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Lynghaug T, Bakke HK, Fuskevåg OM, Nielsen EW, Dietrichs ES. HOW SHOULD TRANEXAMIC ACID BE ADMINISTERED IN HEMORRHAGIC SHOCK? CONTINUOUS SERUM CONCENTRATION MEASUREMENTS IN A SWINE MODEL. Shock 2023; 60:707-712. [PMID: 37695638 PMCID: PMC10662641 DOI: 10.1097/shk.0000000000002222] [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: 06/09/2023] [Revised: 07/02/2023] [Accepted: 08/29/2023] [Indexed: 09/12/2023]
Abstract
ABSTRACT Background : Tranexamic acid (TXA) reduces mortality in trauma patients. Intramuscular (IM) administration could be advantageous in low-resource and military settings. Achieving the same serum concentration as intravenous (IV) administration is important to achieve equal mortality reduction. Therefore, we aimed to investigate whether dividing an IM dose of TXA between two injection sites and whether an increase in dose would lead to serum concentrations comparable to those achieved by IV administration. Methods : Norwegian landrace pigs (n = 29) from a course in hemostatic emergency surgery were given TXA 1 h after start of surgery. Blood samples were drawn at 0, 5, 10, 15, 20, 25, 35, 45, 60, and 85 min. The samples were centrifuged and serum TXA concentrations quantified with liquid chromatography-tandem mass spectrometry. The use of two injection sites was compared with distributing the dose on one injection site, and a dose of 15 mg/kg was compared with a dose of 30 mg/kg. All IM groups were compared with IV administration. Results : The groups were in a similar degree of shock. Increasing the IM dose from the standard of 15 mg/kg to 30 mg/kg resulted in significantly higher serum concentrations of TXA, comparable to those achieved by IV administration. Distributing the IM dose on two injection sites did not affect drug uptake, as shown by equal serum concentrations. Conclusions : For IM administration of TXA, 30 mg/kg should be the standard dose. With a short delay, IM administration will provide equal serum concentrations as IV administration, above what is considered necessary to inhibit fibrinolysis.
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Affiliation(s)
- Trine Lynghaug
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, Faculty of Health Sciences, IKM, UiT, The Arctic University of Norway, Tromsø, Norway
- Department of Health and Care Sciences, Faculty of Health Science, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Håkon Kvåle Bakke
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, Faculty of Health Sciences, IKM, UiT, The Arctic University of Norway, Tromsø, Norway
- Department of Health and Care Sciences, Faculty of Health Science, UiT, The Arctic University of Norway, Tromsø, Norway
- Department of Anaesthesia and Critical Care, University Hospital of North Norway, Tromsø, Norway
| | - Ole Martin Fuskevåg
- Division of Diagnostic Services, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, UiT, The arctic University of Norway, Tromsø, Norway
| | - Erik Waage Nielsen
- Department of Anaesthesia and Critical Care, Nordland Hospital, Bodø, Norway
- University Nord, Bodø, Norway
- Department of Immunology, University of Oslo, Oslo, Norway
- Institute of Clinical Medicine, UiT, The Arctic University of Norway, Norway, Norway
| | - Erik Sveberg Dietrichs
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT, The Arctic University of Norway, Tromsø, Norway
- Department of Oral Biology, University of Oslo, Oslo, Norway
- Centre for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
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Chang YJ, Lin YH, Wang PL, Lin HC. Efficacy of local infiltration of tranexamic acid in subcutaneous surgery: A protocol from a single medical center. Medicine (Baltimore) 2023; 102:e34900. [PMID: 37657042 PMCID: PMC10476745 DOI: 10.1097/md.0000000000034900] [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: 04/26/2023] [Accepted: 08/03/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND The purpose of this study was to explore efficacy of locally injected tranexamic acid (TXA) at a concentration of 1 mg/mL for reduction perioperative bleeding and postoperative complications in subcutaneous tumor excisions. We present the protocol and also compare results between the group of use antithrombotic group and not used. METHODS This is a retrospective study. Fifty-three patients were divided into 3 groups. Group 1 (n = 14): using antithrombotic drugs (antiplatelet or anticoagulants) with locally injected TXA. Group 2 (n = 17): using antithrombotic drugs without locally injected TXA. Group 3 (n = 22): not using antithrombotic drugs but with locally injected TXA. TXA was diluted to 1 mg/mL for use based on our experience. All patients were operated by 1 surgeon in 1 single medical center in Taipei from March 1st, 2020, to March 31st 2022. Outcomes such as the quality of perioperative surgical field and postoperative surgical complications were evaluated and compared. The quality of field was intraoperatively recorded by an assessment and photos from the surgeon. The statistical relationships between the complication rates were analyzed using χ2 test and a 1-way ANOVA by SPSS 25. RESULTS From Groups 1 and 3, a total of 36 patients, 29 patients had a clear surgical field during procedure. When comparing Groups 1 and 2, use of locally injected TXA had greater positive advantage in terms of a clearer vision whilst surgery (P = .031). Group 2 had more minor complications such as hematoma, severe ecchymosis, wound dehiscence, wound infection. By postoperatively reducing hematomas for 24 hours, it significantly reduce the incidence of abovementioned minor complications (P = .036). With the help of locally injected TXA, shorter time was required to remove drain, hence reducing duration of in-hospital stay. CONCLUSION The use of locally injected TXA whilst performing subcutaneous surgery on patients taking antithrombotic drugs is cost-effective. It could reduce bleeding and provide a more effective surgical field. In our study, favorable results were obtained from the use of diluted tranexamic acid (1 mg/mL) mixed with lidocaine, namely in clearing the surgical field as well as reducing postoperative surgical complications.
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Affiliation(s)
- Yao-Jen Chang
- Division of Plastic Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Shilin District, Taipei, Taiwan
| | - Yu-Hsien Lin
- Division of Plastic Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Shilin District, Taipei, Taiwan
| | - Pao-Lo Wang
- Division of Plastic Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Shilin District, Taipei, Taiwan
| | - Hwang-Chi Lin
- Division of Plastic Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Shilin District, Taipei, Taiwan
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Keck M, Bosselmann K, Müller-Wittig S, Wittig KS, Lohmeyer JA. [Topical Application of Tranexamic Acid in Subcutaneous Mastectomy Wounds in Female-to-male Transgender Patients]. HANDCHIR MIKROCHIR P 2022; 54:501-506. [PMID: 36100235 DOI: 10.1055/a-1850-2108] [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: 12/15/2022] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) is an antifibrinolytic drug that can be used to treat and prevent bleeding. Its application in plastic and reconstructive surgery has been very limited to date. To our knowledge, there is a lack of published data on the topical application of TXA in transgender patients undergoing subcutaneous mastectomy. METHODS We performed a retrospective data analysis of female-to-male transgender patients who underwent subcutaneous mastectomy. A total of 22 patients were treated with topical TXA, while 29 patients served as controls. The primary endpoint was the amount of wound secretion in the first 48 hours after surgery. Secondary endpoints were the duration of drainage and the occurrence of postoperative bleeding. RESULTS Within the first 48 hours, the TXA group had an average drain volume of 97±50 ml compared with 180±111 ml in the control group (p<0.01). There was a significantly lower flow rate over the entire period in the group of TXA patients (113±86 ml vs. 265±197 ml). The time of drains in situ was 2.3±0.7 days in TXA patients, while the drains in the control group were in place for an average of 3.4±1.3 days (p<0.01). In the group of patients treated with TXA, there was a tendency towards a lower number of postoperative bleeding and haematoma (9vs. 17%). DISCUSSION There was a significant reduction in the amount of drain fluid within the first 48 hours and over the entire period after topical application of TXA. Also there was a reduction in the length of time patients had a drain in place in the TXA-treated patients. This study demonstrated a significant advantage for the topical application of TXA in subcutaneous mastectomy in female-to-male transgender patients.
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Affiliation(s)
- Maike Keck
- Klinik für Plastische, Ästhetische und Rekonstruktive Chirurgie, Agaplesion Diakonie-Klinikum Hamburg gGmbH, Hamburg, Germany
- Plastische Chirurgie, Universität zu Lübeck, Lubeck, Germany
| | - Kira Bosselmann
- Klinik für Plastische, Ästhetische und Rekonstruktive Chirurgie, Agaplesion Diakonie-Klinikum Hamburg gGmbH, Hamburg, Germany
| | - Stefanie Müller-Wittig
- Klinik für Plastische, Ästhetische und Rekonstruktive Chirurgie, Agaplesion Diakonie-Klinikum Hamburg gGmbH, Hamburg, Germany
| | - Klaus Stephan Wittig
- Klinik für Plastische, Ästhetische und Rekonstruktive Chirurgie, Agaplesion Diakonie-Klinikum Hamburg gGmbH, Hamburg, Germany
| | - Jörn Andreas Lohmeyer
- Klinik für Plastische, Ästhetische und Rekonstruktive Chirurgie, Agaplesion Diakonie-Klinikum Hamburg gGmbH, Hamburg, Germany
- Klinik und Poliklinik für Plastische Chirurgie und Handchirurgie, Klinikum rechts der Isar der Technischen Universität München, Munchen, Germany
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Use of Tranexamic Acid in Liposculpture: A Double-Blind, Multicenter, Randomized Clinical Trial. Plast Reconstr Surg 2022; 150:569-577. [PMID: 35759637 DOI: 10.1097/prs.0000000000009434] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intraoperative hemostasis should be performed with great caution since bleeding is a huge enemy of patient safety during surgery. Tranexamic acid (TXA) is a lysine synthetic derivate that inhibits fibrinolysis and diminishes the bleeding by blocking the 5 lysine-binding sites for plasminogen. PURPOSE We are comparing the efficacy of tranexamic acid vs. placebo as a hemostatic agent in liposculpture procedures. METHODS DESIGN, SETTING AND PARTICIPANTS We conducted a multicenter, double-blinded, randomized, controlled clinical trial in patients who were scheduled for liposculpture in 3 plastic surgery centers (Colombia and Mexico) between January 2019 and February of 2020. Interventions: 141 patients were randomly assigned into three groups: Intravenous (1 gr of TXA), subcutaneous (1 gr of TXA) and placebo (Normal Saline). 47 patients were assigned to each group. 30 patients were male and 111 were female. Main outcome: Evaluate the amount of postoperative bleeding between groups. The primary outcome was measured by the hemoglobin (Hb) point loss at day 1 (Preoperative Hb minus Hb at day 1 postop) and the Hb (mg/dl) point loss at day 5 (Preoperative Hb minus Hb at day 5 postop). RESULTS We found the Intravenous intervention group to have a greater hemoglobin level than the other two groups on both the first postoperative day (P=0.0001) and the fifth postoperative day (P=0.001). There were no statistical differences in Hb values between the placebo and the subcutaneous intervention groups. CONCLUSIONS Intravenous Tranexamic acid is a good therapeutic choice to implement on liposculpture procedures to decrease postoperative bleeding.
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Bakke HK, Fuskevåg OM, Nielsen EW, Dietrichs ES. Intramuscular uptake of tranexamic acid during haemorrhagic shock in a swine model. Scand J Trauma Resusc Emerg Med 2021; 29:171. [PMID: 34922577 PMCID: PMC8684106 DOI: 10.1186/s13049-021-00983-2] [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: 08/31/2021] [Accepted: 11/29/2021] [Indexed: 11/25/2022] Open
Abstract
Background Tranexamic acid (TXA) reduce mortality in bleeding trauma patients, with greater effect if administered early. Serum concentrations above 10 µg/mL are considered sufficient to inhibit fibrinolysis. Normally administered intravenously (i.v.), TXA can also be administered intramuscularly (i.m.). This could be advantageous in low resource and military settings, if sufficient serum concentrations can be reached in shocked patients with reduced muscular blood perfusion. Accordingly, we aimed to: (1) Determine the impact of shock on the pharmacokinetics of i.m. TXA, and (2) Compare the pharmacokinetics of i.v. versus i.m. TXA in ongoing shock. Materials and methods In a prospective experimental study, N = 18 Norwegian landrace pigs (40–50 kg), utilised in a surgical course in haemostatic emergency surgery, were subjected to various abdominal and thoracic trauma. After 1 h of surgery the animals were given 15 mg/kg TXA either i.v. or i.m. A control group without injury, or surgery, received intramuscular TXA. Blood samples were drawn at 0, 5, 15, 25, 35, 45, 60 and 85 min. The samples were centrifuged and analysed with liquid chromatography–tandem mass spectrometry (LC–MS/MS) for TXA serum-concentrations. Results In shocked pigs, i.m. administration resulted in a mean maximum serum concentration (Cmax) of 20.9 µg/mL, and i.v. administration a Cmax of 48.1 µg/mL. Cmax occurred 15 min after i.m. administration and 5 min after i.v. administration. In non-shocked swine, i.m. administration resulted in a Cmax of 36.9 µg/mL after 15 min. In all groups, mean TXA serum concentrations stayed above 10 µg/mL from administration to end of experiments. Conclusions I.m. administration of TXA in shocked pigs provides serum concentrations associated with inhibition of fibrinolysis. It may be an alternative to i.v. and intraosseous administration during stabilisation and transport of trauma patients to advanced medical care.
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Affiliation(s)
- Håkon Kvåle Bakke
- Department of Anaesthesia and Critical Care, University Hospital of North Norway, 9038, Tromsø, Norway. .,Department of Traumatology, University Hospital of North Norway, Tromsø, Norway. .,Department of Health and Care Sciences, Faculty of Health Science, UiT, The Arctic University of Norway, Tromsø, Norway.
| | - Ole Martin Fuskevåg
- Division of Diagnostic Services, University Hospital of North Norway, Tromsø, Norway
| | - Erik Waage Nielsen
- Department of Anaesthesia and Critical Care, Nordland Hospital, Bodø, Bodø, Norway.,University Nord, Bodø, Norway.,Department of Immunology, University of Oslo, Oslo, Norway.,Institute of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Erik Sveberg Dietrichs
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT, The Arctic University of Norway, Tromsø, Norway.,Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
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Strauss ER, Li S, Henderson R, Carpenter R, Guo D, Thangaraju K, Katneni U, Buehler PW, Gobburu JV, Tanaka KA. A pharmacokinetic and plasmin generation pharmacodynamic assessment of a tranexamic acid regimen designed for cardiac surgery with cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2021; 36:2473-2482. [DOI: 10.1053/j.jvca.2021.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/16/2021] [Accepted: 12/23/2021] [Indexed: 11/11/2022]
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Hasan MS, Yunus SN, Ng CC, Chan CYW, Chiu CK, Kwan MK. Tranexamic Acid in Pediatric Scoliosis Surgery: A Prospective Randomized Trial Comparing High-dose and Low-dose Tranexamic Acid in Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion Surgery. Spine (Phila Pa 1976) 2021; 46:E1170-E1177. [PMID: 33882541 DOI: 10.1097/brs.0000000000004076] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective randomized double-blinded trial. OBJECTIVE The objective of this study is to determine the efficacy of high-dose versus low-dose tranexamic acid (TXA) in adolescent idiopathic scoliosis (AIS) corrective surgery. SUMMARY OF BACKGROUND DATA Corrective surgery for AIS is associated with significant blood loss. Evidence on the optimum TXA dose to reduce bleeding in pediatric population is scarce. METHODS A total of 166 AIS patients aged between 10 and 21 years, of American Society of Anesthesiologists (ASA) physical status I and II, preoperative hemoglobin >10 g/dL, platelet count >150,000 cells/L and Cobb angle of >45° scheduled for elective single-stage posterior spinal fusion (PSF) surgery by two attending surgeons were included between March 2017 and November 2018. Patients were randomized into Group A (High Dose, 30 mg/kg TXA loading dose followed by 10 mg/kg/h infusion) and Group B (Low Dose, 10 mg/kg TXA loading dose followed by 1 mg/kg/h infusion). The primary outcome was total surgical blood loss between both groups. Secondary outcomes were transfusion requirement, perioperative changes in hemoglobin and coagulation profiles, adverse events, and factors that influence total blood loss. RESULTS The mean total surgical blood loss between the two groups was not significant (Group A: 928.8 ± 406.1 mL [range: 348-1857 mL]; Group B: 918.1 ± 406.2 mL [range: 271-2000 mL], P = 0.865). The median duration of surgery was 120 minutes. One patient in each group received allogenic blood transfusion during the perioperative period. There were no significant changes in hemoglobin and coagulation profile at pre-operation, post-operation 0 hour and 48 hours. Sex, number of vertebral levels fused, and duration of surgery were independently associated with total surgical blood loss. No adverse events were observed perioperatively. CONCLUSION Low-dose TXA was as efficacious as high-dose TXA in reducing blood loss and allogenic blood transfusion for AIS patients undergoing PSF surgery.Level of Evidence: 1.
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Affiliation(s)
- Mohd Shahnaz Hasan
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Siti Nadzrah Yunus
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ching Choe Ng
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chris Yin Wei Chan
- Department of Orthopedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chee Kidd Chiu
- Department of Orthopedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mun Keong Kwan
- Department of Orthopedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Halpern LM, Bronson WE, Kogan CJ. A New Low Dose of Tranexamic Acid for Decreasing the Rate of Blood Loss in Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. J Pediatr Orthop 2021; 41:333-337. [PMID: 33826563 DOI: 10.1097/bpo.0000000000001820] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies have demonstrated that the use of tranexamic acid (TXA) reduces blood loss and transfusion requirements in children undergoing scoliosis surgery. Although TXA is safe and effective, significant adverse events have been reported. Using the lowest effective dose of TXA is advisable. We evaluated a new low dosing regimen for TXA based on an improved pharmacokinetic model and therapeutic plasma concentration. The purpose of this study is to evaluate the effectiveness of this new low dosing regimen in reducing blood loss and transfusion requirements in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion when compared with a control group who did not receive TXA. METHODS We retrospectively reviewed 90 consecutive patients with idiopathic scoliosis undergoing posterior spinal fusion at our institution from 2017 to 2020. Forty patients received TXA at the new dosing regimen (10 mg/kg load, 5 mg/kg/h infusion) and 50 patients were in the non-TXA control group. The same 2 orthopaedic surgeons, working as a team, performed all surgical procedures. We assessed the use of TXA as an independent risk factor for estimated blood loss and transfusion requirement after adjusting for age, surgical duration, body mass index, major coronal curve, and sex. RESULTS A comparison of the intraoperative cumulative blood loss in the 2 groups showed a significantly lower blood loss in the TXA group. (583.5±272.0 vs. 479.5±288.7 mL, P=0.03) This difference persisted when blood loss was calculated as percent of total blood volume and per vertebral level. Transfusion requirements were lower in the TXA group (4/50 patients vs. 0/40 patients, P=0.13). No patient in the TXA group required a blood transfusion during their hospitalization. CONCLUSION This study is the first to provide evidence that a new low dosing regimen of TXA can significantly reduce blood loss and transfusion requirements for idiopathic scoliosis patients and supports the need for a prospective, randomized clinical trial to confirm these findings. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Affiliation(s)
| | | | - Clark J Kogan
- Center for Interdisciplinary Statistical Education and Research, Washington State University, Pullman, WA
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Effective tranexamic acid concentration for 95% inhibition of tissue-type plasminogen activator-induced hyperfibrinolysis in full-term pregnant women: a prospective interventional study. Blood Coagul Fibrinolysis 2021; 32:186-193. [PMID: 33470644 DOI: 10.1097/mbc.0000000000001015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Postpartum haemorrhage is the leading cause of maternal mortality and morbidity worldwide. Tranexamic acid (TXA) has been shown to reduce blood loss and blood product transfusion requirements. Despite clinical evidence, further studies are needed to better define the pharmacokinetic and pharmacodynamic characteristics of TXA in pregnant women. The objective of our prospective observational ex-vivo study was to define the effective TXA concentration required to inhibit 95% (EC95) of tissue-type plasminogen activator (t-PA)-induced fibrinolysis in full-term pregnant women. Hyperfibrinolysis was induced by adding supraphysiologic concentration of t-PA to blood samples obtained from 30 full-term pregnant women and 10 healthy nonpregnant female volunteers. Increasing TXA concentrations (0--40 μg/ml) were then spiked into the blood samples and inhibition of fibrinolysis was assessed using the lysis index at 30 min of the ROTEM measured on EXTEM and NATEM tests. Effective TXA concentrations required to achieve EC95 were extrapolated using nonlinear regression. EC95 were compared between groups using an extra sum-of-squares F test. EC95 in pregnant women was 14.7 μg/ml (95% CI 12.4--17.5 μg/ml) on EXTEM and 11.2 μg/ml (95% CI 8.3--15.1 μg/ml) on NATEM tests. These values were significantly higher than those obtained in volunteers: 8.7 μg/ml (95% CI 5.5--13.9 μg/ml) and 6.8 μg/ml (95% CI 5.3--8.8 μg/ml), respectively (both P < 0.001). Our results suggest a higher fibrinolytic potential in pregnant women compared with nonpregnant women.
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Optimal Tranexamic Acid Dosing Regimen in Cardiac Surgery: What Are the Missing Pieces? Anesthesiology 2021; 134:143-146. [PMID: 33433620 DOI: 10.1097/aln.0000000000003637] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Arun-Kumar V, Naresh-Babu J. Is There a Role for Preoperative Local Infiltration of Tranexamic Acid in Elective Spine Surgery? A Prospective Randomized Controlled Trial Analyzing the Efficacy of Intravenous, Local Infiltration, and Topical Administration of Tranexamic Acid. Global Spine J 2021; 11:21-27. [PMID: 32875830 PMCID: PMC7734265 DOI: 10.1177/2192568219888446] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
STUDY DESIGN Randomized control trial. OBJECTIVE The purpose of the study is to evaluate the safety and efficacy of tranexamic acid in reducing blood loss when administered through various routes in instrumented spine surgeries. METHODS A total of 104 patients undergoing instrumented spine surgery were randomly assigned to 4 groups (n = 26 in each group). Groups included (1) ivTXA-intravenous administration of tranexamic acid (TXA) 1 hour prior to surgery, (2) loTXA-local infiltration of TXA bilaterally into the paraspinal musculature prior to incision, (3) tTXA-topical application of TXA just before wound closure, and (4) control group. Outcome measures included intraoperative blood loss, postoperative blood loss, need for blood transfusion, length of hospital stay, and hematological parameters. RESULTS All the 3 different modes of TXA administration were found to be effective in reducing blood loss in the treated groups compared with the control group. Intraoperative blood loss was significantly reduced in ivTXA (223.6 ± 40.1 mL, P < .0001) and loTXA (256.07 ± 119 mL, P = .0039) groups when compared with controls (344 ± 88.5 mL).The postoperative blood loss was least in tTXA followed by ivTXA, loTXA, and controls. There was 67% reduction in need for blood transfusion in tTXA group, 55.5% reduction in ivTXA group, and 33% reduction in loTXA group when compared with the control group. CONCLUSION In instrumented spine surgery, ivTXA and loTXA were found to be equally effective in reducing the intraoperative blood loss. The tTXA has better postoperative blood conserving effects. This is the first study to detail about safety and efficacy on local infiltration of TXA in spine surgery, which is an effective and safe method for reducing intraoperative blood loss.
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Affiliation(s)
- Viswanadha Arun-Kumar
- Mallika Spine Centre, Guntur, Andhra Pradesh, India,Viswanadha Arun-Kumar, Mallika Spine Centre, 12-12-30, Old Club Road, Kothapet, Guntur, Andhra Pradesh, India.
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Lier H, Maegele M, Shander A. Tranexamic Acid for Acute Hemorrhage: A Narrative Review of Landmark Studies and a Critical Reappraisal of Its Use Over the Last Decade. Anesth Analg 2019; 129:1574-1584. [PMID: 31743178 DOI: 10.1213/ane.0000000000004389] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The publication of the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage-2 (CRASH-2) study and its intense dissemination prompted a renaissance for the use of the antifibrinolytic agent tranexamic acid (TXA) in acute trauma hemorrhage. Subsequent studies led to its widespread use as a therapeutic as well as prophylactic agent across different clinical scenarios involving bleeding, such as trauma, postpartum, and orthopedic surgery. However, results from the existing studies are confounded by methodological and statistical ambiguities and are open to varied interpretations. Substantial knowledge gaps remain on dosing, pharmacokinetics, mechanism of action, and clinical applications for TXA. The risk for potential thromboembolic complications with the use of TXA must be balanced against its clinical benefits. The present article aims to provide a critical reappraisal of TXA use over the last decade and a "thought exercise" in the potential downsides of TXA. A more selective and individualized use of TXA, guided by extended and functional coagulation assays, is advocated in the context of the evolving concept of precision medicine.
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Affiliation(s)
- Heiko Lier
- From the Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Marc Maegele
- Department for Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Campus Cologne-Merheim, Cologne, Germany
| | - Aryeh Shander
- Department of Anesthesiology, Critical Care Medicine, Hyperbaric Medicine, Englewood Health, TeamHealth Research Institute, Englewood, New Jersey
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Faraoni D, Meier J, New HV, Van der Linden PJ, Hunt BJ. Patient Blood Management for Neonates and Children Undergoing Cardiac Surgery: 2019 NATA Guidelines. J Cardiothorac Vasc Anesth 2019; 33:3249-3263. [DOI: 10.1053/j.jvca.2019.03.036] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 12/22/2022]
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Serum Concentrations and Pharmacokinetics of Tranexamic Acid after Two Means of Topical Administration in Massive Weight Loss Skin-Reducing Surgery. Plast Reconstr Surg 2019; 143:1169e-1178e. [PMID: 31136475 PMCID: PMC6553511 DOI: 10.1097/prs.0000000000005620] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Topical administration of tranexamic acid to reduce bleeding is receiving increasing attention, as it is inexpensive, simple, and possibly beneficial in most surgery. Concerns regarding potential systemic adverse effects such as thromboembolic events and seizures may prevent general use of tranexamic acid. Although serum concentrations after topical application are assumed to be low, proper pharmacokinetic studies of tranexamic acid after topical application are lacking. Methods: The authors have investigated systemic absorption of tranexamic acid after two means of topical administration in patients undergoing abdominoplasty after massive weight loss: a bolus of 200 ml of 5 mg/ml into the wound cavity versus moistening the wound surface with 20 ml of 25 mg/ml. Twelve patients were recruited in each group. Serum concentrations achieved were compared with those after administration of 1 g as an intravenous bolus to arthroplasty patients. Serial blood samples for tranexamic acid analysis were obtained for up to 24 hours. Results: After intravenous administration, the peak serum concentration was 66.1 ± 13.0 µg/ml after 6 ± 2 minutes. Peak serum concentration after topical moistening was 5.2 ± 2.6 µg/ml after 80 ± 33 minutes, and in the topical bolus group, it was 4.9 ± 1.8 µg/ml after 359 ± 70 minutes. Topical moistening resulted in homogenous and predictable absorption across the individuals included, whereas topical bolus administration caused variable and unpredictable serum concentrations. Conclusion: Topical administration of tranexamic acid in patients undergoing abdominoplasty results in low serum concentrations, which are highly unlikely to cause systemic effects.
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Tranexamic acid and perioperative bleeding in children: what do we still need to know? Curr Opin Anaesthesiol 2019; 32:343-352. [PMID: 30893114 DOI: 10.1097/aco.0000000000000728] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Perioperative bleeding and blood product transfusion are associated with significant morbidity and mortality. Prevention and optimal management of bleeding decreases risk and lowers costs. Tranexamic acid (TXA) is an antifibrinolytic agent that reduces bleeding and transfusion in a broad number of adult and pediatric surgeries, as well as in trauma and obstetrics. This review highlights the current pediatric indications and contraindications of TXA. The efficacy and safety profile, given current and evolving research, will be covered. RECENT FINDINGS Based on the published evidence, prophylactic or therapeutic TXA administration is a well-tolerated and effective strategy to reduce bleeding, decrease allogeneic blood product transfusion, and improve pediatric patients' outcomes. TXA is now recommended in recent guidelines as an important part of pediatric blood management protocols. SUMMARY Based on TXA pharmacokinetics, the authors recommend a dosing regimen of between 10 to 30 mg/kg loading dose followed by 5 to 10 mg/kg/h maintenance infusion rate for pediatric trauma and surgery. Maximal efficacy and minimal side-effects with this dosage regime will have to be determined in larger prospective trials including high-risk groups. Furthermore, future research should focus on determining the ideal TXA plasma therapeutic concentration for maximum efficacy and minimal side-effects.
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Cholette JM, Faraoni D, Goobie SM, Ferraris V, Hassan N. Patient Blood Management in Pediatric Cardiac Surgery: A Review. Anesth Analg 2019; 127:1002-1016. [PMID: 28991109 DOI: 10.1213/ane.0000000000002504] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.
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Affiliation(s)
- Jill M Cholette
- From the Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston, Massachusetts.,Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Ferraris
- Department of Surgery, University of Kentucky Chandler Medical Center & Lexington Veterans Affairs Medical Center, Lexington, Kentucky
| | - Nabil Hassan
- Division of Pediatric Critical Care, Children's Hospital of Illinois At OSF St Frances, University of Illinois at Peoria, Peoria, Illinois
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Faraoni D, Rahe C, Cybulski KA. Use of antifibrinolytics in pediatric cardiac surgery: Where are we now? Paediatr Anaesth 2019; 29:435-440. [PMID: 30365221 DOI: 10.1111/pan.13533] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/18/2018] [Accepted: 10/20/2018] [Indexed: 01/24/2023]
Abstract
Fibrinolytic activation is a major and preventable source of bleeding in neonates and children undergoing cardiac surgery with cardiopulmonary bypass. Based on the existing literature (adult and pediatric; cardiac and noncardiac), prophylactic administration of antifibrinolytic agents can help reduce fibrinolytic activation, and consequently reduces perioperative bleeding and the requirement for blood product transfusion. Due to the increased risk of renal failure and mortality reported in adults undergoing cardiac surgery, aprotinin should not be considered as a safe option in neonates and children. Further well-designed studies would be required before the prophylactic administration of aprotinin could be considered in pediatric cardiac surgery. The lysine analogs, tranexamic acid and ϵ-aminocaproic acid,, should be considered as safe and effective antifibrinolytic agents. Although no major side effects have been reported following the administration of lysine analogs in children undergoing cardiac surgery, high-dose tranexamic acid should not be recommended in order to avoid the increased risk of clinical seizures. Despite the recent advances made in our understanding of the pharmacokinetics of tranexamic acid and ϵ-aminocaproic acid,, the optimal plasmatic concentration to be targeted remains unknown. Further studies are therefore urgently needed to better define the optimal dose regimen to be used in neonates and children. In the meantime, the dose regimen published in the most recent pharmacokinetic studies can be used. Although no studies have assessed the effect of massive bleeding and transfusion on the plasmatic concentrations of the lysine analogs, additional boluses might be considered in the presence of bleeding and/or when signs of fibrinolytic activations are observed on viscoelastic hemostatic assays.
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Affiliation(s)
- David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cornelius Rahe
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Karen A Cybulski
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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What concentration of tranexamic acid is needed to inhibit fibrinolysis? A systematic review of pharmacodynamics studies. Blood Coagul Fibrinolysis 2019; 30:1-10. [PMID: 30585835 PMCID: PMC6365258 DOI: 10.1097/mbc.0000000000000789] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
: Intravenous tranexamic acid (TXA) reduces death because of bleeding in patients with trauma and postpartum haemorrhage. However, in some settings intravenous injection is not feasible. To find different routes of administration, we first need to determine the minimal concentration of TXA in the blood that is required to inhibit fibrinolysis.We conducted a systematic review of in-vitro and in-vivo pharmacodynamics studies. We searched MEDLINE, EMBASE, OviSP, and ISI Web of Science from database inception to November 2017 for all in-vitro (including simulated clotting models) or in-vivo studies reporting the relationship between the TXA concentration in blood or plasma and any reliable measure of fibrinolysis.We found 21 studies of which 20 were in vitro and one was in vivo. Most in-vitro studies stimulated fibrinolysis with tissue plasminogen activator and measured fibrinolysis using viscoelastic, optical density, or immunological assays. TXA concentrations between 10 and 15 mg/l resulted in substantial inhibition of fibrinolysis, although concentrations between 5 and 10 mg/l were partly inhibitory.TXA concentrations of 10-15 mg/l may be suitable targets for pharmacokinetic studies, although TXA concentrations above 5 mg/l may also be effective.
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Miyata S, Itakura A, Ueda Y, Usui A, Okita Y, Ohnishi Y, Katori N, Kushimoto S, Sasaki H, Shimizu H, Nishimura K, Nishiwaki K, Matsushita T, Ogawa S, Kino S, Kubo T, Saito N, Tanaka H, Tamura T, Nakai M, Fujii S, Maeda T, Maeda H, Makino S, Matsunaga S. TRANSFUSION GUIDELINES FOR PATIENTS WITH MASSIVE BLEEDING. ACTA ACUST UNITED AC 2019. [DOI: 10.3925/jjtc.65.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Shigeki Miyata
- Department of Clinical Laboratory Medicine, National Cerebral and Cardiovascular Center
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Yuichi Ueda
- Nara Prefectural Hospital Organization, Nara Prefecture General Medical Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University
| | - Yoshihiko Ohnishi
- Operation Room, Anesthesiology, National Cerebral and Cardiovascular Center
| | - Nobuyuki Katori
- Department of Anesthesiology, Keio University School of Medicine
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | | | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | | | | | - Satoru Ogawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine
| | | | | | - Nobuyuki Saito
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital
| | - Hiroshi Tanaka
- Department of Surgery, Division of Minimum Invasive Surgery, Kobe University
| | | | - Michikazu Nakai
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | - Satoshi Fujii
- Department of Laboratory Medicine, Asahikawa Medical University
| | - Takuma Maeda
- Division of Transfusion Medicine, National Cerebral and Cardiovascular Center
| | - Hiroo Maeda
- Transfusion Medicine and Cell Therapy, Saitama Medical Center/Saitama Medical University
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Shigetaka Matsunaga
- Department of Obstetrics and Gynecology, Saitama Medical Center/Saitama Medical University
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Nielsen VG, Ford PM. The ratio of concentrations of aminocaproic acid and tranexamic acid that prevent plasmin activation of platelets does not provide equivalent inhibition of plasmatic fibrinolysis. J Thromb Thrombolysis 2019; 46:365-370. [PMID: 29926296 DOI: 10.1007/s11239-018-1705-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Aminocaproic acid (EACA) availability has recently been decreased whereas tranexamic acid (TXA) is still available as an antifibrinolytic agent to decrease blood loss associated with procedures involving cardiopulmonary bypass (CPB) by inhibiting plasmin mediated platelet activation. Given that the clinical inclination is to substitute TXA for EACA, we sought to compare the antifibrinolytic efficacy of the two agents using the clinically accepted molar ratio of EACA:TXA (7.9:1) that prevents platelet activation in a viscoelastic based system under a variety of conditions in human plasma; 25-50% therapeutic concentration (EACA 32.5-65 µg/ml, TXA 5-10 µg/ml) in the presence of 1500-3000 IU tissue-type plasminogen activator, with 0-50% dilution of plasma with buffer. In all equipotent concentrations, TXA provided superior antifibrinolytic action compared to EACA. It is hoped that this work will serve as a rationale to further investigate these and other similar agents, especially now in a time of unpredictable unavailability of key medications needed to optimize patient care. It is also our wish that these data assist perfusionists, anesthesiologists and cardiothoracic surgeons with their consideration of using an antifibrinolytic agent when managing complex patients with hypercoagulable states (e.g., ventricular assist device explant, infective endocarditis) undergoing CPB.
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Affiliation(s)
- Vance G Nielsen
- Department of Anesthesiology, The University of Arizona College of Medicine, P.O. Box 245114, 1501 North Campbell Avenue, Tucson, AZ, 85724-5114, USA.
| | - Paul M Ford
- Department of Anesthesiology, The University of Arizona College of Medicine, P.O. Box 245114, 1501 North Campbell Avenue, Tucson, AZ, 85724-5114, USA
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21
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Seelhammer TG, Mangla J, Demirci O. The Use of Thromboelastography to Titrate Tranexamic Acid Therapy for Abatement of Lysis-Induced Hemorrhagic Complications During Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2018; 33:1059-1062. [PMID: 30765211 DOI: 10.1053/j.jvca.2018.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Troy G Seelhammer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| | - Jimmi Mangla
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Onur Demirci
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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22
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The effects of hemorrhage on the pharmacokinetics of tranexamic acid in a swine model. J Trauma Acute Care Surg 2018; 85:S44-S48. [DOI: 10.1097/ta.0000000000001861] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Brenner A, Shakur-Still H, Chaudhri R, Fawole B, Arulkumaran S, Roberts I. The impact of early outcome events on the effect of tranexamic acid in post-partum haemorrhage: an exploratory subgroup analysis of the WOMAN trial. BMC Pregnancy Childbirth 2018; 18:215. [PMID: 29879947 PMCID: PMC5992712 DOI: 10.1186/s12884-018-1855-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 05/25/2018] [Indexed: 11/17/2022] Open
Abstract
Background In severe post-partum haemorrhage, death can occur within hours of bleeding onset so interventions to control the bleeding must be given immediately. In clinical trials of treatments for life-threatening bleeding, established treatments are given priority and the trial treatment is usually given last. However, enrolling patients in whom severe maternal morbidity or death is imminent or inevitable at the time of randomisation may dilute the effects of a trial treatment. Methods We conducted an exploratory analysis of data from the WOMAN trial, an international, randomised placebo-controlled trial of the effects of tranexamic acid on death and surgical intervention in 20,060 women with post-partum haemorrhage. We assessed the impact of early maternal death or hysterectomy due to exsanguination on the effect of tranexamic acid on each of these respective outcomes. We conducted repeated analyses excluding patients with these outcomes at increasing intervals from the time of randomisation. We quantified treatment effects using risk ratios (RR) and 99% confidence intervals (CI) and prepared cumulative failure plots. Results Among 14,923 women randomised within 3 h of delivery (7518 tranexamic acid and 7405 placebo), there were 216 bleeding deaths (1.5%) and 383 hysterectomies due to bleeding (2.8%). After excluding deaths from exsanguination at increasing time intervals following randomization, there was a significant reduction in the risk of death due to bleeding with tranexamic acid (RR = 0.41; 99% CI 0.19–0.89). However, after excluding hysterectomies at increasing time intervals post-randomization, there was no reduction in the risk of hysterectomy due to bleeding with tranexamic acid (RR = 0.79; 99% CI 0.33–1.86). Conclusions Findings from this analysis provide further evidence that tranexamic acid reduces the risk of death from exsanguination in women who experience postpartum haemorrhage. It is uncertain whether tranexamic acid reduces the risk of hysterectomy for bleeding after excluding early hysterectomies. Trial registration ISRCTN trial registration number ISRCTN76912190, 8 Dec 2008; ClinicalTrials.gov number NCT00872469, 30 March 2009; PACTR number PACTR201007000192283, 9 Feb 2010; EudraCT number 2008–008441-38, 8 Dec 2010 (retrospectively registered). Electronic supplementary material The online version of this article (10.1186/s12884-018-1855-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amy Brenner
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Haleema Shakur-Still
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Rizwana Chaudhri
- Holy Family Hospital, Gynaecology & Obstetrics Unit 1, F-762 Said Pur Road, Satellite Town, Rawalpindi, Pakistan
| | - Bukola Fawole
- Department of Obstetrics & Gynaecology, College of Medicine, University of Ibadan, Queen Elizabeth Road, Ibadan, Nigeria
| | - Sabaratnam Arulkumaran
- St George's University of London, Room 1.126, First Floor, Jenner Wing, Cranmer Terrace, London, SW17 0RE, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Ducloy-Bouthors AS, Jeanpierre E, Saidi I, Baptiste AS, Simon E, Lannoy D, Duhamel A, Allorge D, Susen S, Hennart B. TRAnexamic acid in hemorrhagic CESarean section (TRACES) randomized placebo controlled dose-ranging pharmacobiological ancillary trial: study protocol for a randomized controlled trial. Trials 2018; 19:149. [PMID: 29490690 PMCID: PMC5831219 DOI: 10.1186/s13063-017-2421-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 12/15/2017] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Evidence increases that a high or a standard dose of tranexamic acid (TA) reduces postpartum bleeding. The TRACES pharmacobiological substudy aims to establish a therapeutic strategy in hemorrhagic (H) Cesarean section (CS) with respect to the intensity of fibrinolysis by using innovative assays. METHOD/DESIGN The TRACES trial is a multicenter, randomized, double-blind, placebo-controlled, TA dose-ranging study that measures simultaneously plasmatic and uterine and urine TA concentrations and the plasmin peak inhibition tested by a simultaneous thrombin plasmin generation assay described by Van Geffen (novel hemostasis assay [NHA]). Patients undergoing H CS (>800 mL) will receive blindly TA 0.5 g or 1 g or placebo. A non-hemorrhagic (NH) group will be recruited to establish plasmin generation profile. Venous blood will be sampled before, at the end, and then at 30, 60, 120, and 360 min after injection. Uterine bleeding will be sampled after injection. Urine will be sampled 2 h and 6 h after injection. The number of patients entered into the study will be 114 H + 48 NH out of the 390 patients of the TRACES clinical trial. DISCUSSION To explore the two innovative assays, a preliminary pilot study was conducted. Blood samples were performed repeatedly in patients undergoing either a H (>800 mL) or NH (<800 mL) CS and in non-pregnant women (NP). H patients received TA (0-2 g). Dose-dependent TA plasmatic concentrations were determined by LC-MS/MS quantification. Plasmin generation and its inhibition were tested in vitro and in vivo using the simultaneous thrombin-plasmin generation assay (STPGA). The pilot study included 15 patients in the H group, ten patients in the NH group, and seven patients in the NP group. TA plasmatic concentration showed a dose-dependent variation. STPGA inter-assay variation coefficients were < 20% for all plasmin parameters. Inter-individual dispersion of plasmin generation capacity was higher in H and NH groups than in NP group. Profile evolution over time was different between groups. This preliminary technical validation study allows TRACES pharmacobiological trial to be conducted. TRIAL REGISTRATION ClinicalTrials.gov, NCT02797119. Registered on 13 June 2016.
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Affiliation(s)
- Anne-Sophie Ducloy-Bouthors
- Pole anesthésie réanimation, maternité Jeanne de Flandre, centre hospitalier regional et universitaire, 2 avenue Oscar Lambret, 59037, Lille, France.
| | - Emmanuelle Jeanpierre
- Laboratoire d'hémostase-hémobiologie, centre biologie pathologie, centre hospitalier regional et universitaire, 2 avenue Oscar Lambret, 59037, Lille, France
| | - Imen Saidi
- Laboratoire d'hémostase-hémobiologie, centre biologie pathologie, centre hospitalier regional et universitaire, 2 avenue Oscar Lambret, 59037, Lille, France
| | - Anne-Sophie Baptiste
- Pole anesthésie réanimation, maternité Jeanne de Flandre, centre hospitalier regional et universitaire, 2 avenue Oscar Lambret, 59037, Lille, France
| | - Elodie Simon
- Pharmacie centrale, centre biologie pathologie, centre hospitalier regional et universitaire, 2 avenue Oscar Lambret, 59037, Lille, France
| | - Damien Lannoy
- Pharmacie centrale, centre biologie pathologie, centre hospitalier regional et universitaire, 2 avenue Oscar Lambret, 59037, Lille, France
| | - Alain Duhamel
- Unité de biostatistiques, Université Lille 2, 2 avenue Oscar Lambret, 59037, Lille, France
| | - Delphine Allorge
- Laboratoire de toxicologie, centre biologie pathologie, centre hospitalier regional et universitaire, 2 avenue Oscar Lambret, 59037, Lille, France
| | - Sophie Susen
- Laboratoire d'hémostase-hémobiologie, centre biologie pathologie, centre hospitalier regional et universitaire, 2 avenue Oscar Lambret, 59037, Lille, France
| | - Benjamin Hennart
- Laboratoire de toxicologie, centre biologie pathologie, centre hospitalier regional et universitaire, 2 avenue Oscar Lambret, 59037, Lille, France
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Grassin-Delyle S, Theusinger OM, Albrecht R, Mueller S, Spahn DR, Urien S, Stein P. Optimisation of the dosage of tranexamic acid in trauma patients with population pharmacokinetic analysis. Anaesthesia 2018; 73:719-729. [DOI: 10.1111/anae.14184] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2017] [Indexed: 01/14/2023]
Affiliation(s)
- S. Grassin-Delyle
- Plateforme de spectrométrie de masse MasSpecLab; INSERM; UMR 1173; UFR des Sciences de la Santé Simone Veil; Université Versailles Saint Quentin; Université Paris Saclay; Montigny le Bretonneux France
- Département des maladies respiratoires; Hôpital Foch; Suresnes France
| | - O. M. Theusinger
- Department of Anaesthesiology; University Hospital Balgrist and University Hospital of Zurich; Zurich Switzerland
| | - R. Albrecht
- Swiss Air-Ambulance Rega (Rettungsflugwacht/Garde Aérienne); Zurich Switzerland
| | - S. Mueller
- Schutz und Rettung Zurich; Zurich Switzerland
| | - D. R. Spahn
- Institute of Anesthesiology; University and University Hospital of Zurich; Zurich Switzerland
| | - S. Urien
- CIC-0901 Inserm Necker-Cochin; URC Paris Centre; AP-HP; Paris France
- EA-3620 Université Paris Descartes; Sorbonne Paris Cité France
| | - P. Stein
- Swiss Air-Ambulance Rega (Rettungsflugwacht/Garde Aérienne); Zurich Switzerland
- Institute of Anesthesiology; University and University Hospital of Zurich; Zurich Switzerland
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The 2017 Seventh World Congress of Pediatric Cardiology & Cardiac Surgery: week in review: congenital cardiac anaesthesia. Cardiol Young 2017; 27:2012-2017. [PMID: 29286275 DOI: 10.1017/s1047951117002190] [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: 11/06/2022]
Abstract
The seventh meeting of the World Congress of Pediatric Cardiology and Cardiac Surgery was an opportunity for healthcare professionals from around the world to meet and discuss current issues affecting patients with acquired and CHD. A dedicated anaesthesia track facilitated the exchange of ideas and fostered many new friendships. This review highlights the congenital cardiac anaesthesia track and the involvement of the Congenital Cardiac Anesthesia Society in the congress.
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Fabresse N, Fall F, Etting I, Devillier P, Alvarez JC, Grassin-Delyle S. LC–MS/MS determination of tranexamic acid in human plasma after phospholipid clean-up. J Pharm Biomed Anal 2017; 141:149-156. [DOI: 10.1016/j.jpba.2017.04.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/09/2017] [Accepted: 04/16/2017] [Indexed: 01/22/2023]
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28
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Gertler R, Gruber M, Grassin-Delyle S, Urien S, Martin K, Tassani-Prell P, Braun S, Burg S, Wiesner G. Pharmacokinetics of tranexamic acid in neonates and infants undergoing cardiac surgery. Br J Clin Pharmacol 2017; 83:1745-1757. [PMID: 28245519 DOI: 10.1111/bcp.13274] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/15/2017] [Accepted: 02/21/2017] [Indexed: 11/30/2022] Open
Abstract
AIM Tranexamic acid (TXA) continues to be one of the antifibrinolytics of choice during paediatric cardiac surgery. However, in infants less than 1 year of age, the optimal dosing based on pharmacokinetic (PK) considerations is still under discussion. METHODS Forty-three children less than 1 year of age were enrolled, of whom 37 required the use of cardiopulmonary bypass (CPB) and six were operated on without CPB. Administration of 50 mg kg-1 TXA intravenously at the induction of anaesthesia was followed by 50 mg kg-1 into the CPB prime in the CPB group. Plasma concentrations of TXA were analysed by gas chromatography-mass spectrometry. PK data were investigated using nonlinear mixed-effect models. RESULTS A two-compartment model was fitted, with the main covariates being allometrically scaled bodyweight, CPB, postmenstrual age (PMA). Intercompartmental clearance (Q), peripheral volume (V2), systemic clearance, (CL) and the central volume (V1) were calculated. Typical values of the PK parameter estimates were as follows: CL = 3.78 [95 % confidence interval (CI) 2.52, 5.05] l h-1 ; central volume of distribution = 13.6 (CI 11.7, 15.5) l; Q = 16.3 (CI 13.5, 19.2) l h-1 ; V2 = 18.0 (CI 16.1, 19.9) l. Independently of age, 10 mg kg-1 TXA as a bolus, a subsequent infusion of 10 mg kg-1 h-1 , then a 4 mg kg-1 bolus into the prime and a reduced infusion of 4 mg kg-1 h-1 after the start of CPB are required to maintain TXA concentrations continuously above 20 μg ml-1 , the threshold value for an effective inhibition of fibrinolysis and far lower than the usual peak concentrations (the '10-10-4-4 rule'). CONCLUSIONS The introduction of a modified dosing regimen using a starting bolus followed by an infusion and a CPB prime bolus would prohibit the potential risk of seizures caused by high peak concentrations and also maintain therapeutic plasma concentration above 20 μg ml-1 .
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Affiliation(s)
- Ralph Gertler
- Klinik für Anaesthesie, operative und allgemeine Intensivmedizin, Notfallmedizin, Klinikum Links der Weser, University Medical Center Hamburg-Eppendorf, Bremen, Germany.,Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Michael Gruber
- Department of Anesthesia, University Hospital Regensburg, Regensburg, Germany
| | - Stanislas Grassin-Delyle
- Département des Maladies des Voies Respiratoires, Hôpital Foch, Université Versailles Saint Quentin en Yvelines, Université Paris Saclay, F-92150, Suresnes, France.,Plateforme de spectrométrie de masse et INSERM UMR1173, UFR Sciences de la Santé Simone Veil, Université Versailles Saint Quentin en Yvelines, Université Paris Saclay, F-78180, Montigny-le-Bretonneux, France
| | - Saïk Urien
- CIC1419 Inserm Necker-Cochin, URC Paris Descartes Necker Cochin, AP-HP, Paris, France.,EAU7323, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Klaus Martin
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Peter Tassani-Prell
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Siegmund Braun
- Institute of Laboratory Medicine, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Simon Burg
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Gunther Wiesner
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
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Arantes GC, Pereira RMR, de Melo DB, Alonso N, Duarte MDCMB. Effectiveness of tranexamic acid for reducing intraoperative bleeding in palatoplasties: A randomized clinical trial. J Craniomaxillofac Surg 2016; 45:642-648. [PMID: 28318926 DOI: 10.1016/j.jcms.2016.12.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 11/27/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Few data are available regarding blood loss during cleft palate surgery. This study assessed the effect of using tranexamic acid in the reduction of intraoperative bleeding. METHODS A double-blind, randomized clinical trial compared intraoperative bleeding and the incidence of oronasal fistulas after palatoplasties in a control group that was given placebo and an intervention group that was given 10 mg/kg tranexamic acid followed by a continuous infusion of 1 mg/kg/h of the same until the end of surgery. Patients who underwent primary palatoplasty with no known or suspected coagulation disorders at our institution during the study period were included in the study. RESULTS 70 patients were allocated, 66 received the intervention. Blood loss was reduced by 11.9%, without statistical significance. The incidence of fistulas in the intervention and control groups was 12.9% and 18.75%, respectively. The reduction of 5.8% (CI 95%: 12%-23.8%) was not significant. CONCLUSIONS The reduction of intraoperative blood loss was lower than expected and not statistically significant; a larger sample is needed to confirm the observed reduction. The drug did not seem to have negative effects on flap viability.
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Affiliation(s)
- Guilherme C Arantes
- Department of Plastic Surgery of the Professor Fernando Figueira Integral Medicine Institute (Instituto de Medicina Integral Prof. Fernando Figueira), Recife, Pernambuco (PE), Brazil.
| | - Rui Manoel R Pereira
- Plastic Surgery of the Professor Fernando Figueira Integral Medicine Institute (Instituto de Medicina Integral Prof. Fernando Figueira) (Head: Prof. Rui Manoel R. Pereira), Recife, PE, Brazil
| | - Daniela B de Melo
- Department of Plastic Surgery of the Professor Fernando Figueira Integral Medicine Institute (Instituto de Medicina Integral Prof. Fernando Figueira), Recife, PE, Brazil
| | - Nivaldo Alonso
- Postgraduate Program Sensu Stricto of the University of Sao Paulo (Universidade de Sao Paulo - USP), Brazil
| | - Maria do Carmo M B Duarte
- Postgraduate Program Sensu Stricto of the Professor Fernando Figueira Integral Medicine Institute (Instituto de Medicina Integral Prof. Fernando Figueira), Recife, PE, Brazil
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Sidlik R, Strauss T, Morag I, Shenkman B, Tamarin I, Lubetsky A, Livnat T, Kenet G. Assessment of Functional Fibrinolysis in Cord Blood Using Modified Thromboelastography. Pediatr Blood Cancer 2016; 63:839-43. [PMID: 26749087 DOI: 10.1002/pbc.25865] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/10/2015] [Accepted: 11/13/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND The fibrinolytic system in newborns is immature and probably impaired. The aim of this study was to prospectively evaluate functional fibrinolytic capacity of newborn's cord blood using a new thromboelastometry (rotational thromboelastogram, ROTEM®) test. METHODS Infants born at Sheba Medical Center were studied prospectively. Cord blood was obtained immediately after clumping, and ROTEM parameters were assessed applying non-activated TEM (NATEM) assay with increasing concentration of tissue plasminogen activator (tPA, 0-200 U/ml). Baseline clotting time (CT), clot formation time (CFT), alpha angle, and maximum clot firmness (MCF) were compared among infants versus adults. Each infant's demographic information was prospectively followed up until discharge. RESULTS One hundred one newborns were tested. CT and CFT values were lower and alpha angles were higher among neonate's cord blood compared to adults (n = 23; P = 0.001, 0.03, and 0.02, respectively). The addition of tPA significantly shortened CT and CFT, and reduced alpha angles and MCF in both groups. The lysis index at 30 min (LI30) and lysis onset time (LOT) decreased significantly, and fibrinolysis was more rapid in the newborns. Hematocrit and platelet counts in neonates correlated with LI30 (P = 0.035 and 0.037, respectively) and LOT (P = 0.02) when higher tPA concentrations were used. ROTEM values were unrelated to the occurrence of postnatal complications. CONCLUSIONS This first report of functional fibrinolysis in cord blood demonstrated that neonatal fibrinolysis may be augmented as compared to adult values. Further studies are required to validate this test and assess its predictive value and clinical relevance.
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Affiliation(s)
- Rakefet Sidlik
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Tzipora Strauss
- Neonatology Department, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iris Morag
- Neonatology Department, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boris Shenkman
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Ilia Tamarin
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Aharon Lubetsky
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Tami Livnat
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Gili Kenet
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
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Effective tranexamic acid concentration for 95% inhibition of tissue-type plasminogen activator induced hyperfibrinolysis in children with congenital heart disease. Eur J Anaesthesiol 2015; 32:844-50. [DOI: 10.1097/eja.0000000000000316] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Ausen K, Fossmark R, Spigset O, Pleym H. Randomized clinical trial of topical tranexamic acid after reduction mammoplasty. Br J Surg 2015; 102:1348-53. [PMID: 26349843 PMCID: PMC4600231 DOI: 10.1002/bjs.9878] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 03/16/2015] [Accepted: 05/18/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND The antifibrinolytic drug tranexamic acid is currently being rediscovered for both trauma and major surgery. Intravenous administration reduces the need for blood transfusion and blood loss by about one-third, but routine administration in surgery is not yet advocated owing to concerns regarding thromboembolic events. The aim of this study was to investigate whether topical application of tranexamic acid to a wound surface reduces postoperative bleeding. METHODS This was a randomized double-blind placebo-controlled trial on 30 consecutive women undergoing bilateral reduction mammoplasty. On one side the wound surfaces were moistened with 25 mg/ml tranexamic acid before closure, and placebo (saline) was used on the other side. Drain fluid production was measured for 24 h after surgery, and pain was measured after 3 and 24 h. Postoperative complications including infection, seroma, rebleeding and suture reactions were recorded. RESULTS Topical application of tranexamic acid to the wound surface after reduction mammoplasty reduced drain fluid production by 39 per cent (median 12·5 (range 0-44) versus 20·5 (0-100) ml; P = 0·038). Adverse effects were not observed. There were no significant differences in postoperative pain scores or complications. CONCLUSION Topical application of dilute tranexamic acid reduced bleeding in this model. The study adds to the evidence that this simple procedure may reduce wound bleeding after surgery. REGISTRATION NUMBER NCT01964781 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- K Ausen
- Departments of Plastic and Reconstructive Surgery, St Olav's University Hospital, Trondheim, Norway
| | - R Fossmark
- Departments of Internal Medicine, St Olav's University Hospital, Trondheim, Norway
- Departments of Cancer Research and Molecular Medicine, Children's and Women's Health, Trondheim, Norway
| | - O Spigset
- Departments of Clinical Pharmacology, St Olav's University Hospital, Trondheim, Norway
- Departments of Laboratory Medicine, Children's and Women's Health, Trondheim, Norway
| | - H Pleym
- Clinic of Anaesthesia and Intensive Care, St Olav's University Hospital, Trondheim, Norway
- Departments of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Faraoni D, Van der Linden P, Ducloy-Bouthors AS, Goobie SM, DiNardo JA, Nielsen VG. Quantification of Fibrinolysis Using Velocity Curves Measured with Thromboelastometry in Children with Congenital Heart Disease. Anesth Analg 2015; 121:486-91. [DOI: 10.1213/ane.0000000000000795] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Abstract
Antifibrinolytic therapy reduces bleeding and chest tube drainage output in cardiac surgical patients but is associated with potential side effects. Two phase-II studies with new compounds were terminated prematurely. There is increasing evidence of adverse side effects with tranexamic acid.
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Experimental model of hyperfibrinolysis designed for rotational thromboelastometry in children with congenital heart disease. Blood Coagul Fibrinolysis 2015; 26:290-7. [DOI: 10.1097/mbc.0000000000000238] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pharmacokinetics of Tranexamic Acid in Neonates, Infants, and Children Undergoing Cardiac Surgery with Cardiopulmonary Bypass. Anesthesiology 2015; 122:746-58. [DOI: 10.1097/aln.0000000000000570] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract
Background:
Tranexamic acid (TXA) is one of the most commonly used antifibrinolytic medications in children undergoing repair of congenital heart defects. However, a pharmacokinetics analysis of TXA has never been performed in neonates or young children undergoing complex cardiac surgeries using cardiopulmonary bypass, hypothermia, circulatory arrest, and ultrafiltration. A comprehensive pharmacokinetics study was performed in this patient population.
Methods:
Fifty-five patients ranging from 2 days through 4 yr old were categorized into three groups: children less than 2 months old, infants 2 months to 1 yr old, and children greater than 1 yr old and weighing up to 20 kg. TXA was given as a bolus of 100 mg/kg followed by an infusion of 10 mg · kg−1 · h−1 throughout the surgery. A dose of 100 mg/kg was placed in the cardiopulmonary bypass prime. A total of 16 to 18 samples were obtained from all patients throughout surgery. Plasma TXA concentrations were measured by high-performance liquid chromatography and modeled under a nonlinear mixed-effects framework with a two-compartment structural model.
Results:
Cardiopulmonary bypass had a statistically significant impact on all pharmacokinetic parameters. Age was a better covariate than body weight, affecting both the distribution and the elimination of TXA. However, weight performed well in some cases. Other covariates including body surface area, pump prime volume, ultrafiltrate volume, and body temperature did not improve the model.
Conclusions:
This TXA pharmacokinetic analysis is reported for the first time in neonates and young children undergoing complex cardiac surgeries with cardiopulmonary bypass. Dosing recommendations are provided as guidance for maintaining desired target concentrations.
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Raveendran R, Wong J. Tranexamic acid reduces surgical bleeding: does one size fit all? ACTA ACUST UNITED AC 2013; 19:e12. [PMID: 24288175 DOI: 10.1136/eb-2013-101584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Raviraj Raveendran
- Department of Anesthesia, Toronto Western Hospital, University of Toronto, , Toronto, Ontario, Canada
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Faraoni D, Goobie SM. New Insights About the Use of Tranexamic Acid in Children Undergoing Cardiac Surgery. Anesth Analg 2013; 117:760-762. [DOI: 10.1213/ane.0b013e3182a22278] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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