, Hamamreh R, Mohd AB, Abdelaziz A, Khaity A. Efficacy and safety of tranexamic acid in prevention of postpartum hemorrhage: a systematic review and meta-analysis of 18,649 patients. BMC Pregnancy Childbirth 2023; 23:817. [PMID: 38001439 PMCID: PMC10668444 DOI: 10.1186/s12884-023-06100-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 11/01/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND In this meta-analysis, we aimed to update the clinical evidence regarding the efficacy and safety of TXA in the prevention of PPH. METHODS A literature search of PubMed, Scopus, Web of Science, Google Scholar, and Cochrane Library from inception until December 2022 was conducted. We included randomized controlled trials (RCTs) comparing TXA with a placebo among pregnant women. All relevant outcomes, such as total blood loss, the occurrence of nausea and/or vomiting, and changes in hemoglobin, were combined as odds ratios (OR) or mean differences (MD) in the meta-analysis models using STATA 17 MP. RESULTS We included 59 RCTs (18,649 patients) in this meta-analysis. For cesarean birth, TXA was favored over the placebo in reducing total blood loss (MD= -2.11 mL, 95%CI [-3.09 to -1.14], P < 0.001), and occurrence of nausea or/and vomiting (OR = 1.36, 95%CI [1.07 to 1.74], P = 0.01). For vaginal birth, the prophylactic use of TXA was associated with lower total blood loss, and higher occurrence of nausea and/or vomiting (MD= -0.89 mL, 95%CI [-1.47 to -0.31], OR = 2.36, 95%CI [1.32 to 4.21], P = 0.02), respectively. However, there were no differences between the groups in changes in hemoglobin during vaginal birth (MD = 0.20 g/dl, 95%CI [-0.07 to 0.48], P = 0.15). The overall risk of bias among the included studies varies from low to high risk of bias using ROB-II tool for RCTs. CONCLUSIONS This meta-analysis suggested that TXA administration is effective among women undergoing cesarean birth or vaginal birth in lowering total blood loss and limiting the occurrence of PPH. Further clinical trials are recommended to test its efficacy on high-risk populations.
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Affiliation(s)
- Nada Mostafa Al-Dardery
- Faculty of Medicine, Fayoum University, Fayoum, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Omar Ahmed Abdelwahab
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed Abouzid
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznan, Poland
- Doctoral School, Poznan University of Medical Sciences, Poznan, Poland
| | - Khaled Albakri
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Ali Elkhadragy
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Rawan Hamamreh
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Ahmed B Mohd
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Ahmed Abdelaziz
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Abdulrhman Khaity
- Medical Research Group of Egypt (MRGE), Cairo, Egypt.
- Faculty of Medicine, Elrazi University, Khartoum, 11115, Sudan.
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Altamirano-Cruz MA, Velarde JE, Valderrama-Molina CO, Azi M, Belangero WD, Bidolegui F, Carabelli GS, Gómez A, Pires RE, Xicará JA, Giordano V. Availability and use of resources for emergency fracture care of pelvic trauma associated with haemorrhagic shock in Latin America: A cross-sectional study. Injury 2023; 54 Suppl 6:110733. [PMID: 38143149 DOI: 10.1016/j.injury.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/14/2023] [Accepted: 04/12/2023] [Indexed: 12/26/2023]
Abstract
Determining the true availability of resources and understanding the level of training of surgeons involved in the treatment of patients with pelvic fractures and haemorrhagic shock is critical. In the herein study, the availability of technical, technological, and human resources for the care of this injury in Latin America region was analysed, and the preferences of orthopaedic trauma surgeons when performing interventions for the diagnosis and treatment of patients with pelvic trauma and associated haemorrhagic shock was described. A cross sectional web-based survey containing questions on knowledge, attitudes, and practices with respect to imaging resources, emergency pelvic stabilization methods, and interventions used for bleeding control was sent to 948 Latin America orthopaedic trauma surgeons treating pelvic fractures in the emergency department. Differences between regional clusters, level of training, type of hospital, and pelvic surgery volume were assessed. 368 responses were obtained, with 37.5% of respondents reporting formal training in pelvic surgery and 36.0% having available protocol for managing these patients. The most frequently used interventions were the supra-acetabular pelvic external fixator and pelvic packing. Limited hospital and imaging resources are available for the care of patients with pelvic trauma and associated haemorrhagic shock throughout Latin America. In addition, the training of orthopaedic trauma surgeons dealing with this type of injury and the volume of pelvic surgeries per year is heterogeneous. It should be urgently considered to develop management protocols adapted to Latin America according to the availability of resources, as well as to promote training in this severe life-threatening traumatic condition.
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Affiliation(s)
| | | | | | - Matheus Azi
- Departamento de Ortopedia, Hospital Manoel Victorino, Secretaria Estadual de Saúde do Estado da Bahia, Salvador, Brazil
| | - William Dias Belangero
- Departamento de Ortopedia, Reumatologia e Traumatologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas UNICAMP, Campinas, SP, Brazil
| | - Fernando Bidolegui
- Servicio de Ortopedia y Traumatologia, Hospital Sirio-Libanes, ECICARO, Buenos Aires, Argentina
| | - Guido Sebastián Carabelli
- Sector de Trauma, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Amparo Gómez
- Servicio Ortopedia, Hospital Universitario de la Samaritana, Bogota, Colombia
| | - Robinson Esteves Pires
- Departamento do Aparelho Locomotor, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - José Arturo Xicará
- Centro Universitario de Occidente, Universidad de San Carlos de Guatemala, Quetzaltenango, Guatemala; Cruz Roja Guatemalteca, Delegación Quetzaltenango, Quetzaltenango, Guatemala
| | - Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, RJ, Brazil; Clínica São Vicente, Rede D'or São Luiz, Rio de Janeiro, RJ, Brazil
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11
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Om A, Marxen T, Kebede S, Losken A. The Usage of Intravenous Tranexamic Acid in Reduction Mammaplasty Safely Reduces Hematoma Rates. Ann Plast Surg 2023; 90:S371-S374. [PMID: 36729851 PMCID: PMC10578999 DOI: 10.1097/sap.0000000000003296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Bleeding complications are not uncommon after breast reduction surgery, and recently, tranexamic acid (TXA) as an antifibrinolytic agent has been used in various surgical specialties as a way to minimizes such adverse outcomes. We elected to evaluate the effectiveness of intravenous (IV) intraoperative TXA in reduction mammoplasty patients. METHODS This is a retrospective chart review of clinical charts of all patients who received reduction mammoplasty by a single surgeon at Emory University Hospital or its affiliated Aesthetic Center from January 1, 2020, to March 1, 2022. Seventy-four consecutive breast reduction patients received 1-g IV TXA intraoperatively compared with 117 consecutive controls. The outcome of interest included 30-day postoperative bleeding complications. RESULTS There was no significant difference in age ( P = 0.92), body mass index ( P = 0.98), percentage of smokers ( P = 0.56), operating time ( P = 0.87), estimated blood loss ( P = 0.90), or weight removed ( P = 0.98) between patients in each arm. There were 19 bleeding events (16.2%) in the non-TXA arm compared with 1 bleeding event (1.4%) in the TXA arm ( P = 0.0143). Of the 19, 6 (5.1%) were major events, and 13 were minor events (11.1%); the only bleeding event in the TXA arm was minor. Number needed to treat all bleeding events with use of TXA was 7, and the number needed to treat minor hematomas was 11. There was no significant difference in the rate of seroma, wound healing complications, infection, or nipple necrosis between the 2 arms ( P > 0.05). CONCLUSIONS The use of IV TXA is a safe and effective way to reduce hematoma rates in patients receiving reduction mammoplasty.
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Affiliation(s)
- Anjali Om
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University, Atlanta, GA
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Lier H, Gooßen K, Trentzsch H. [The chapters "Stop the bleed-prehospital" and "Coagulation management and volume therapy (emergency departement)" in the new S3 guideline "Polytrauma/severe injury treatment"]. Notf Rett Med 2023; 26:259-268. [PMID: 37261335 PMCID: PMC10117256 DOI: 10.1007/s10049-023-01147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2023] [Indexed: 06/02/2023]
Abstract
The S3 guideline on the treatment of patients with severe/multiple injuries by the German Association of the Scientific Medical Societies was updated between 2020 and 2022. This article describes the essence of the new chapter "Stop the bleed-prehospital" and the revised chapter "Coagulation management and volume therapy".
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Affiliation(s)
- H. Lier
- Medizinische Fakultät und Uniklinik Köln, Klinik für Anästhesiologie und Operative Intensivmedizin, Universität zu Köln, Kerpener Straße 62, 50937 Köln, Deutschland
- Sektion „Klinische Hämotherapie und Hämostasemanagement“ der Deutschen Gesellschaft für Intensiv- und Notfallmedizin (DIVI), Schumannstr. 2, 10117, Berlin, Deutschland
| | - K. Gooßen
- Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke, Ostmerheimer Straße 200, 51109 Köln, Deutschland
| | - H. Trentzsch
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336 München, Deutschland
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13
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Kanakaris NK, Bouamra O, Lecky F, Giannoudis PV. Severe trauma with associated pelvic fractures: The impact of regional trauma networks on clinical outcome. Injury 2023:S0020-1383(23)00348-0. [PMID: 37085351 DOI: 10.1016/j.injury.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
Lately, the care of severely injured patients in the United Kingdom has undergone a significant transformation. The establishment of regional trauma networks (RTN) with designated Major Trauma Centers (MTCs) and satellite hospitals called Trauma Units (TUs) has centralized the care of severely injured patients in the MTCs. Pelvic fractures are notoriously linked with hypovolemic shock or even death from excessive blood loss. The aim of this prospective cohort study is to compare the profile of severely injured patients with combined pelvic fractures and their mortality between two different distinct eras of an advanced healthcare system. Anonymized consecutive patient records submitted to TARN UK between 2002 and 2017 by NHS England hospitals were analyzed. Records of patients without a pelvic fracture, or with isolated pelvic fractures (no other serious injury with abbreviated injury scale AIS >2) were excluded. All patients with known outcomes were included and were divided into 2 distinct periods (pre-RTN era: between January 2002 and March 2008 (control group); and RTN era April 2013 to June 2017 (study group)). Data from the transition period from April 2008 to March 2013 were excluded to minimize the effect of variations between the developing networks and MTCs during that era. Overall, the study group included 10,641 patients, whereas the control group was 3152 patients, with a median age of 52.4 and 35.1 years and an ISS of 24 and 27 respectively. A systolic blood pressure below 90mmHg was observed in 7.2% of patients in the study group and 10.4% in the control group. A significant increase of the median time to death (from 8hrs to 188hrs) was observed between the two eras. The cumulative mortality of severely injured patients with pelvic fractures decreased significantly from 17.8% to 12.4% (p<0.0001). The recorded improvement of survivorship in the subgroup of severely injured patients with a pelvic fracture (32% lower in the post-RTN than in the pre-RTN period: OR 1.32 (95% CI 1.21 - 1.44), following the first 5 years of established regional trauma networks in NHS England, is encouraging, and should be attributed to a wide range of factors that translate to all levels of trauma care.
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Affiliation(s)
- Nikolaos K Kanakaris
- LEEDS Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
| | - Omar Bouamra
- Trauma Research and Audit Network, University of Manchester, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Fiona Lecky
- Trauma Research and Audit Network, University of Manchester, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford, United Kingdom; Centre for Urgent and Emergency Care REsearch (CURE), Health Services Research Section, School of Health and Related Research, University of Sheffield, United Kingdom
| | - Peter V Giannoudis
- LEEDS Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom.
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Antifibrinolytics in the treatment of traumatic brain injury. Curr Opin Anaesthesiol 2022; 35:583-592. [PMID: 35900731 PMCID: PMC9594127 DOI: 10.1097/aco.0000000000001171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Traumatic brain injury (TBI) is a leading cause of trauma-related deaths, and pharmacologic interventions to limit intracranial bleeding should improve outcomes. Tranexamic acid reduces mortality in injured patients with major systemic bleeding, but the effects of antifibrinolytic drugs on outcomes after TBI are less clear. We therefore summarize recent evidence to guide clinicians on when (not) to use antifibrinolytic drugs in TBI patients. RECENT FINDINGS Tranexamic acid is the only antifibrinolytic drug that has been studied in patients with TBI. Several recent studies failed to conclusively demonstrate a benefit on survival or neurologic outcome. A large trial with more than 12 000 patients found no significant effect of tranexamic acid on head-injury related death, all-cause mortality or disability across the overall study population, but observed benefit in patients with mild to moderate TBI. Observational evidence signals potential harm in patients with isolated severe TBI. SUMMARY Given that the effect of tranexamic acid likely depends on a variety of factors, it is unlikely that a 'one size fits all' approach of administering antifibrinolytics to all patients will be helpful. Tranexamic acid should be strongly considered in patients with mild to moderate TBI and should be avoided in isolated severe TBI.
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15
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Patel PA, Wyrobek JA, Butwick AJ, Pivalizza EG, Hare GMT, Mazer CD, Goobie SM. Update on Applications and Limitations of Perioperative Tranexamic Acid. Anesth Analg 2022; 135:460-473. [PMID: 35977357 DOI: 10.1213/ane.0000000000006039] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tranexamic acid (TXA) is a potent antifibrinolytic with documented efficacy in reducing blood loss and allogeneic red blood cell transfusion in several clinical settings. With a growing emphasis on patient blood management, TXA has become an integral aspect of perioperative blood conservation strategies. While clinical applications of TXA in the perioperative period are expanding, routine use in select clinical scenarios should be supported by evidence for efficacy. Furthermore, questions regarding optimal dosing without increased risk of adverse events such as thrombosis or seizures should be answered. Therefore, ongoing investigations into TXA utilization in cardiac surgery, obstetrics, acute trauma, orthopedic surgery, neurosurgery, pediatric surgery, and other perioperative settings continue. The aim of this review is to provide an update on the current applications and limitations of TXA use in the perioperative period.
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Affiliation(s)
- Prakash A Patel
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Julie A Wyrobek
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Evan G Pivalizza
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center, Houston, Texas
| | - Gregory M T Hare
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Barletta JF, Erstad BL. Dosing Medications for Coagulopathy Reversal in Patients with Extreme Obesity. J Emerg Med 2022; 63:541-550. [PMID: 35906122 DOI: 10.1016/j.jemermed.2022.04.036] [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: 02/17/2022] [Revised: 03/22/2022] [Accepted: 04/23/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND The reversal of anticoagulant or antiplatelet medications is a priority in the management of patients with severe injury with the goal of minimizing further bleeding without thrombotic complications. There are few studies, however, evaluating the dosing of reversal agents in the setting of trauma specific to patients with extreme obesity. Nevertheless, clinicians must still make decisions, balancing concerns of ongoing bleeding with excessive thrombosis. OBJECTIVES We describe the literature pertaining to dosing of medications used for the reversal of both drug-induced and trauma-related coagulopathy with the intent of providing a framework for clinicians to make dosing decisions in this challenging population. DISCUSSION Obesity is known to impact both the volume of distribution and the clearance of medications, but these changes are not usually linear with size nor are they uniform across drugs. Current strategies for dosing reversal agents in obesity include a capped dose (e.g., prothrombin complex concentrates), fixed dosages (e.g., andexanet alfa, idarucizumab, and tranexamic acid), and weight-based dosing (e.g., desmopressin). Extreme obesity, however, was not highly prevalent in the studies that have validated these dosing strategies. In fact, many of the clinical studies fail to report the average weight of the patients included. CONCLUSION Future studies should make efforts to increase reporting of patients with obesity included in clinical trials along with results stratified by weight class. In the meantime, doses listed in product labels should be used. Desmopressin should be dosed using either ideal body weight or a dose-capping strategy.
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Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Glendale
| | - Brian L Erstad
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
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Alfitian J, Scheyerer MJ, Rohde A, Schick V, Kammerer T, Schier R. Omission of tranexamic acid does not increase the amount of perioperative blood transfusions in patients undergoing one-level spinal fusion surgery: a retrospective propensity score-matched noninferiority study. Arch Orthop Trauma Surg 2022; 143:2943-2950. [PMID: 35708870 DOI: 10.1007/s00402-022-04494-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 05/18/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Application of tranexamic acid (TXA) in spine surgery is very frequent even without signs of hyperfibrinolysis, although its beneficial blood-saving effects are offset by harmful adverse events such as thromboembolic incidents. Thus, we investigated whether in relatively less invasive spinal procedures such as one-level posterior spinal fusion, omission of TXA affects the requirement for blood transfusions. METHODS We conducted a retrospective propensity score-matched noninferiority study with 212 patients who underwent one-level posterior spine fusion and who were stratified according to whether they received TXA intraoperatively at our tertiary care center. The primary endpoint was the volume of transfused packed red cells. Testing for noninferiority or equivalence was performed by two one-sided testing procedure (TOST) with a priori defined noninferiority margins ([Formula: see text]). RESULTS After propensity score matching a total of five patients (11.6%) treated with TXA were transfused compared with five patients (11.6%) who did not receive TXA. The majority of patients (51.2%) had a risk-increasing condition. The risk difference (no TXA-TXA) of intraoperative transfusion was - 4.7% (CI 90% - 13.62 to 4.32%), and omitting TXA was noninferior ([Formula: see text] = [Formula: see text] 10%). The mean intergroup difference in transfused volume (no TXA-TXA) was - 23.26 ml intraoperatively (CI 90% - 69.34 to 22.83 ml) and - 46.51 ml overall (CI 90% - 181.12 to 88.1 ml), respectively, suggesting equivalence of TXA omission ([Formula: see text] = [Formula: see text] 300 ml). The hemoglobin decline between both groups was also equivalent (with [Formula: see text] = [Formula: see text] 1 g/dl) both on the first postoperative day ([Formula: see text] Hb = 0.02 g/dl, CI 90% - 0.53 to 0.56 g/dl) and at discharge ([Formula: see text] Hb = - 0.29 g/dl, CI 90% - 0.89 to 0.31 g/dl). CONCLUSION We demonstrated that requirement of transfusion is rare among one-level fusion surgery and the omission of TXA is noninferior with regard to blood transfusion in high-risk patients undergoing this procedure. Therefore, the prophylactic use of TXA cannot be recommended here, suggesting to focus on alternative blood conservation strategies, if necessary.
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Affiliation(s)
- Jonas Alfitian
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Max Joseph Scheyerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedics and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Axel Rohde
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedics and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Volker Schick
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany
| | - Tobias Kammerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany
| | - Robert Schier
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany
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Alphonsus CS, Swanevelder J, Biccard BM. Bleeding and tranexamic acid in patients undergoing noncardiac surgery. J Cardiothorac Vasc Anesth 2022; 36:3727-3729. [DOI: 10.1053/j.jvca.2022.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 11/11/2022]
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19
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Latest advances in postpartum hemorrhage management. Best Pract Res Clin Anaesthesiol 2022; 36:123-134. [PMID: 35659949 DOI: 10.1016/j.bpa.2022.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 11/20/2022]
Abstract
Hemorrhage is the leading cause of maternal mortality worldwide. A maternal health priority is improving how healthcare providers prevent and manage postpartum hemorrhage (PPH). Because anesthesiologists can help facilitate how hospitals develop approaches for PPH prevention and anticipatory planning, we review the potential utility of PPH risk-assessment tools, bundles, and protocols. Anesthesiologists rely on clinical and diagnostic information for initiating and evaluating medical management. Therefore, we review modalities for measuring blood loss after delivery, which includes visual, volumetric, gravimetric, and colorimetric approaches. Point-of-care technologies for assessing changes in central hemodynamics (ultrasonography) and coagulation profiles (rotational thromboelastometry and thromboelastography) are also discussed. Anesthesiologists play a critical role in the medical and transfusion management of PPH. Therefore, we review blood ordering and massive transfusion protocols, fixed-ratio vs. goal-directed transfusion approaches, coagulation changes during PPH, and the potential clinical utility of the pharmacological adjuncts, tranexamic acid, and fibrinogen concentrate.
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20
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Laikhter E, Comer CD, Shiah E, Manstein SM, Bain PA, Lin SJ. A Systematic Review and Meta-Analysis Evaluating the Impact of Tranexamic Acid Administration in Aesthetic Plastic Surgery. Aesthet Surg J 2022; 42:548-558. [PMID: 34486647 DOI: 10.1093/asj/sjab333] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Recent evidence suggests tranexamic acid (TXA) may improve outcomes in aesthetic surgery patients. OBJECTIVES This systematic review aimed to investigate the impact of TXA use in aesthetic plastic surgery on bleeding and aesthetic outcomes. METHODS A systematic literature search was conducted to identify studies evaluating TXA use in aesthetic plastic surgery. The primary outcome of interest was perioperative bleeding, reported as total blood loss (TBL), ecchymosis, and hematoma formation. Meta-analyses analyzing TBL and postoperative hematoma were performed. RESULTS Of 287 identified articles, 14 studies evaluating TXA use in rhinoplasty (6), rhytidectomy (3), liposuction (3), reduction mammaplasty (1), and blepharoplasty (1) were included for analysis. Of 820 total patients, 446 (54.4%) received TXA. Meta-analysis demonstrated TXA is associated with 26.3 mL average blood loss reduction (95% CI, -40.0 to -12.7 mL; P < 0.001) and suggested a trend toward decreased odds of postoperative hematoma with TXA use (odds ratio, 0.280; 95% CI, 0.076-1.029; P = 0.055). Heterogeneity among reporting of other outcomes precluded meta-analysis; however, 5 of 7 studies found significantly decreased postoperative ecchymosis levels within 7 days of surgery, 3 studies found statistically significant reductions in postoperative drain output, and 1 study reported significantly improved surgical site quality for patients who received TXA (P = 0.001). CONCLUSIONS TXA is associated with decreased blood loss and a trend toward decreased hematoma formation in aesthetic plastic surgery. Its use has the potential to increase patient satisfaction with postoperative recovery and decrease costs associated with complications, including hematoma evacuation. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Elizabeth Laikhter
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
| | - Carly D Comer
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
| | - Eric Shiah
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
| | - Samuel M Manstein
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
| | - Paul A Bain
- Countway Library, Harvard Medical School , Boston, MA , USA
| | - Samuel J Lin
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
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21
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Honeybul S, Ho KM, Rosenfeld JV. The role of tranexamic acid in traumatic brain injury. J Clin Neurosci 2022; 99:1-4. [PMID: 35220154 DOI: 10.1016/j.jocn.2022.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/12/2022] [Accepted: 02/17/2022] [Indexed: 12/29/2022]
Abstract
Evidence from recent trials evaluating efficacy of antifibrinolytic agents in the context of traumatic brain injury may lead to changes in the management of patients with traumatic brain injury. Tranexamic acid (TXA) reduces the proteolytic action of plasmin on fibrin clots, resulting in an inhibition of fibrinolysis and stabilisation of established blood clots. There has been significant interest in use of the drug as a therapeutic agent in the context of severe haemorrhage; however, considerable controversies regarding its efficacy remain. A number of trials have demonstrated a small but significant decrease in mortality following its administration, but the results have been somewhat inconsistent and may not be generalisable. The results of the CRASH-3 trial were that there was no statistical difference in the number of traumatic brain injury related deaths (18.5% with TXA and 19.8% with placebo; relative risk [RR] 0·94; 95% confidence interval [CI] 0·86-1·02). Nonetheless, there was a subgroup of patients for whom TXA appeared to provide benefit, and this was in patients with mild and moderate injury (with a Glasgow Coma Score > 8). This is potentially a very important finding that may have huge potential implications; however, we believe it does not currently provide indisputable evidence to support the administration of TXA to all patients with TBI. Further work is required to better define the subset of patients who may benefit as well as to evaluate the long-term functional benefit in order to determine which types of severe traumatic brain injury patients would derive more benefits than harms from TXA.
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Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia 6009, Australia; Royal Perth Hospital, Wellington Street, Perth, Australia.
| | - Kwok M Ho
- Department of Intensive Care Medicine and School of Population Health, University of Western Australia, Australia
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, The Alfred Hospital, Emeritus Professor of Surgery Monash University, Melbourne, Australia; Surgery, F.Edward Hebert School of Medicine, Uniformed, Services University of the Health Sciences, Bethesda, MD, USA
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22
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Lier H, Fries D. Emergency Blood Transfusion for Trauma and Perioperative Resuscitation: Standard of Care. Transfus Med Hemother 2022; 48:366-376. [PMID: 35082568 DOI: 10.1159/000519696] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022] Open
Abstract
Uncontrolled and massive bleeding with derangement of coagulation is a major challenge in the management of both surgical and seriously injured patients. The underlying mechanism of trauma-induced or -associated coagulopathy is tissue injury in the presence of shock and acidosis provoking endothelial damage, activation of inflammation, and coagulation disbalancing. Furthermore, the combination of ongoing blood loss and consumption of blood components that are essential for effective coagulation worsens uncontrolled hemorrhage. Additionally, therapeutic actions, such as resuscitation with replacement fluids or allogeneic blood products, can further aggravate coagulopathy. Of the coagulation factors essential to the clotting process, fibrinogen is the first to be consumed to critical levels during acute bleeding and current evidence suggests that normalizing fibrinogen levels in bleeding patients improves clot formation and clot strength, thereby controlling hemorrhage. Three different therapeutic approaches are discussed controversially. Whole blood transfusion is used especially in the military scenario and is also becoming more and more popular in the civilian world, although it is accompanied by a strong lack of evidence and severe safety issues. Transfusion of allogeneic blood concentrates in fixed ratios without any targets has been investigated extensively with disappointing results. Individualized and target-controlled coagulation management based on point-of-care diagnostics with respect to the huge heterogeneity of massive bleeding situations is an alternative and advanced approach to managing coagulopathy associated with massive bleeding in the trauma as well as the perioperative setting.
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Affiliation(s)
- Heiko Lier
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic for Anesthesiology and Intensive Care Medicine, Cologne, Germany
| | - Dietmar Fries
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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23
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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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Colomina MJ, Contreras L, Guilabert P, Koo M, Méndez E, Sabate A. Clinical use of tranexamic acid: evidences and controversies. Braz J Anesthesiol 2021; 72:795-812. [PMID: 34626756 DOI: 10.1016/j.bjane.2021.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/03/2021] [Accepted: 08/08/2021] [Indexed: 11/26/2022] Open
Abstract
Tranexamic acid (TXA) significantly reduces blood loss in a wide range of surgical procedures and improves survival rates in obstetric and trauma patients with severe bleeding. Although it mainly acts as a fibrinolysis inhibitor, it also has an anti-inflammatory effect, and may help attenuate the systemic inflammatory response syndrome found in some cardiac surgery patients. However, the administration of high doses of TXA has been associated with seizures and other adverse effects that increase the cost of care, and the administration of TXA to reduce perioperative bleeding needs to be standardized. Tranexamic acid is generally well tolerated, and most adverse reactions are considered mild or moderate. Severe events are rare in clinical trials, and literature reviews have shown tranexamic acid to be safe in several different surgical procedures. However, after many years of experience with TXA in various fields, such as orthopedic surgery, clinicians are now querying whether the dosage, route and interval of administration currently used and the methods used to control and analyze the antifibrinolytic mechanism of TXA are really optimal. These issues need to be evaluated and reviewed using the latest evidence to improve the safety and effectiveness of TXA in treating intracranial hemorrhage and bleeding in procedures such as liver transplantation, and cardiac, trauma and obstetric surgery.
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Affiliation(s)
- Maria J Colomina
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain.
| | - Laura Contreras
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Patricia Guilabert
- Universitat Autònoma de Barcelona, Vall d'Hebron University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Maylin Koo
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain
| | - Esther Méndez
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Antoni Sabate
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain
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Infrastructure, logistics and clinical practice management of acute trauma hemorrhage and coagulopathy: a survey across German trauma centers. Eur J Trauma Emerg Surg 2021; 48:4461-4472. [PMID: 34564733 DOI: 10.1007/s00068-021-01788-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Early detection and management of acute trauma hemorrhage and coagulopathy have been associated with improved outcomes, but local infrastructure, logistics and clinical strategies may differ. METHODS To assess local differences in infrastructure, logistics and clinical management of acute trauma hemorrhage and coagulopathy we have conducted a web-based survey amongst clinicians working in DGU®-certified supraregional, regional and local trauma centers. RESULTS 137/1875 respondents completed the questionnaire yielding a response rate of 7.3%. The majority specified to work as head of department or senior consultant (95%) in trauma/orthopedic surgery (80%) of supraregional (38%), regional (34%) or local (27%) trauma centers. Conventional coagulation assays are most frequently used to monitor bleeding trauma patients. Only half of the respondents (53%) rely on extended coagulation tests, e.g. viscoelastic hemostatic assays. Tests to assess preinjury use of direct oral anticoagulants and platelet inhibitors are still not widely available and vary according to level of care. Conventional blood products are widely available but there remain differences between trauma centers of different level of care to access other hemostatic therapies, e.g. coagulation factor concentrates. Trauma centers of higher level of care are more likely to implement treatment protocols. CONCLUSION This survey confirms still existing differences in infrastructure, logistics and clinical practice management for the detection of acute trauma hemorrhage and coagulopathy amongst DGU®-certified supraregional, regional and local trauma centers. Further work is recommended to locally implement diagnostics, therapies and treatment algorithms compliant to current guidelines to ensure the best possible outcomes in bleeding trauma patients.
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Tranexamic acid is beneficial for blood management of high tibial osteotomy: a randomized controlled study. Arch Orthop Trauma Surg 2021; 141:1463-1472. [PMID: 32715401 DOI: 10.1007/s00402-020-03558-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The purpose of this study was to investigate whether TXA can effectively reduce blood loss after HTO and related complications and to evaluate its safety. MATERIALS AND METHODS From March 2016 to March 2018, 100 patients who underwent medial opening wedge HTO in the Department of Orthopedics, the second affiliated hospital of xi'an jiaotong university, with an average age of 52.8 ± 3.2 years, were randomly divided into the TXA group (using intravenous TXA) and the control group (using the same amount of normal saline), with 50 patients in each group. The postoperative wound drainage volume, decrease in hemoglobin and hematocrit value, total blood loss, wound healing, blood transfusion, deep venous thrombosis (DVT) and pulmonary embolism (PE) were compared between the two groups. RESULTS The drainage volume on the first postoperative day and the total drainage volume of the TXA group were significantly lower compared with those of the control group (145.7 vs 264.5 ml, 282.3 vs 413.2 ml, P < 0.05). The decreases in the hemoglobin and hematocrit values on the postoperative first, second and fifth days were lower in the TXA group than those in the control group (1.4 VS 3.5, 2.6 vs 3.3, 1.9 vs 2.9 g, P < 0.05; 3.3 vs 5.5, 5.0 vs 9.1, 3.8 vs 7.2%, P < 0.05), and the mean total blood loss was also lower in the TXA group than that in the control group (477.9 vs 834.6 ml, P < 0.05). In the control group, 1 patient had wound hematoma requiring additional paracentesis and pressure dressing, 1 patient had superficial wound infection requiring additional debridement, and 1 patient had postoperative blood transfusion compared to none in the TXA group (P > 0.05). There was no symptomatic DVT or PE in either of the groups. CONCLUSION Intravenous TXA can effectively and safely reduce blood loss and bleeding-related complications after HTO and was beneficial for the blood management of HTO.
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Johnson-Arbor K, Verstraete R. Bloodless Management of the Anemic Patient in the Emergency Department. Ann Emerg Med 2021; 79:48-57. [PMID: 34353645 DOI: 10.1016/j.annemergmed.2021.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/26/2021] [Accepted: 06/14/2021] [Indexed: 11/16/2022]
Abstract
Anemia is a commonly encountered condition in emergency medicine; transfusion of packed red blood cells is commonly performed for anemic patients in the emergency department (ED), but some patients are unable to accept transfusion of blood products due to medical or religious concerns. The unique, acute, and time-sensitive nature of emergency medicine practice requires that physicians maintain an enhanced awareness of bloodless medicine treatment modalities. Identification of bloodless medicine patient preferences in the ED can help guide physicians in the recommendation of acceptable methods of treating anemia in this patient population. A focus on early hemostasis and resuscitation, instead of attempts to convince the patient to accept blood transfusion, can be lifesaving in patients with acute bleeding. Treatment strategies including the use of methods to reduce unnecessary blood loss, enhance red blood cell production, and increase the oxygen-carrying capacity of blood should also be considered early in patient presentation. Timely involvement of the Hospital Liaison Committee can help facilitate successful interpersonal communication and shared decisionmaking between emergency physicians and bloodless medicine patients. By embracing an understanding of bloodless medicine patient needs as well as available treatment strategies, ED physicians can contribute to optimal overall outcomes for anemic bloodless medicine patients.
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Affiliation(s)
- Kelly Johnson-Arbor
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC; MedStar Institute for Quality and Safety, MedStar Health, Columbia, MD.
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Hall K, Drobatz K. Volume Resuscitation in the Acutely Hemorrhaging Patient: Historic Use to Current Applications. Front Vet Sci 2021; 8:638104. [PMID: 34395568 PMCID: PMC8357988 DOI: 10.3389/fvets.2021.638104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
Acute hemorrhage in small animals results from traumatic and non-traumatic causes. This review seeks to describe current understanding of the resuscitation of the acutely hemorrhaging small animal (dog and cat) veterinary patient through evaluation of pre-clinical canine models of hemorrhage and resuscitation, clinical research in dogs and cats, and selected extrapolation from human medicine. The physiologic dose and response to whole blood loss in the canine patient is repeatable both in anesthetized and awake animals and is primarily characterized clinically by increased heart rate, decreased systolic blood pressure, and increased shock index and biochemically by increased lactate and lower base excess. Previously, initial resuscitation in these patients included immediate volume support with crystalloid and/or colloid, regardless of total volume, with a target to replace lost vascular volume and bring blood pressure back to normal. Newer research now supports prioritizing hemorrhage control in conjunction with judicious crystalloid administration followed by early consideration for administration of platelets, plasma and red blood during the resuscitation phase. This approach minimizes blood loss, ameliorates coagulopathy, restores oxygen delivery and correct changes in the glycocalyx. There are many hurdles in the application of this approach in clinical veterinary medicine including the speed with which the bleeding source is controlled and the rapid availability of blood component therapy. Recommendations regarding the clinical approach to volume resuscitation in the acutely hemorrhaging veterinary patient are made based on the canine pre-clinical, veterinary clinical and human literature reviewed.
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Affiliation(s)
- Kelly Hall
- Department of Clinical Sciences, Critical Care Services, Colorado State University, Fort Collins, CO, United States
| | - Kenneth Drobatz
- Section of Critical Care, Department of Clinical Studies, University of Pennsylvania, Philadelphia, PA, United States
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Shander A, Javidroozi M, Sentilhes L. Tranexamic acid and obstetric hemorrhage: give empirically or selectively? Int J Obstet Anesth 2021; 48:103206. [PMID: 34343820 DOI: 10.1016/j.ijoa.2021.103206] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 06/09/2021] [Accepted: 06/26/2021] [Indexed: 11/30/2022]
Abstract
Antifibrinolytic agents such as tranexamic acid (TXA) inhibit the fibrinolytic pathway and protect blood clots from being degraded, thereby promoting hemostasis. They have been used to reduce blood loss in various settings including obstetrics. Based on current evidence, TXA can be considered as a therapeutic adjunct to control postpartum hemorrhage (PPH) after vaginal and cesarean deliveries, with earlier administration preferred. This strategy has been demonstrated to reduce mortality due to bleeding (but not the incidence of transfusion) in developing countries. On the other hand, the benefit-risk ratio of TXA has not been fully assessed in developed countries which have much lower PPH-related mortality rates and better access to other management modalities. As a proposed prophylactic agent to prevent PPH, the level of evidence is currently insufficient to recommend the routine use of TXA to prevent blood loss after vaginal and cesarean deliveries. The results of large new multicenter studies assessing the impact of TXA on maternal blood loss-related outcomes after cesarean delivery are awaited. While most studies to date have focused on empirical and one-size-fit-all dosing of TXA, more selective and individualized treatment protocols (possibly guided by functional coagulation assays) are needed to pave the way for safer and more effective use of this inexpensive and widely used medication.
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Affiliation(s)
- A Shander
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, NJ, USA.
| | - M Javidroozi
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, NJ, USA
| | - L Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
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Ma J, Lu H, Chen X, Wang D, Wang Q. The efficacy and safety of tranexamic acid in high tibial osteotomy: a systematic review and meta-analysis. J Orthop Surg Res 2021; 16:373. [PMID: 34116690 PMCID: PMC8194157 DOI: 10.1186/s13018-021-02512-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/31/2021] [Indexed: 12/26/2022] Open
Abstract
Objective The present meta-analysis was conducted to evaluate the efficacy and safety of the application of tranexamic acid (TXA) in patients undergoing high tibial osteotomy (HTO). Methods PubMed (MEDLINE), EMBASE, and Cochrane Library were systematically searched for relevant literature from inception until 1 February 2021. A combined searching strategy of subject words and random words was adopted. After testing for potential publication bias and/or heterogeneity, we aggregated variables by using the random-effect model. The primary comparison outcome measures were total blood loss, hemoglobin decrease, drain output, wound complications, thrombotic events, and blood transfusion rate of the TXA group versus control. The meta-analysis was performed using the RevMan 5.3 software. Results A total of 5 studies were included involving 532 patients. The results showed that there were significant differences in the two groups concerning total blood loss (95% confidence interval [CI] − 332.74 to − 146.46, P < 0.00001), hemoglobin decrease on postoperative day (POD) 1, 2, and 5 (POD 1 95% CI − 1.34 to − 0.63, P < 0.00001; POD 2 95% CI − 1.07 to − 0.68, P < 0.00001; POD 5 95% CI − 1.46 to − 0.84, P < 0.00001), drain output (POD total 95% CI − 195.86 to − 69.41, P < 0.00001) and wound complications (RR = 0.34, 95% CI 0.12 to 0.97, P = 0.04). Nonsignificant differences were found in the incidence of thromboembolic events (RR = 0.46, 95% CI 0.09 to 2.41, P = 0.36) and blood transfusion rate (RR = 0.25, 95% CI 0.03 to 2.27, P = 0.22). Conclusions This meta-analysis of the available evidence demonstrated that TXA could reduce total blood loss, hemoglobin decrease, drain output, and wound complications without increasing the incidence of thromboembolic events in patients undergoing HTO. But there is no obvious evidence that TXA could reduce blood transfusion rates. Further studies, including more large-scale and well-designed randomized controlled trials, are warranted to assess the efficacy and safety issues of routine TXA use in HTO patients.
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Affiliation(s)
- Jimin Ma
- Department of Orthopedics, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Hanli Lu
- Department of Orthopedics, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Xinxing Chen
- Department of Orthopedics, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Dasai Wang
- Department of Orthopedics, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Qiang Wang
- Department of Orthopedics, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China.
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Pekrul I, Schachtner T, Zwißler B, Möhnle P. [Tranexamic acid for bleeding prophylaxis in orthopedic surgery and trauma-standard or customized therapy?]. Anaesthesist 2021; 70:515-521. [PMID: 33620508 PMCID: PMC8190014 DOI: 10.1007/s00101-021-00928-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 11/23/2022]
Abstract
The use of tranexamic acid (TXA) is established in the treatment of bleeding, especially of bleeding due to hyperfibrinolysis. In recent years the prophylactic use of TXA in trauma and orthopedic surgery has increased leading to open questions regarding potentially associated risks and a possible classification as off label use. The available literature provides a sound basis for the recommendation that TXA can be used in these indications provided that an individual risk assessment is done in patients with increased risks for thromboembolic complications. Although the prophylactic use of TXA in orthopedic surgery and trauma is not explicitly listed in the product characteristics, it should not be regarded as an off label use.
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Affiliation(s)
- Isabell Pekrul
- Klinik für Anaesthesiologie, Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Universität München (LMU), Marchioninistr. 15, 81377, München, Deutschland
| | - Thomas Schachtner
- Anästhesie und Intensivmedizin, Schön Klinik München Harlaching, München, Deutschland
| | - Bernhard Zwißler
- Klinik für Anaesthesiologie, Universität München (LMU), München, Deutschland
| | - Patrick Möhnle
- Klinik für Anaesthesiologie, Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Universität München (LMU), Marchioninistr. 15, 81377, München, Deutschland.
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Wong J, George RB, Hanley CM, Saliba C, Yee DA, Jerath A. Tranexamic acid: current use in obstetrics, major orthopedic, and trauma surgery. Can J Anaesth 2021; 68:894-917. [PMID: 33993459 DOI: 10.1007/s12630-021-01967-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE In this Continuing Professional Development module, we review the practical pharmacology of tranexamic acid and its clinical use in trauma, obstetrics, and major orthopedic surgery. PRINCIPAL FINDINGS Tranexamic acid is a synthetic drug that inhibits fibrinolysis. Multiple clinical trials in various clinical settings have shown that it can reduce blood loss, transfusion rates, and bleeding-associated mortality. In trauma and obstetrical bleeding, early tranexamic acid administration (< three hours) may have greater clinical benefits. Overall, tranexamic acid use appears safe with no significant increase of thromboembolic or seizure events. Nevertheless, current evidence has limitations related to wide heterogeneity in dose, route, and timing of drug administration, as well as generalizability of the large-scale trial findings to higher income nations. CONCLUSIONS Tranexamic acid is an efficacious and safe pharmacological-based blood conservation technique in the management of clinically significant hemorrhage. All anesthesiologists should have a good understanding of the pharmacotherapeutic properties and perioperative role of tranexamic acid therapy both inside and outside of the operating room. The use of tranexamic acid is likely to continue to rise with endorsement by various clinical guidelines and healthcare organizations. Further quantitative research is needed to evaluate optimal dosing and drug efficacy in these clinical scenarios.
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Affiliation(s)
- Jean Wong
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network and Women's College Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Ronald B George
- Department of Anesthesia and Perioperative Care, UCSF, San Francisco, CA, USA
| | - Ciara M Hanley
- Department of Anesthesia, Sunnybrook Health Science Centre, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Chadi Saliba
- Department of Anesthesia, Sunnybrook Health Science Centre, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Doreen A Yee
- Department of Anesthesia, Sunnybrook Health Science Centre, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Angela Jerath
- Department of Anesthesia, Sunnybrook Health Science Centre, Toronto, ON, Canada.
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Sunnybrook Research Institute, Sunnybrook Health Science Centre, Toronto, ON, Canada.
- Toronto General Hospital Research Institute, Toronto, ON, Canada.
- Institute of Clinical Evaluative Sciences, Toronto, ON, Canada.
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Fahmy NG, Eskandar FSL, Khalil WAMA, Sobhy MII, Amin AMAA. Assessment the role of tranexamic acid in prevention of postpartum hemorrhage. AIN-SHAMS JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.1186/s42077-021-00154-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Abstract
Background
Postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality and morbidity worldwide. It is believed that hemostatic imbalance secondary to release of tissue plasminogen activator (tPA) and subsequent hyperfibrinolysis plays a major role in PPH pathogenesis. Antifibrinolytic drugs such as tranexamic acid (TXA) are widely used in hemorrhagic conditions associated with hyperfibrinolysis. TXA reduced maternal death due to PPH and its use as a part of PPH treatment is recommended, and in recent years, a number of trials have investigated the efficacy of prophylactic use of TXA in reducing the incidence and the severity of PPH.
The study is aiming to assess the efficacy of tranexamic acid in reducing blood loss throughout and after the lower segment cesarean section and reducing the risk of postpartum hemorrhage.
Results
The amount of blood loss was significantly lower in the study group than the control group (416.12±89.95 and 688.68±134.77 respectively). Also the 24-h postoperative hemoglobin was significantly higher in the study group (11.66±0.79 mg/dl) compared to the control group (10.53±1.07mg/dl), and the 24-h postoperative hematocrit value was significantly higher in the study group (34.99±2.40) compared to control (31.62±3.22).
Conclusion
Prophylactic administration of tranexamic acid reduces intraoperative and postoperative bleeding in cesarean section and the incidence of postpartum hemorrhage.
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Taeuber I, Weibel S, Herrmann E, Neef V, Schlesinger T, Kranke P, Messroghli L, Zacharowski K, Choorapoikayil S, Meybohm P. Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality: A Systematic Review, Meta-analysis, and Meta-regression. JAMA Surg 2021; 156:e210884. [PMID: 33851983 PMCID: PMC8047805 DOI: 10.1001/jamasurg.2021.0884] [Citation(s) in RCA: 133] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/14/2021] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Tranexamic acid (TXA) is an efficient antifibrinolytic agent; however, concerns remain about the potential adverse effects, particularly vascular occlusive events, that may be associated with its use. OBJECTIVE To examine the association between intravenous TXA and total thromboembolic events (TEs) and mortality in patients of all ages and of any medical disciplines. DATA SOURCE Cochrane Central Register of Controlled Trials and MEDLINE were searched for eligible studies investigating intravenous TXA and postinterventional outcome published between 1976 and 2020. STUDY SELECTION Randomized clinical trials comparing intravenous TXA with placebo/no treatment. The electronic database search yielded a total of 782 studies, and 381 were considered for full-text review. Included studies were published in English, German, French, and Spanish. Studies with only oral or topical tranexamic administration were excluded. DATA EXTRACTION AND SYNTHESIS Meta-analysis, subgroup and sensitivity analysis, and meta-regression were performed. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. MAIN OUTCOMES AND MEASURES Vascular occlusive events and mortality. RESULTS A total of 216 eligible trials including 125 550 patients were analyzed. Total TEs were found in 1020 (2.1%) in the group receiving TXA and 900 (2.0%) in the control group. This study found no association between TXA and risk for total TEs (risk difference = 0.001; 95% CI, -0.001 to 0.002; P = .49) for venous thrombosis, pulmonary embolism, venous TEs, myocardial infarction or ischemia, and cerebral infarction or ischemia. Sensitivity analysis using the risk ratio as an effect measure with (risk ratio = 1.02; 95% CI, 0.94-1.11; P = .56) and without (risk ratio = 1.03; 95% CI, 0.95-1.12; P = .52) studies with double-zero events revealed robust effect size estimates. Sensitivity analysis with studies judged at low risk for selection bias showed similar results. Administration of TXA was associated with a significant reduction in overall mortality and bleeding mortality but not with nonbleeding mortality. In addition, an increased risk for vascular occlusive events was not found in studies including patients with a history of thromboembolism. Comparison of studies with sample sizes of less than or equal to 99 (risk difference = 0.004; 95% CI, -0.006 to 0.014; P = .40), 100 to 999 (risk difference = 0.004; 95% CI, -0.003 to 0.011; P = .26), and greater than or equal to 1000 (risk difference = -0.001; 95% CI, -0.003 to 0.001; P = .44) showed no association between TXA and incidence of total TEs. Meta-regression of 143 intervention groups showed no association between TXA dosing and risk for venous TEs (risk difference, -0.005; 95% CI, -0.021 to 0.011; P = .53). CONCLUSIONS AND RELEVANCE Findings from this systematic review and meta-analysis of 216 studies suggested that intravenous TXA, irrespective of dosing, is not associated with increased risk of any TE. These results help clarify the incidence of adverse events associated with administration of intravenous TXA and suggest that TXA is safe for use with undetermined utility for patients receiving neurological care.
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Affiliation(s)
- Isabel Taeuber
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, Frankfurt, Germany
| | - Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tobias Schlesinger
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Leila Messroghli
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Suma Choorapoikayil
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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Bossers SM, Loer SA, Bloemers FW, Den Hartog D, Van Lieshout EMM, Hoogerwerf N, van der Naalt J, Absalom AR, Peerdeman SM, Schwarte LA, Boer C, Schober P. Association Between Prehospital Tranexamic Acid Administration and Outcomes of Severe Traumatic Brain Injury. JAMA Neurol 2021; 78:338-345. [PMID: 33284310 DOI: 10.1001/jamaneurol.2020.4596] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance The development and expansion of intracranial hematoma are associated with adverse outcomes. Use of tranexamic acid might limit intracranial hematoma formation, but its association with outcomes of severe traumatic brain injury (TBI) is unclear. Objective To assess whether prehospital administration of tranexamic acid is associated with mortality and functional outcomes in a group of patients with severe TBI. Design, Setting, and Participants This multicenter cohort study is an analysis of prospectively collected observational data from the Brain Injury: Prehospital Registry of Outcome, Treatments and Epidemiology of Cerebral Trauma (BRAIN-PROTECT) study in the Netherlands. Patients treated for suspected severe TBI by the Dutch Helicopter Emergency Medical Services between February 2012 and December 2017 were included. Patients were followed up for 1 year after inclusion. Data were analyzed from January 10, 2020, to September 10, 2020. Exposures Administration of tranexamic acid during prehospital treatment. Main Outcomes and Measures The primary outcome was 30-day mortality. Secondary outcomes included mortality at 1 year, functional neurological recovery at discharge (measured by Glasgow Outcome Scale), and length of hospital stay. Data were also collected on demographic factors, preinjury medical condition, injury characteristics, operational characteristics, and prehospital vital parameters. Results A total of 1827 patients were analyzed, of whom 1283 (70%) were male individuals and the median (interquartile range) age was 45 (23-65) years. In the unadjusted analysis, higher 30-day mortality was observed in patients who received prehospital tranexamic acid (odds ratio [OR], 1.34; 95% CI, 1.16-1.55; P < .001), compared with patients who did not receive prehospital tranexamic acid. After adjustment for confounders, no association between prehospital administration of tranexamic acid and mortality was found across the entire cohort of patients. However, a substantial increase in the odds of 30-day mortality persisted in patients with severe isolated TBI who received prehospital tranexamic acid (OR, 4.49; 95% CI, 1.57-12.87; P = .005) and after multiple imputations (OR, 2.05; 95% CI, 1.22-3.45; P = .007). Conclusions and Relevance This study found that prehospital tranexamic acid administration was associated with increased mortality in patients with isolated severe TBI, suggesting the judicious use of the drug when no evidence for extracranial hemorrhage is present.
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Affiliation(s)
- Sebastiaan M Bossers
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Stephan A Loer
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Frank W Bloemers
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Nico Hoogerwerf
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, the Netherlands.,Helicopter Emergency Medical Service Lifeliner 3, Nijmegen, the Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Saskia M Peerdeman
- Department of Neurosurgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Lothar A Schwarte
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, the Netherlands
| | - Christa Boer
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Patrick Schober
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, the Netherlands
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Abstract
OBJECTIVES This study aims to investigate the effect of tranexamic acid (TXA) on the union of closed femoral fractures using radiological and histological methods in an experimental rat model. MATERIALS AND METHODS This experimental study was conducted between June 2017 and February 2018. Closed femoral fractures were created in 36 male Wistar albino rats (age: three months [range, 2.5-3.5 months], weighing 200 grams [range, 180-220 grams]). Half of the animals randomly divided into two groups were administered intravenous single dose of TXA (30 mg/kg), whereas the animals in the control group did not receive any medication. The animals in the two groups were randomly divided into three groups with six animals each and cervical dislocation was performed at days 15, 30, and 45, and radiological and histopathological healing scores were compared. RESULTS When the mean radiological scores of the TXA and control groups were compared, a statistically significant difference was found in favor of the TXA group at day 15 (p=0.019), but no significant difference was found in the mean scores on days 30 and 45 (p=0.138 and p=0.269, respectively). Histopathological examination also showed a statistically significant difference between the 15-day mean score values in favor of the TXA group ( p = 0. 017 ). CONCLUSION The use of systemic TXA accelerates early bone formation and fracture healing.
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Edwards TH, Dubick MA, Palmer L, Pusateri AE. Lessons Learned From the Battlefield and Applicability to Veterinary Medicine-Part 1: Hemorrhage Control. Front Vet Sci 2021; 7:571368. [PMID: 33521075 PMCID: PMC7841008 DOI: 10.3389/fvets.2020.571368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 12/14/2020] [Indexed: 11/25/2022] Open
Abstract
In humans, the leading cause of potentially preventable death on the modern battlefield is undoubtedly exsanguination from massive hemorrhage. The US military and allied nations have devoted enormous effort to combat hemorrhagic shock and massive hemorrhage. This has yielded numerous advances designed to stop bleeding and save lives. The development of extremity, junctional and truncal tourniquets applied by first responders have saved countless lives both on the battlefield and in civilian settings. Additional devices such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and intraperitoneal hemostatic foams show great promise to address control the most difficult forms (non-compressible) of hemorrhage. The development of next generation hemostatic dressings has reduced bleeding both in the prehospital setting as well as in the operating room. Furthermore, the research and fielding of antifibrinolytics such as tranexamic acid have shown incredible promise to ameliorate the effects of acute traumatic coagulopathy which has led to significant morbidity and mortality in service members. Advances from lessons learned on the battlefield have numerous potential parallels in veterinary medicine and these lessons are ripe for translation to veterinary medicine.
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Affiliation(s)
- Thomas H Edwards
- US Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Michael A Dubick
- US Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Lee Palmer
- Special Forces Group, Alabama Army National Guard, Auburn, AL, United States
| | - Anthony E Pusateri
- US Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
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Lier H, Hofer S, Annecke T. Anästhesiologisches Management der peripartalen Hämorrhagie. Anasthesiol Intensivmed Notfallmed Schmerzther 2020; 55:686-701. [PMID: 33242902 DOI: 10.1055/a-1070-6697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hanley C, Callum J, Jerath A. Tranexamic acid and trauma coagulopathy: where are we now? Br J Anaesth 2020; 126:12-17. [PMID: 33069339 DOI: 10.1016/j.bja.2020.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 01/16/2023] Open
Affiliation(s)
- Ciara Hanley
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Angela Jerath
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Giordano V, Giannoudis VP, Giannoudis PV. Current trends in resuscitation for polytrauma patients with traumatic haemorrhagic shock. Injury 2020; 51:1945-1948. [PMID: 32829760 DOI: 10.1016/j.injury.2020.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Vincenzo Giordano
- Hospital Municipal Miguel Couto, Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro - Rio de Janeiro - RJ - Brasil
| | - Vasileios P Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom.
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Alabdrabalnabi F, Alshahrani M, Ismail N. Nebulized tranexamic acid for recurring hemoptysis in critically ill patients: case series. Int J Emerg Med 2020; 13:45. [PMID: 32819268 PMCID: PMC7439666 DOI: 10.1186/s12245-020-00304-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/07/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hemoptysis is a clinical condition encountered in the emergency department (ED) and must be managed and investigated urgently to maintain the patient's hemostasis. The management of hemoptysis depends on treating the underlying cause. Tranexamic acid (TXA) is an anti-fibrinolytic drug used to systemically control bleeding. There are a few studies available that investigate the use of nebulized tranexamic acid for hemoptysis with contradictory results. Our paper demonstrates three cases where patients presented with significant hemoptysis and had significant improvement in symptoms following the administration of nebulized tranexamic acid. The overall need for blood transfusion was reduced. RESULTS Three patients presented to the emergency room for evaluation of hemoptysis. All three patients had different underlying pathologies resulting in their hemoptysis and were monitored in the ICU. Initial conventional medical therapies including the correction of coagulopathy and discontinuing offending agents were utilized for treatment. After persistent symptoms, nebulized TXA at a dose of 500 mg three times a day was administered. The patients were all discharged from the hospital with improvement in their symptoms. CONCLUSION Tranexamic acid may be considered in the treatment of hemoptysis regardless of the underlying cause. This may be utilized pending further workup and investigation into the underlying source of the bleeding.
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Affiliation(s)
- Fatimah Alabdrabalnabi
- Imam Abdulrahman Bin Faisal University and King Fahad University hospital, Dammam, Saudi Arabia
| | - Mohammed Alshahrani
- Imam Abdulrahman Bin Faisal University and King Fahad University hospital, Dammam, Saudi Arabia
| | - Nadia Ismail
- Imam Abdulrahman Bin Faisal University and King Fahad University hospital, Dammam, Saudi Arabia
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Shander A, Goobie SM, Warner MA, Aapro M, Bisbe E, Perez-Calatayud AA, Callum J, Cushing MM, Dyer WB, Erhard J, Faraoni D, Farmer S, Fedorova T, Frank SM, Froessler B, Gombotz H, Gross I, Guinn NR, Haas T, Hamdorf J, Isbister JP, Javidroozi M, Ji H, Kim YW, Kor DJ, Kurz J, Lasocki S, Leahy MF, Lee CK, Lee JJ, Louw V, Meier J, Mezzacasa A, Munoz M, Ozawa S, Pavesi M, Shander N, Spahn DR, Spiess BD, Thomson J, Trentino K, Zenger C, Hofmann A. Essential Role of Patient Blood Management in a Pandemic: A Call for Action. Anesth Analg 2020; 131:74-85. [PMID: 32243296 PMCID: PMC7173035 DOI: 10.1213/ane.0000000000004844] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2020] [Indexed: 01/01/2023]
Abstract
The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. Global health care now faces unprecedented challenges with widespread and rapid human-to-human transmission of SARS-CoV-2 and high morbidity and mortality with COVID-19 worldwide. Across the world, medical care is hampered by a critical shortage of not only hand sanitizers, personal protective equipment, ventilators, and hospital beds, but also impediments to the blood supply. Blood donation centers in many areas around the globe have mostly closed. Donors, practicing social distancing, some either with illness or undergoing self-quarantine, are quickly diminishing. Drastic public health initiatives have focused on containment and "flattening the curve" while invaluable resources are being depleted. In some countries, the point has been reached at which the demand for such resources, including donor blood, outstrips the supply. Questions as to the safety of blood persist. Although it does not appear very likely that the virus can be transmitted through allogeneic blood transfusion, this still remains to be fully determined. As options dwindle, we must enact regional and national shortage plans worldwide and more vitally disseminate the knowledge of and immediately implement patient blood management (PBM). PBM is an evidence-based bundle of care to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This multinational and diverse group of authors issue this "Call to Action" underscoring "The Essential Role of Patient Blood Management in the Management of Pandemics" and urging all stakeholders and providers to implement the practical and commonsense principles of PBM and its multiprofessional and multimodality approaches.
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Affiliation(s)
- Aryeh Shander
- From the Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, New Jersey
| | - Susan M. Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew A. Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matti Aapro
- Cancer Center Clinique Genolier, Genolier, Switzerland
| | - Elvira Bisbe
- Department of Anesthesiology, Perioperative Medicine Research Group, Hospital del Mar Medical Research Institute (IMIM), IMIM, Barcelona, Spain
| | | | - Jeannie Callum
- Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Melissa M. Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
| | - Wayne B. Dyer
- Australian Red Cross Lifeblood and Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jochen Erhard
- Department of Surgery, Evangelisches Klinikum Niederrhein, Duisburg, Germany
| | - David Faraoni
- Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Shannon Farmer
- Medical School, Division of Surgery, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
- School of Health Sciences and Graduate Studies, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Tatyana Fedorova
- Institute of Anesthesiology, Resuscitation and Transfusiology of the National Medical Research Center of Obstetrics, Gynecology and Perinatology named after Acad. V. I. Kulakov, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Steven M. Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Bernd Froessler
- Department of Anesthesia, Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Hans Gombotz
- Department of Anesthesiology and Intensive Care, General Hospital Linz, Linz, Austria
| | - Irwin Gross
- Northern Light Health, Brewer, Maine
- Accumen, Inc, San Diego, California
| | - Nicole R. Guinn
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Thorsten Haas
- Department of Anesthesiology, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Jeffrey Hamdorf
- Medical School, The University of Western Australia, Western Australia Patient Blood Management Group, Perth, Western Australia, Australia
| | - James P. Isbister
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mazyar Javidroozi
- From the Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, New Jersey
| | - Hongwen Ji
- Department of Anesthesiology and Transfusion Medicine, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Young-Woo Kim
- Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy and Center for Gastric Cancer, National Cancer Center, Ilsandong-gu, Goyang, Korea
| | - Daryl J. Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Johann Kurz
- Austrian Federal Ministry of Health, Vienna, Austria
- Department Applied Sciences, University of Applied Sciences, Vienna, Austria
| | - Sigismond Lasocki
- Département Anesthésie-Réanimation, Anesthésie Samu Urgences Réanimation, CHU Angers, Angers, France
| | - Michael F. Leahy
- Department of Haematology, PathWest Laboratory Medicine, University of Western Australia, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Cheuk-Kwong Lee
- Hong Kong Red Cross Blood Transfusion Service, Hong Kong Special Administrative Region, China
| | - Jeong Jae Lee
- Department of Obstetrics and Gynecology, Soonchunhyang University Hospital, Seoul, Korea
| | - Vernon Louw
- Division Clinical Haematology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jens Meier
- Clinic of Anesthesiology and Intensive Care Medicine, Johannes Kepler University Linz, Linz, Austria
| | | | - Manuel Munoz
- Department of Surgical Sciences, Biochemistry and Immunology, School of Medicine, University of Málaga, Málaga, Spain
| | - Sherri Ozawa
- Patient Blood Management, Englewood Health, Englewood, New Jersey
| | - Marco Pavesi
- Department of Anesthesiology and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Nina Shander
- Jerry M. Wallace School of Osteopathic Medicine, Campbell University, Buies Creek, North Carolina
| | - Donat R. Spahn
- Institute of Anesthesiology, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Bruce D. Spiess
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Jackie Thomson
- South African National Blood Service, Johannesburg, South Africa
| | - Kevin Trentino
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Data and Digital Innovation, East Metropolitan Health Service, Perth, Western Australia, Australia
| | - Christoph Zenger
- Center for Health Law and Management, University of Bern, Bern, Switzerland
| | - Axel Hofmann
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
- Medical School, The University of Western Australia, Crawley, Western Australia, Australia
- School of Health Sciences and Graduate Studies, Curtin University, Perth, Western Australia, Australia
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Lier H, Shander A. Tranexamic acid: the king is dead, long live the king! Br J Anaesth 2020; 124:659-662. [DOI: 10.1016/j.bja.2020.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 02/22/2020] [Accepted: 02/23/2020] [Indexed: 12/26/2022] Open
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Wurtz JW, Wurtz LD, Ziemba-Davis M, Deckard ER, Meneghini RM. Topical Tranexamic Acid Increases Early Postoperative Pain After Total Hip Arthroplasty. J Arthroplasty 2020; 35:S219-S225. [PMID: 32098737 DOI: 10.1016/j.arth.2020.01.069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/14/2020] [Accepted: 01/24/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) has reduced blood transfusion following total hip arthroplasty (THA). However, non-human studies have linked TXA exposure with increased pain and decreased periarticular cell viability and cell death. This study evaluated early pain following THA performed with and without topical TXA. METHODS A consecutive series of 213 THAs performed without TXA were compared to 169 THAs performed with topical TXA. A single surgeon using identical perioperative medical and pain control protocols performed procedures. Prospectively collected inpatient pain scores, time to first opioid, and opioid consumption in morphine milligram equivalents were evaluated in relation to TXA use and 10 additional covariates. Univariate relationships between independent and dependent variables with P ≤ .20 were entered into multivariate analysis using the General Linear Model. RESULTS Patients who received topical TXA reported higher mean 24-hour pain scores compared to patients who did not receive TXA (P = .006). Patients with topical TXA requested opioids significantly sooner (means of 152 vs 246 minutes, P = .033). An average of 56.07 morphine milligram equivalents were consumed during the first 24 hours after post-acute care unit discharge by patients who received topical TXA compared to 31.26 by patients who did not receive TXA (P < .001). CONCLUSION Topical TXA use was associated with greater early postoperative pain and opioid consumption in primary THA patients. Findings were supported by the magnitude of observed effects and the likelihood of clinical relevance. Replication and consideration of potential adverse consequences of TXA use in elective settings is encouraged.
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Affiliation(s)
| | - L Daniel Wurtz
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Mary Ziemba-Davis
- IU Health Hip & Knee Center, IU Health Physicians, Orthopedics & Sports Medicine, Fishers, IN
| | - Evan R Deckard
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN; IU Health Hip & Knee Center, IU Health Physicians, Orthopedics & Sports Medicine, Fishers, IN
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Fischer K, Awudi E, Varon J, Surani S. Role of Tranexamic Acid in the Clinical Setting. Cureus 2020; 12:e8221. [PMID: 32582482 PMCID: PMC7306641 DOI: 10.7759/cureus.8221] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/21/2020] [Indexed: 12/29/2022] Open
Abstract
Tranexamic acid (TXA) is labeled as an antifibrinolytic agent that decreases mortality, reduces blood loss after trauma or surgery, and lowers transfusion requirements in trauma patients with bleeding. This review of the literature is related to TXA use in a variety of settings, with a specific focus on trauma patients, to assess therapeutic efficacy and safety. As seen in large, randomized, placebo-controlled trials, TXA has been shown to decrease mortality over placebo in trauma patients, It is also noted to have good safety parameters upon administration and should be recommended for use in trauma patients with bleeding. Further studies are warranted for the use of TXA in gastrointestinal bleeding and pediatric trauma.
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Affiliation(s)
- Kyle Fischer
- Pharmacy, Texas A&M Rangel College of Pharmacy, Kingsville, USA
| | - Elizabeth Awudi
- Pharmacy, Corpus Christi Medical Center, Corpus Christi, USA
| | - Joseph Varon
- Critical Care, United General Hospital, Houston, USA
- Critical Care, University of Texas Health Science Center, Houston, USA
| | - Salim Surani
- Internal Medicine, Corpus Christi Medical Center, Corpus Christi, USA
- Internal Medicine, University of North Texas, Dallas, USA
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Butwick A, Lyell D, Goodnough L. How do I manage severe postpartum hemorrhage? Transfusion 2020; 60:897-907. [PMID: 32319687 DOI: 10.1111/trf.15794] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 03/10/2020] [Accepted: 03/10/2020] [Indexed: 02/06/2023]
Abstract
In the United States, postpartum hemorrhage (PPH) accounts for 4.6% of all maternal deaths and is responsible for major peripartum medical and surgical morbidity. Therefore, a national health priority is to ensure that women who experience severe PPH receive timely, appropriate, and effective treatment. In this article, we describe our system-wide approach for the planning and delivery of women with suspected placenta accreta spectrum disorder, a condition associated with life-threatening blood loss at the time of delivery. We also highlight current evidence related to transfusion decision making and hemostatic monitoring during active postpartum bleeding. Specifically, we describe how we activate and use the massive transfusion protocol to obtain sufficient volumes and types of blood products. We also describe how we use viscoelastic monitoring (thromboelastography) and standard laboratory tests to assess the maternal coagulation profile. Finally, we review the findings of recent studies examining the potential efficacy of tranexamic acid and fibrinogen concentrate as adjuncts for PPH prevention and treatment. We describe how we have incorporated these drugs into PPH treatment protocols at our institution.
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Affiliation(s)
- Alexander Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Deirdre Lyell
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Lawrence Goodnough
- Department of Pathology and Medicine (Hematology), Stanford University School of Medicine, Stanford, California, USA
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July J, Pranata R. Tranexamic acid is associated with reduced mortality, hemorrhagic expansion, and vascular occlusive events in traumatic brain injury - meta-analysis of randomized controlled trials. BMC Neurol 2020; 20:119. [PMID: 32252661 PMCID: PMC7133014 DOI: 10.1186/s12883-020-01694-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023] Open
Abstract
Background This systematic review and meta-analysis aimed to synthesize the latest evidence on the efficacy and safety of tranexamic acid (TXA) on traumatic brain injury (TBI). Methods We performed a systematic literature search on topics that compared intravenous TXA to placebo in patients with TBI up until January 2020 from several electronic databases. Results There were 30.522 patients from 7 studies. Meta-analysis showed that TXA was associated with reduced mortality (RR 0.92 [0.88, 0.97], p = 0.002; I2: 0%) and hemorrhagic expansion (RR 0.79 [0.64, 0.97], p = 0.03; I2: 0%). Both TXA and control group has a similar need for neurosurgical intervention (p = 0.87) and unfavourable Glasgow Outcome Scale (GOS) (p = 0.59). The rate for vascular occlusive events (p = 0.09), and its deep vein thrombosis subgroup (p = 0.23), pulmonary embolism subgroup (p = 1), stroke subgroup (p = 0.38), and myocardial infarction subgroup (p = 0.15) were similar in both groups. Subgroup analysis on RCTs with low risk of bias showed that TXA was associated with reduced mortality and hemorrhagic expansion. TXA was associated with reduced vascular occlusive events (RR 0.85 [0.73, 0.99], p = 0.04; I2: 4%). GRADE was performed for the RCT with low risk of bias subgroup, it showed a high certainty of evidence for lower mortality, less hemorrhage expansion, and similar need for neurosurgical intervention in TXA group compared to placebo group. Conclusion TXA was associated with reduced mortality and hemorrhagic expansion but similar need for neurosurgical intervention and unfavorable GOS. Vascular occlusive events were slightly lower in TXA group on subgroup analysis of RCTs with low risk of bias.
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Affiliation(s)
- Julius July
- Department of Neurosurgery, Medical Faculty of Pelita Harapan University, Lippo Village Tangerang, Neuroscience Centre Siloam Hospital, Lippo Village, Tangerang, Indonesia.
| | - Raymond Pranata
- Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia
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Faraoni D, Levy JH. Tranexamic Acid for Acute Hemorrhage: When Is Enough Evidence Enough? Anesth Analg 2020; 129:1459-1461. [PMID: 31743163 DOI: 10.1213/ane.0000000000004481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- David Faraoni
- From the Division of Cardiac Anesthesia, Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina
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Franchini M, Mannucci PM. The never ending success story of tranexamic acid in acquired bleeding. Haematologica 2020; 105:1201-1205. [PMID: 32336684 PMCID: PMC7193503 DOI: 10.3324/haematol.2020.250720] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/16/2020] [Indexed: 12/13/2022] Open
Abstract
Tranexamic acid (TXA) is an anti-fibrinolytic agent that acts by inhibiting plasminogen activation and fibrinolysis. Although its first clinical use dates back more than 50 years, this hemostatic agent is still the object of intense clinical and developmental research. In particular, renewed interest in TXA has arisen following evidence that it has a beneficial effect in reducing blood loss in a variety of medical and surgical conditions at increased risk of bleeding. Given this characteristic, TXA is currently considered a mainstay of Patient Blood Management programs aimed at reducing patients’ exposure to allogeneic blood transfusion. Importantly, recent large randomized controlled trials have consistently documented that the use of TXA confers a survival advantage in a number of globally critical clinical conditions associated with acute bleeding, including traumatic injury and post-partum hemorrhage, without increasing the thromboembolic risk.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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50
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Shander A, Zacharowski K, Spahn DR. Red cell use in trauma. Curr Opin Anaesthesiol 2020; 33:220-226. [PMID: 32004168 DOI: 10.1097/aco.0000000000000837] [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
PURPOSE OF REVIEW Red cell transfusions are commonly used in management of hemorrhage in trauma patients. The appropriate indications and criteria for transfusion are still debated. Here, we summarize the recent findings on the use of red cell transfusion in trauma setting. RECENT FINDINGS Recent evidence continues to support the long-established link between allogeneic transfusion and worse clinical outcomes, reinstating the importance of more judicious use of allogeneic blood and careful consideration of benefits versus risks when making transfusion decisions. Studies support restrictive transfusion strategies (often based on hemoglobin thresholds of 7-8 g/dl) in most patient populations, although some argue more caution in specific populations (e.g. patients with traumatic brain injury) and more studies are needed to determine if these patients benefit from less restrictive transfusion strategies. It should be remembered that anemia remains an independent risk factor for worse outcomes and red cell transfusion does not constitute a lasting treatment. Anemia should be properly assessed and managed based on the cause and using hematinic medications as indicated. SUMMARY Although the debate on hemoglobin thresholds for transfusion continues, clinicians should not overlook proper management of the underlying issue (anemia).
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine; Englewood Hospital and Medical Center.,TeamHealth Research Institute; Englewood.,Icahn School Of Medicine at Mount Sinai, New York, NY, USA
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Main, Germany
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zürich, Zürich, Switzerland
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