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Zhang Y, Zhao W, Hu M, Liu X, Peng Q, Meng B, Yang S, Feng X, Zhang L. The Efficacy and Safety of Topical Saline Irrigation with Tranexamic Acid on Perioperative Blood Loss in Patients Treated with Percutaneous Endoscopic Interlaminar Diskectomy: A Retrospective Study. J Neurol Surg A Cent Eur Neurosurg 2024; 85:280-287. [PMID: 37586408 DOI: 10.1055/s-0043-1769127] [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: 08/18/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is safe and effective in preventing bleeding during spinal surgery. However, there is currently no relevant research on the efficacy and safety of adding TXA to the saline irrigation fluid in percutaneous endoscopic interlaminar diskectomy (PEID). This study aimed to evaluate the efficacy and safety of topical saline irrigation with TXA for PEID in the treatment of lumbar disk herniation. METHODS In this single-center, retrospective cohort study, patients who underwent PEID for L5-S1 lumbar disk herniation were included and allocated to two groups according to whether they had been administered TXA. PEID was performed with saline irrigation fluid containing 0.33 g of TXA per 1 L of saline in the TXA group (n = 38). In the control group (n = 51), the saline irrigation fluid was injected with the same volume of normal saline. All PEIDs were performed by the same spine surgery team. The hidden blood loss (HBL), intraoperative blood loss (IBL), total blood loss (TBL), amount of fluid used, operation time, visual clarity, hospital stay, blood transfusion rate, coagulation index, and complication rate were compared between the two groups. RESULTS The TBL, HBL, and IBL in the TXA group were significantly lower than those of the control group. The postoperative hemoglobin in the TXA group was significantly higher than that of the control group. Visual clarity was significantly better and the operation time was significantly shorter in the TXA group. However, there was no significant difference in postoperative hematocrit, blood coagulation function, amount of fluid used, blood transfusion rate, and perioperative complications between the two groups. CONCLUSION In PEID, the addition of TXA to topical saline irrigating fluid can significantly reduce the HBL, IBL, and TBL. The addition of TXA to topical saline irrigating fluid can improve visual clarity in the surgery and reduce operation time, but it does not change the coagulation function or the complication rate.
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Affiliation(s)
- Yu Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Wenjie Zhao
- Graduate School of Dalian Medical University, Dalian, China
| | - Man Hu
- Graduate School of Dalian Medical University, Dalian, China
| | - Xin Liu
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Qing Peng
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Bo Meng
- Graduate School of Dalian Medical University, Dalian, China
| | - Sheng Yang
- Graduate School of Dalian Medical University, Dalian, China
| | - Xinmin Feng
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Liang Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
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Tan G, Li J, Xu J, Zhu Y, Zhang H. The efficacy and safety of different does of intravenous tranexamic acid on blood loss in fresh foot and ankle fractures: a prospective, randomized controlled study. BMC Musculoskelet Disord 2024; 25:274. [PMID: 38589854 PMCID: PMC11003133 DOI: 10.1186/s12891-024-07410-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/02/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND There are a few studies on the effectiveness and safety of intravenous administration of tranexamic acid(TXA) in patients who underwent foot and ankle surgery, especially for preoperative hidden blood loss in patients with freshfoot and ankle fractures. Thus, the aim of this study was to investigate whether intravenous administration of different doses of TXA can effectively reduce perioperative blood loss and blood loss before surgery and to determine its safety. METHODS A total of 150 patients with fresh closed foot and ankle fractures from July 2021 to July 2023 were randomly divided into a control group (placebo controlled [PC]), standard-dose group (low-dose group [LD], 1 g/24 h; medium-dose group [MD], 2 g/24 h), and high-dose group (HD, 3 g/24 h; ultrahigh-dose group [UD], 4 g/24 h). After admission, all patients completed hematological examinations as soon as possible and at multiple other time points postsurgery. RESULTS There was a significant difference in the incidence of hidden blood loss before the operation between the TXA group and the control group, and the effect was greater in the overdose groups than in the standard-dose groups. There were significant differences in surgical blood loss (intraoperative and postoperative), postoperative HGB changes, and hidden blood loss among the groups. The TXA groups showed a significant decrease in blood loss compared to that of the control group, and the overdose groups had a more significant effect than the standard-dose groups. A total of 9 patients in the control group had early wound infection or poor healing, while only 1 patient in the other groups had this complication, and the difference among the groups was significant. No patients in any group suffered from late deep wound infection, cardiovascular or cerebrovascular events or symptomatic VTE. CONCLUSION This is the first study on whether TXA can reduce preoperative hidden blood loss in patients with freshfoot and ankle fractures. In our study, on the one hand, intravenous application of TXA after foot and ankle fractures as soon as possible can reduce preoperative blood loss and postoperative blood loss. On the other hand, TXA can also lower wound complications, and over-doses of TXA are more effective than standard doses. Moreover, overdoses of TXA do not increase the incidence of DVT.
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Affiliation(s)
- Gang Tan
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37 of Guoxue lane, Wuhou District, Chengdu, Sichuan, 610041, China
- Department of Orthopaedics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jia Li
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37 of Guoxue lane, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Jing Xu
- Operating Room, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yongzhan Zhu
- Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangdong, China.
| | - Hui Zhang
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37 of Guoxue lane, Wuhou District, Chengdu, Sichuan, 610041, China.
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Dong W, Tang Y, Lei M, Ma Z, Zhang X, Shen J, Hao J, Jiang W, Hu Z. The effect of perioperative sequential application of multiple doses of tranexamic acid on postoperative blood loss after PLIF: a prospective randomized controlled trial. Int J Surg 2024; 110:2122-2133. [PMID: 38215261 PMCID: PMC11020010 DOI: 10.1097/js9.0000000000001083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/27/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Tranexamic acid (TXA) has been utilized in spinal surgery to effectively reduce intraoperative blood loss (IBL) and allogeneic blood transfusion rates. However, the traditional TXA regimen might last the entire duration of hyperfibrinolysis caused by surgical trauma, resulting in its limited ability to reduce postoperative blood loss (PBL). Therefore, the aim of this study was to investigate the effectiveness of perioperative sequential administration of multiple doses of TXA in reducing PBL in patients who underwent posterior lumbar interbody fusion (PLIF). METHODS From October 2022 to June 2023, 231 patients who were diagnosed with lumbar degenerative disease and scheduled to undergo PLIF were prospectively enrolled in the present study. The patients were randomly divided into three groups. Moreover, all patients received an intravenous injection of TXA at a dose of 15 mg/kg 15 min before the surgical skin incision. Patients in Group A received a placebo of normal saline after surgery, while patients in Group B received three additional intravenous injections of TXA at a dose of 15 mg/kg every 24 h. Patients in Group C received three additional intravenous injections of TXA at a dose of 15 mg/kg every 5 h. The primary outcome measure was PBL. In addition, this study assessed total blood loss (TBL), IBL, routine blood parameters, liver and kidney function, coagulation parameters, fibrinolysis indexes, inflammatory indicators, drainage tube removal time (DRT), length of hospital stay (LOS), blood transfusion rate, and incidence of complications for all subjects. RESULTS The PBL, TBL, DRT, and LOS of Group B and Group C were significantly lower than those of Group A ( P <0.05). The level of D-dimer (D-D) in Group C was significantly lower than that in Group A on the first day after the operation ( P =0.002), and that in Group B was significantly lower than that in Group A on the third day after the operation ( P =0.003). The interleukin-6 levels between the three groups from 1 to 5 days after the operation were in the order of Group A > Group B > Group C. No serious complications were observed in any patient. The results of multiple stepwise linear regression analysis revealed that PBL was positively correlated with incision length, IBL, smoking history, history of hypertension, preoperative fibrinogen degradation product level, and blood transfusion. It was negatively correlated with preoperative levels of fibrinogen, red blood cells, blood urea nitrogen, and age. Compared to female patients, male patients had an increased risk of PBL. Finally, the incidence of PBL was predicted. CONCLUSIONS Sequential application of multiple doses of TXA during the perioperative period could safely and effectively reduce PBL and TBL, shorten DRT and LOS, reduce postoperative D-D generation, and reduce the postoperative inflammatory response. In addition, this study provided a novel prediction model for PBL in patients undergoing PLIF.
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Affiliation(s)
- Wei Dong
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Yuchen Tang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Miao Lei
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Zhaoxin Ma
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Xiaojun Zhang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Jieliang Shen
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Jie Hao
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Wei Jiang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
| | - Zhenming Hu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Orthopedic Laboratory of Chongqing Medical University
- Department of Orthopedics Surgery, University-Town Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
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Brown NJ, Hartke JN, Pacult M, Burkett KR, Gendreau J, Catapano JS, Lawton MT. Tranexamic Acid Demonstrates Efficacy without Increased Risk for Venous Thromboembolic Events in Cranial Neurosurgery: Systematic Review of the Evidence and Current Applications in Nontraumatic Pathologies. World Neurosurg 2024; 183:29-40. [PMID: 38052364 DOI: 10.1016/j.wneu.2023.11.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND The cautionary stance normally taken towards tranexamic acid (TXA) is rooted in concerns regarding its complication profile, namely its purported risk for venous thromboembolic events (VTEs). In the present review, we intend to bring increased attention to TXA as a remarkably valuable tool that does not appear to increase the risk for VTE when used as indicated in select patients. METHODS We queried three databases to identify reporting use of TXA during nontraumatic cranial neurosurgery procedures (excluded traumatic brain injury). Data gathered included VTE complications, deep venous thrombosis, use of allogeneic blood transfusions, estimated blood loss, and operative duration. RESULTS Twenty-eight studies were deemed eligible for inclusion in the present meta-analysis, including nine studies on surgical resection of intracranial neoplasms, ten studies on aneurysmal subarachnoid hemorrhage, and nine studies on craniosynostosis. In brain tumor surgery, TXA appears to successfully reduce blood loss without predisposing patients to VTE or seizure (P < 0.01). However, it does not appear to reduce rates of vasospasm in aneurysmal subarachnoid hemorrhage (P = 0.27), and its administration is not associated with clinically meaningful differences in long term neurological outcomes. For pediatric patients undergoing craniosynostosis procedures, TXA similarly reduces blood loss (P < 0.01). Nonetheless, low dosing protocols should be used because they appear effective and the effects of high dose TXA in children have not been studied. CONCLUSIONS TXA is an effective hemostatic agent that can be administered to reduce blood loss and transfusion requirements for a wide range of neurosurgical applications in a broad spectrum of patient populations.
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Affiliation(s)
- Nolan J Brown
- Department of Neurological Surgery, University of California-Irvine, Orange, California, USA
| | - Joelle N Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mark Pacult
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kyle R Burkett
- Department of Neurological Surgery, University of California-Irvine, Orange, California, USA
| | - Julian Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Mitha R, Colan JA, Hernandez-Rovira MA, Jawad-Makki MAH, Patel RP, Elsayed GA, Shaw JD, Okonkwo DO, Buell TJ, Hamilton DK, Agarwal N. Topical tranexamic acid (TXA) is non-inferior to intravenous TXA in adult spine surgery: a meta-analysis. Neurosurg Rev 2024; 47:48. [PMID: 38224410 DOI: 10.1007/s10143-023-02254-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 01/16/2024]
Abstract
Tranexamic acid (TXA) has long been utilized in spine surgery and can be administered through intravenous (IV) and topical routes. Although, topical and IV administration of TXA are both effective in decreasing blood loss during spine surgery, complications like deep vein thrombosis (DVT) and pulmonary embolism have been reported with the use of intravenous TXA (ivTXA). These potential complications may be mitigated through the use of topical TXA (tTXA). To assess optimal dosing protocols and efficacy of topical TXA in spine surgery, Embase, Ovid-MEDLINE, Scopus, Cochrane, and clinicaltrials.gov were queried for original research on the use of tTXA in adult patients undergoing spine surgery. Data parameters analyzed included blood loss, transfusion rate, thromboembolic, and other complications. Data was synthesized and confidence evaluated according to the Grades of Recommendation, Assessment, Development, and Evaluation approach. Nineteen studies were included in the final analysis with 2197 patients. Of the 18 published studies, 9 (50%) displayed high levels of evidence. Topical TXA showed a trend towards a lower risk of transfusion and complications. Protocols that used 1g tTXA showed a significantly reduced risk for transfusion when compared to controls (risk ratio -1.05, 95% CI (-1.62, -0.48); P = 0.94, I2 = 0%). Complications associated with tTXA included DVTs and wound infections. Topical TXA was non-inferior to intravenous TXA with similar efficacy and complication profiles for bleeding control in spine surgery; however, more studies are needed to discern benefits and risks.
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Affiliation(s)
- Rida Mitha
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
| | - Jhair Alejandro Colan
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
| | | | - Mohamed-Ali H Jawad-Makki
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
| | - Rujvee P Patel
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Galal A Elsayed
- Och Spine, Weill Cornell Medicine, New-York Presbyterian Hospital, New York, NY, 10065, USA
| | - Jeremy D Shaw
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA.
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA.
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Tang X, Li K, Zheng F, He Y, Yang Y, Wang D. The effect of perioperative tranexamic acid (TXA) in patients with calcaneal fractures: a meta-analysis and systematic review of randomized controlled trials. J Orthop Surg Res 2023; 18:495. [PMID: 37438798 DOI: 10.1186/s13018-023-03924-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/11/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Calcaneal fractures are a common orthopedic disease, account for approximately 2% of all bone fractures, and represent 60% of fractures of tarsal bones. Tranexamic acid (TXA) is a synthetic antifibrinolytic drug that competitively blocks the lysine-binding sites of plasminogen, plasmin, and tissue plasminogen activator, delaying fibrinolysis and blood clot degradation. However, the effect of TXA on patients with calcaneal surgery remains controversial. Our objective was to evaluate the effectiveness of TXA in calcaneal fractures surgeries. METHODS The electronic literature databases of Pubmed, Embase, and Cochrane library were searched in December 2022. The data on blood loss, the stay in the hospital, the duration of surgery, hemoglobin, hematocrit, platelet count, prothrombin time, activated partial thromboplastin time, and wound complication were extracted. The Stata 22.0 software was used for the meta-analysis. RESULTS Four randomized controlled studies met our inclusion criteria. This meta-analysis showed that TXA significantly reduced postoperative blood loss during the first 24 h (p < 0.001), improved the level of hemoglobin (p < 0.001) and hematocrit (p = 0.03), and reduced the risk of wound complications (p = 0.04). There was no significant difference between the two groups regarding total and intraoperative blood loss, hospital stay, duration of surgery, platelet count, activated partial thromboplastin time, and prothrombin time. CONCLUSION TXA significantly reduced blood loss during the first 24 h postoperatively, improved the level of hemoglobin and hematocrit, and reduced the risk of wound complications. Given the evidence, TXA can be used in patients with calcaneal fractures and had the potential benefit of blood reduction. PROTOCOL REGISTRATION The protocol was registered in PROSPERO (registration No. CRD42023391211).
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Affiliation(s)
- Xiumei Tang
- Department of Respiratory and Critical Care Medicine, Med-X Center for Manufacturing, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
- Health Management Center, General Practice Medical Center, West China Hospital, Sichuan University/Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Kai Li
- Department of Respiratory and Critical Care Medicine, Med-X Center for Manufacturing, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
- Department of Pulmonary and Critical Care Medicine, Chengdu Third People's Hospital, Southwest Jiaotong University, Chengdu, 610031, Sichuan, People's Republic of China
- Department of Respiratory Medicine, The People's Hospital of Pujiang County, Chengdu, 611630, Sichuan, People's Republic of China
| | - Fuyuan Zheng
- Department of Undergraduate Students, West China School of Medicine, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yue He
- Department of Orthopaedics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Yang Yang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China.
| | - Duan Wang
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, 610041, People's Republic of China.
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Hmidan Simsam M, Delorme L, Grimm D, Priestap F, Bohnert S, Descoteaux M, Hilsden R, Laverty C, Mickler J, Parry N, Rochwerg B, Sherman C, Smith S, Toole J, Vogt K, Wilson S, Ball I. Efficacy of high dose tranexamic acid (TXA) for hemorrhage: A systematic review and meta-analysis. Injury 2023; 54:857-870. [PMID: 36746710 DOI: 10.1016/j.injury.2022.12.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Standard dose (≤ 1 g) tranexamic acid (TXA) has established mortality benefit in trauma patients. The role of high dose IV TXA (≥2 g or ≥30 mg/kg as a single bolus) has been evaluated in the surgical setting, however, it has not been studied in trauma. We reviewed the available evidence of high dose IV TXA in any setting with the goal of informing its use in the adult trauma population. METHODS We searched MEDLINE, EMBASE and unpublished sources from inception until July 27, 2022 for studies that compared standard dose with high dose IV TXA in adults (≥ 16 years of age) with hemorrhage. Screening and data abstraction was done independently and in duplicate. We pooled trial data using a random effects model and considered randomized controlled trials (RCTs) and observational cohort studies separately. We assessed the individual study risk of bias using the Cochrane Risk of Bias for RCTs and the Newcastle-Ottawa Scale for observational cohort studies. The overall certainty of evidence was assessed using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation). RESULTS We included 20 studies with a combined total of 12,523 patients. Based on pooled RCT data, and as compared to standard dose TXA, high dose IV TXA probably decreases transfusion requirements (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.76 to 0.97, moderate certainty) but with possibly no effect on blood loss (mean difference [MD] 43.31 ml less, 95% CI 135.53 to 48.90 ml less, low certainty), and an uncertain effect on thromboembolic events (OR 1.33, 95% CI 0.86 to 2.04, very low certainty) and mortality (OR 0.70, 95% CI 0.37 to 1.32, very low certainty). CONCLUSION When compared to standard dose, high dose IV TXA probably reduces transfusion requirements with an uncertain effect on thromboembolic events and mortality. LEVEL OF EVIDENCE Systematic review and meta-analysis, level IV.
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Affiliation(s)
- Mohammad Hmidan Simsam
- Schulich School of Medicine and Dentistry, Western University, 1397 Medway Park Dr, London, Ontario N6G 0Z6, Canada.
| | - Laurence Delorme
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Dylan Grimm
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Fran Priestap
- London Health Sciences Centre Trauma Program, London, Ontario, Canada
| | | | | | - Rich Hilsden
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Royal Canadian Medical Service, Canada; Department of Surgery, Western University, London, Ontario, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada
| | | | | | - Neil Parry
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada
| | - Bram Rochwerg
- Department of Medicine, MacMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Shane Smith
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Royal Canadian Medical Service, Canada; Department of Surgery, Western University, London, Ontario, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada
| | | | - Kelly Vogt
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada
| | | | - Ian Ball
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Royal Canadian Medical Service, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Cao Z, Li Q, Guo J, Li Y, Wu J. Optimal administration strategies of tranexamic acid to minimize blood loss during spinal surgery: results of a Bayesian network meta-analysis. Ann Med 2022; 54:2053-2063. [PMID: 35862264 PMCID: PMC9307111 DOI: 10.1080/07853890.2022.2101687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Tranexamic acid (TXA) has been widely used for bleeding reduction in spinal surgery. Available evidence is insufficient to inform clinical decisions making and there remains a lack of comprehensive comparisons of dose regimens and delivery routes. This study is aimed to assess and compare different strategies regarding the involvement of TXA in spinal surgery for the optimal pathway of efficacy and safety. MATERIALS AND METHODS Cochrane Library, PubMed, Embase, Scopus and CNKI were searched for the period from January 1990 to October 2021. A random-effect model was built in the Bayesian network meta-analysis. The surface under the cumulative ranking analysis (SUCRA) and clustering rank analysis was performed for ranking the effects. RESULTS The current network meta-analysis incorporated data from 33 studies with 3302 patients. Combination administration showed superior effects on reducing intraoperative bleeding (SUCRA 78.78%, MD -129.67, 95% CI [(-222.33, -40.58)]) than placebo, and was ranked as top in reducing postoperative bleeding (SUCRA 86.91%, MD -169.92, 95% CI [(-262.71, -83.52)]), changes in haemoglobin (SUCRA 97.21%, MD -1.28, 95% CI [(-1.84, -0.73)]), and perioperative blood transfusion (SUCRA 93.23%, RR 0.10, 95% CI [(0.03, 0.25)]) simultaneously, and was shown as the best effectiveness and safety (cluster-rank value for IBL and VTE: 4057.99 and for TRF and VTE: 4802.26). CONCLUSIONS Intravenous (IV) plus topical administration of TXA appears optimal in the reduction of perioperative bleeding and blood transfusion, while the local infiltration administration is not effective for blood conservation. Further studies are required to verify the current findings.
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Affiliation(s)
- Ziqin Cao
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha, P. R. China
| | - Qiangxiang Li
- Ningxia Geriatric Disease Clinical Research Center, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, P. R. China.,National Clinical Research Center for Geriatric Disorders of Xiangya Hospital, Central South University (Sub-Center of Ningxia), Yinchuan, P. R. China.,Department of Hunan Institute of Geriatrics, Hunan People's Hospital, Changsha, P. R. China
| | - Jia Guo
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, P. R. China
| | - Yajia Li
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, P. R. China
| | - Jianhuang Wu
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha, P. R. China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, P. R. China
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Du W, Wang HX, Zhang JT, Wang F, Zhang X, Shen Y, Chen R, Zhang L. Cervical alignment and clinical outcome of anterior decompression with fusion vs. posterior decompression with fixation in kyphotic cervical spondylotic myelopathy. Front Neurosci 2022; 16:1029327. [PMID: 36507328 PMCID: PMC9728799 DOI: 10.3389/fnins.2022.1029327] [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] [Received: 08/27/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
Background context Cervical kyphosis is a common but potentially debilitating and challenging condition. There is controversy on the optimal surgical strategy for the treatment of kyphotic cervical spondylotic myelopathy (KCSM) using either anterior approach or posterior approach. Introduction The purpose of this study was to investigate the surgical efficacy of anterior decompression with fusion (ADF) vs. posterior decompression with fixation (PDF) for the treatment of KCSM, and to further analyze the changes of cervical spinal alignment parameters and axial symptoms (AS) severity after kyphotic correction. Materials and methods We retrospectively reviewed 117 patients with KCSM who had undergone ADF (58 patients) and PDF (59 patients) between January 2016 and December 2020. Cervical spinal alignment parameters, including curvature index (CI) and C2-7 Cobb angle, were measured on the PreOP and PostOP lateral radiographs. Recovery rate was calculated based on the Japanese Orthopedic Association (JOA) score. AS severity was quantified by Neck Disability Index (NDI). A P-value less than 0.05 was considered to be significant. Results The patient mean age, gender, presenting symptoms and follow-up time were similar between the two groups (P > 0.05). However, there were statistically significant differences (P < 0.001) between the two groups regarding the operation levels, operating time and intraoperative blood loss. Analysis of PostOP follow-up data showed significant differences (P < 0.001) in CI, correction of CI, C2-7 Cobb angle, and NDI between the two groups, whereas no significant differences in JOA score (P = 0.16) and recovery rate (P = 0.14). There were significant differences (P < 0.001) in CI, C2-7 Cobb angle, JOA score, and NDI between PreOP and PostOP follow-up in each group. Correction of CI showed positive correlation with recovery of NDI in Group ADF (r = 0.51, P < 0.001), and in Group PDF (r = 0.45, P < 0.001). Conclusion Satisfied neurological improvement was obtained by ADF and PDF for patients with KCSM. Cervical kyphotic correction caused significant improvement of AS, and was more favorable with ADF than with PDF. Surgeons should pay full consideration of the merits and shortcomings of each approach when deciding on a surgical plan.
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Affiliation(s)
- Wei Du
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hai-Xu Wang
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jing-Tao Zhang
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Feng Wang
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xu Zhang
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yong Shen
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Rong Chen
- Department of Neurology, Hebei Key Laboratory of Vascular Homeostasis, Hebei Collaborative Innovation Center for Cardio-Cerebrovascular Disease, The Second Hospital of Hebei Medical University, Shijiazhuang, China,*Correspondence: Rong Chen,
| | - Li Zhang
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, China,Li Zhang,
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Kanhere AP, Lambrechts MJ, Issa TZ, Karamian BA, Hendow CJ, Reddy YC, Slota PJ, D'Antonio ND, Kaye ID, Canseco JA, Woods BI, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. The Effect of Tranexamic Acid on Operative and Postoperative Blood Loss in Transforaminal Lumbar Interbody Fusions. World Neurosurg 2022; 166:e443-e450. [PMID: 35840090 DOI: 10.1016/j.wneu.2022.07.020] [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: 05/18/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The purpose of this retrospective cohort study was to evaluate the effect of tranexamic acid (TXA) on reducing perioperative blood loss and length of stay after transforaminal lumbar interbody fusion (TLIF). Spine surgery is associated with the potential for significant blood loss, and adequate hemostasis is essential to visualizing crucial structures during the approach and procedure. Although TXA use has been extensively studied in the pediatric and adult spinal deformity literature, there is a dearth of literature on its efficacy in reducing blood loss for patients who undergo 1- to 3-level TLIF. METHODS All patients requiring 1- to 3-level TLIF who received a preoperative loading dose of TXA were grouped and compared with patients who didn't receive TXA. Demographic, surgical, and laboratory values were collected and analyzed. Continuous and categorical variables were analyzed with χ2, Kruskal-Wallis, or analysis of variance tests, depending on normality and data type. Multiple linear regressions were developed to determine independent predictors of the estimated blood loss (EBL), total blood loss, drain output, and length of stay. Statistical significance was set at P < 0.05. RESULTS Patients who received preoperative TXA had more comorbidities (P = 0.006), longer surgery length (P < 0.001), and longer length of stay (P = 0.004). TXA was independently associated with a decreased day 0, 1, 2, and total drain output (P < 0.001, P = 0.001, P = 0.007, P < 0.001, respectively), but was not associated with a change in EBL, total blood loss, or length of stay. CONCLUSIONS The application of preoperative TXA for patients undergoing 1- to 3-level TLIF reduced drain output in the first 2 postoperative days, but it did not affect hospital length of stay, total blood loss, or EBL.
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Affiliation(s)
- Arun P Kanhere
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Tariq Ziad Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Chelsea J Hendow
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yashas C Reddy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Paul J Slota
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nicholas D D'Antonio
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Beyer RS, Hatter MJ, Streetman D. Encouragement for Further Study of Tranexamic Acid Administration for Sacroiliac Joint Fusion Surgery. Geriatr Orthop Surg Rehabil 2022; 13:21514593221098606. [PMID: 35557600 PMCID: PMC9087243 DOI: 10.1177/21514593221098606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 11/20/2022] Open
Abstract
TO THE EDITOR: We read with great interest the article by Huynh et al.regarding the
association between tranexamic acid (TXA) and blood loss in patients undergoing surgical
treatment for hip fracture (Huynh PAN, Miller M, Will R. Intravenous Tranexamic Acid
Decreases Blood Transfusions and Blood Loss for Patients with Surgically Treated Hip
Fractures. Geriatric Orthopedic Surg Rehabil. 2021). The authors illustrated, via
retrospective chart review of 505 patients who were surgically treated for hip fractures,
that patients administered TXA had statistically significant decreases in perioperative
blood loss and reduced relative risk of transfusion. Huynh et al. reported no
statistically significant increases in thromboembolic events in patients given TXA.
Mechanistically, TXA is a synthetic anti-fibrinolytic that competitively inhibits the
plasminogen activation pathway. By preventing activated plasmin from de-stabilizing the
fibrin matrix, TXA promotes clot formation. Given the anti-fibrinolytic effects of TXA,
concerns in the literature exist regarding its use being associated with increased risk
for thromboembolic events. However, it is important to note the complication profile
associated with TXA is minimal, as elucidated by Brown et al., specifically finding that
no patients who were administered TXA perioperatively experienced a thromboembolic event
(or at least, there were no reports of thromboembolism or any other adverse events). While
administration of TXA may theoretically increase the risk for thrombosis, Brown et al.
showed this does not seem to occur in spinal laminectomy and fusion with posterior
instrumentation. Similarly, in a systematic review of the literature describing TXA use in
intracranial tumor resection, this study revealed a statistically significant reduction in
the need for intraoperative blood transfusion in patients administered TXA. Upon
consideration of postoperative outcomes, no significant increase in complication rate was
found. This evidence in the existing literature on TXA use in orthopedic, spinal, and
cranial neurosurgery exemplifies the wide potential of TXA for reducing blood loss with
minimal complications in surgical procedures, especially involving the craniospinal
axis.
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Affiliation(s)
- Ryan S Beyer
- Department of Neurological Surgery, University of California Irvine, Orange, CA, USA
| | - Matthew J Hatter
- Department of Neurological Surgery, University of California Irvine, Orange, CA, USA
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