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O'Donnell O, Gallagher C, Davey MG, Coulter J, Regan M. A systematic review and meta-analysis assessing the use of tranexamic acid (TXA) in acute gastrointestinal bleeding. Ir J Med Sci 2024; 193:705-719. [PMID: 37794272 PMCID: PMC10961292 DOI: 10.1007/s11845-023-03517-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/04/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Gastrointestinal bleeding results in significant morbidity, cost and mortality. TXA, an antifibrinolytic agent, has been proposed to reduce mortality; however, many studies report conflicting results. METHODS The aim of the study was to perform the first systematic review and meta-analysis of RCTs to evaluate the efficacy TXA for both upper and lower gastrointestinal bleeding. This was performed per PRISMA guidelines. PubMed, EMBASE, Cochrane and Scopus databases were searched for RCTs. Dichotomous variables were pooled as risk ratios (RR) with 95% confidence intervals (CI) using the MH method with random effects modelling. RESULTS Fourteen RCTs were identified with 14,338 patients and mean age of 58.4 years. 34.9% (n = 5008) were female and 65.1% (n = 9330) male. There was no significant difference in mortality between TXA and placebo (RR 0.86 95% CI (0.74 to 1.00), P: 0.05). The secondary outcomes, similarly, did not yield significant results. These included rebleeding, need for surgical intervention (RR: 0.75 95% CI (0.53, 1.07)), endoscopic intervention (RR: 0.92 95% CI (0.70, 1.22)), transfusion requirement (RR: 1.01 95% CI (0.94, 10.7)) and length of stay (RR: 0.03 95% CI (- 0.03, 0.08)). There was no increased risk of VTE, RR: 1.29 95% CI (0.53, 3.16). One trial (n = 12,009) reported an increased risk of seizure in the TXA group, RR: 1.73 95% CI (1.03-2.93). CONCLUSION TXA does not reduce mortality in patients with acute upper or lower gastrointestinal bleeding and may confer an increased risk of seizures. The authors do not recommend the use of TXA in acute gastrointestinal bleeding.
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Affiliation(s)
- Oisín O'Donnell
- Department of General and Colorectal Surgery, Galway University Hospitals, Saolta University Health Care Group, Newcastle Road, Galway, H91YR71, Ireland.
- School of Postgraduate Studies, Royal College of Surgeon in Ireland, Dublin, D02YN77, Ireland.
| | - Clodagh Gallagher
- University of Limerick, Sreelane, Castletroy, Co., Limerick, V94 T9PX, Ireland
| | - Matthew G Davey
- Department of General and Colorectal Surgery, Galway University Hospitals, Saolta University Health Care Group, Newcastle Road, Galway, H91YR71, Ireland
- The National University of Ireland Galway, University Rd, Galway, H91TK33, Ireland
| | - Jonathan Coulter
- Department of General and Colorectal Surgery, Galway University Hospitals, Saolta University Health Care Group, Newcastle Road, Galway, H91YR71, Ireland
| | - Mark Regan
- Department of General and Colorectal Surgery, Galway University Hospitals, Saolta University Health Care Group, Newcastle Road, Galway, H91YR71, Ireland
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Shaw J, Zakhary B, Coimbra R, Moore L, Scalea T, Kundi R, Teeter W, Romagnoli A, Moore E, Sauaia A, Dennis B, Brenner M. Use of Tranexamic Acid With Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated With Higher Distal Embolism Rates: Results From the American Association of Surgery for Trauma Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery Trial. Am Surg 2023; 89:4208-4217. [PMID: 37431165 DOI: 10.1177/00031348231177918] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) use has been associated with thrombotic complications. OBJECTIVE We aim to investigate outcomes associated with TXA use in the setting of high- (HP) and low-profile (LP) introducer sheaths for resuscitative endovascular balloon occlusion of the aorta (REBOA). PARTICIPANTS The Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery (AORTA) database was queried for patients who underwent REBOA using a low-profile 7 French (LP) or high-profile, 11-14 French (HP) introducer sheaths between 2013 and 2022. Demographics, physiology, and outcomes were examined for patients who survived beyond the index operation. RESULTS 574 patients underwent REBOA (503 LP, 71 HP); 77% were male, mean age was 44 ± 19 and mean injury severity score (ISS) was 35 ± 16. 212 patients received TXA (181 [36%] LP, 31 [43.7%] HP). There were no significant differences in admission vital signs, GCS, age, ISS, SBP at AO, CPR at AO, and duration of AO among LP and HP patients. Overall, mortality was significantly higher in the HP (67.6%) vs the LP group (54.9%; P = .043). Distal embolism was significantly higher in the HP group (20.4%) vs the LP group (3.9%; P < .001). Logistic regression demonstrated that TXA use was associated with a higher rate of distal embolism in both groups (OR = 2.92; P = .021). 2 LP patients (one who received TXA) required an amputation. CONCLUSION Patients who undergo REBOA are profoundly injured and physiologically devastated. Tranexamic acid was associated with a higher rate of distal embolism in those who received REBOA, regardless of access sheath size. For patients receiving TXA, REBOA placement should be accompanied by strict protocols for immediate diagnosis and treatment of thrombotic complications.
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Affiliation(s)
| | - Bishoy Zakhary
- Riverside University Health System, Department of Surgery, 26520 Cactus Ave, Moreno Valley, CA 92555
| | - Raul Coimbra
- Riverside University Health System, Department of Surgery, 26520 Cactus Ave, Moreno Valley, CA 92555
| | - Laura Moore
- University of Texas Health Science Center at Houston (UTHealth), Department of Surgery, 6431 Fannin Street, Houston TX 77030
| | - Thomas Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - William Teeter
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Anna Romagnoli
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Ernest Moore
- University of Colorado Anschutz Medical Campus, Department of Surgery, 12631 East 17th Avenue, Aurora, CO 80045
| | - Angela Sauaia
- University of Colorado Anschutz Medical Campus, Department of Surgery, 12631 East 17th Avenue, Aurora, CO 80045
| | - Bradley Dennis
- Vanderbilt University Medical Center, Division of Acute Care Surgery, 1161 21st,Avenue South, Medical Center North, D-5203, Nashville, TN 37232
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Kivlehan SM, Hexom BJ, Bonney J, Collier A, Nicholson BD, Quao NSA, Rybarczyk MM, Selvam A, Rees CA, Roy CM, Bhaskar N, Becker TK. Global emergency medicine: A scoping review of the literature from 2021. Acad Emerg Med 2022; 29:1264-1274. [PMID: 35913419 DOI: 10.1111/acem.14575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/17/2022] [Accepted: 07/26/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The objective was to identify the most important and impactful peer-reviewed global emergency medicine (GEM) articles published in 2021. The top articles are summarized in brief narratives and accompanied by a comprehensive list of all identified articles that address the topic during the year to serve as a reference for clinicians, researchers, and policy makers. METHODS A systematic PubMed search was carried out to identify all GEM articles published in 2021. Title and abstract screening was performed by trained reviewers and editors to identify articles in one of three categories based on predefined criteria: disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and emergency medicine development (EMD). Included articles were each scored by two reviewers using established rubrics for original (OR) and review (RE) articles. The top 5% of articles overall and the top 5% of articles from each category (DHR, ECRLS, EMD, OR, and RE) were included for narrative summary. RESULTS The 2021 search identified 44,839 articles, of which 444 articles screened in for scoring, 25% and 22% increases from 2020, respectively. After removal of duplicates, 23 articles were included for narrative summary. ECRLS constituted the largest category (n = 16, 70%), followed by EMD (n = 4, 17%) and DHR (n = 3, 13%). The majority of top articles were OR (n = 14, 61%) compared to RE (n = 9, 39%). CONCLUSIONS The GEM peer-reviewed literature continued to grow at a fast rate in 2021, reflecting the continued expansion and maturation of this subspecialty of emergency medicine. Few high-quality articles focused on DHR and EMD, suggesting a need for further efforts in those fields. Future efforts should focus on improving the diversity of GEM research and equitable representation.
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Affiliation(s)
- Sean M Kivlehan
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Humanitarian Initiative, Cambridge, Massachusetts, USA
| | - Braden J Hexom
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Joseph Bonney
- Department of Emergency Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Global Health and Infectious Disease Research Group, Kumasi Center for Collaborative Research in Tropical Medicine, Kumasi, Ghana
| | - Amanda Collier
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Benjamin D Nicholson
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Nana Serwaa A Quao
- Department of Emergency Medicine, Accident and Emergency Centre, Korle Bu Teaching Hospital, Accra, Ghana
| | - Megan M Rybarczyk
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anand Selvam
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Charlotte M Roy
- Department of Emergency Medicine, Loma Linda University, Loma Linda, California, USA
| | | | - Torben K Becker
- Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA
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