The prophylactic role of tranexamic acid to reduce blood loss during radical surgery: A prospective study

Impact on blood loss and transfusion rates following administration of tranexamic acid in major oncological abdominal and pelvic surgery: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Major bleeding and receiving blood products in cancer surgery are associated with increased postoperative complications and worse outcomes. Tranexamic acid (TXA) reduces blood loss and improves outcomes in various surgical specialities. We performed a systematic review and meta-analysis to investigate TXA use on blood loss in elective abdominal and pelvic cancer surgery.

METHODS

A literature search was performed for studies comparing intravenous TXA versus placebo/no TXA in patients undergoing major elective abdominal or pelvic cancer surgery.

RESULTS

Twelve articles met the inclusion criteria, consisting of 723 patients who received TXA and 659 controls. Patients receiving TXA were less likely to receive a red blood cell (RBC) transfusion (p < 0.001, OR 0.4 95% CI [0.25, 0.63]) and experienced less blood loss (p < 0.001, MD -197.8 ml, 95% CI [-275.69, -119.84]). The TXA group experienced a smaller reduction in haemoglobin (p = 0.001, MD -0.45 mmol/L, 95% CI [-0.73, -0.18]). There was no difference in venous thromboembolism (VTE) rates (p = 0.95, OR 0.98, 95% CI [0.46, 2.08]).

CONCLUSIONS

TXA use reduced blood loss and RBC transfusion requirements perioperatively, with no significant increased risk of VTE. However, further studies are required to assess its benefit for cancer surgery in some sub-specialities.

Use of tranexamic acid in bleeding control of transabdominal and transvaginal hysterectomy

Background:

Hysterectomy is one of the most common gynecology surgeries. This study aimed to compare perioperative bleeding in transabdominal and transvaginal hysterectomy.

Materials and Methods:

This prospective, double-blind, randomized, controlled clinical trial was performed on 80 patients undergoing hysterectomy referred to Shahid Beheshti Hospital, Isfahan, Iran. Patients were divided into two groups of 40; the first group (T) received 1 g intravenous tranexamic acid (TXA) for 20 min preoperatively. The second group (S) received 10 cc normal saline as placebo. Blood samples were taken before and 12 h after surgery for assessment of hemoglobin, hematocrit, and platelet count, the prothrombin time, activated partial thromboplastin time, and serum creatinine as well as volume of blood transfusion.

Results:

There were no significant differences between the two groups in heart rate, diastolic blood pressure (BP), systolic BP, and mean arterial pressure before, during, and after surgery (P > 0.05). There was no significant difference in blood variables before and after surgery (P > 0.05) except the platelet count that was in the normal range in both groups after surgery (P = 0.022). The mean volume of blood transfused in the case group was significantly lower than the control group during surgery (P = 0.008) and 12 h after surgery (P = 0.01).

Conclusion:

The prophylactic administration of TXA results in a significant reduction in need for blood transfusion and the duration of surgery. Given the lower risks of using TXA compared to the other drugs, it is recommended in hysterectomy to control bleeding.

Role of tranexamic acid in reducing perioperative blood loss in transthoracic esophagectomy

Background and objectives: Transthoracic esophagectomy is usually associated with significant perioperative bleeding and blood loss. The present study investigated the role of prophylactic tranexamic acid on intra- and postoperative blood loss and the need for blood transfusion in transthoracic esophagectomy (Ivor Lewis esophagectomy). Materials and Methods: Patients who underwent laparotomy and right thoracotomy with intrathoracic anastomosis for esophageal malignancy were enrolled in the study. The enrolled cases were divided into two groups namely Group A and B. Informed consents were obtained from all the enrolled patients. Group A patients received a standard dose of 1 gram of intravenous tranexamic acid one hour before the beginning of surgery while Group B patients did not receive any tranexamic acid before or after the surgery. Peroperative blood loss was estimated and noted. Post-operative blood loss was assessed from the surgical drains. Results: A total of 55 cases were included in the study. Group A and B had 27 and 28 cases respectively. The mean age of the Group A and Group B patients was 60.1 ± 6.2 and 60 ± 6.9 years respectively. Out of 27 cases in Group A, 7 (25%) patients had a postoperative haemorrhage (blood loss) up to 300 ml and among the remaining 20, only 2 (7%) patients required blood transfusion as hematocrit fell below 20%. Compared to Group A, patients in Group B who did not receive preoperative tranexamic acid, 21(75%) patients had postoperative haemorrhage up to 300 ml (Group A vs. Group B: p=0.0002). Regarding intraoperative blood loss no significant (p >0.05) difference was observed among the cases in two groups. Conclusion: The study revealed that administration of prophylactic tranexamic acid resulted into fewer postoperative blood loss in transthoracic esophagectomy. IMC J Med Sci 2022; 16(1): 003 *Correspondence: Farooq Ahmad Ganie, Department of Cardiovascular and Thoracic Surgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar -190011, J & K, India. E-mail: farooq.ganie@yamil.com

Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality: A Systematic Review, Meta-analysis, and Meta-regression

IMPORTANCE

Tranexamic acid (TXA) is an efficient antifibrinolytic agent; however, concerns remain about the potential adverse effects, particularly vascular occlusive events, that may be associated with its use.

OBJECTIVE

To examine the association between intravenous TXA and total thromboembolic events (TEs) and mortality in patients of all ages and of any medical disciplines.

DATA SOURCE

Cochrane Central Register of Controlled Trials and MEDLINE were searched for eligible studies investigating intravenous TXA and postinterventional outcome published between 1976 and 2020.

STUDY SELECTION

Randomized clinical trials comparing intravenous TXA with placebo/no treatment. The electronic database search yielded a total of 782 studies, and 381 were considered for full-text review. Included studies were published in English, German, French, and Spanish. Studies with only oral or topical tranexamic administration were excluded.

DATA EXTRACTION AND SYNTHESIS

Meta-analysis, subgroup and sensitivity analysis, and meta-regression were performed. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

MAIN OUTCOMES AND MEASURES

Vascular occlusive events and mortality.

RESULTS

A total of 216 eligible trials including 125 550 patients were analyzed. Total TEs were found in 1020 (2.1%) in the group receiving TXA and 900 (2.0%) in the control group. This study found no association between TXA and risk for total TEs (risk difference = 0.001; 95% CI, -0.001 to 0.002; P = .49) for venous thrombosis, pulmonary embolism, venous TEs, myocardial infarction or ischemia, and cerebral infarction or ischemia. Sensitivity analysis using the risk ratio as an effect measure with (risk ratio = 1.02; 95% CI, 0.94-1.11; P = .56) and without (risk ratio = 1.03; 95% CI, 0.95-1.12; P = .52) studies with double-zero events revealed robust effect size estimates. Sensitivity analysis with studies judged at low risk for selection bias showed similar results. Administration of TXA was associated with a significant reduction in overall mortality and bleeding mortality but not with nonbleeding mortality. In addition, an increased risk for vascular occlusive events was not found in studies including patients with a history of thromboembolism. Comparison of studies with sample sizes of less than or equal to 99 (risk difference = 0.004; 95% CI, -0.006 to 0.014; P = .40), 100 to 999 (risk difference = 0.004; 95% CI, -0.003 to 0.011; P = .26), and greater than or equal to 1000 (risk difference = -0.001; 95% CI, -0.003 to 0.001; P = .44) showed no association between TXA and incidence of total TEs. Meta-regression of 143 intervention groups showed no association between TXA dosing and risk for venous TEs (risk difference, -0.005; 95% CI, -0.021 to 0.011; P = .53).

CONCLUSIONS AND RELEVANCE

Findings from this systematic review and meta-analysis of 216 studies suggested that intravenous TXA, irrespective of dosing, is not associated with increased risk of any TE. These results help clarify the incidence of adverse events associated with administration of intravenous TXA and suggest that TXA is safe for use with undetermined utility for patients receiving neurological care.

Efficacy and safety of antifibrinolytics in oncological surgery: a systematic review and meta-analysis

Background and objectives

Contents

Conclusions

Exclusion criteria and adverse events in perioperative trials of tranexamic acid: a systematic review and meta-analysis

BACKGROUND

Tranexamic acid (TXA) is an inexpensive therapy effective at minimizing perioperative blood loss and transfusion. However, it remains underutilized due to safety concerns. To date, no evidence-based guidelines exist identifying which patients should not receive TXA therapy. This study determined patient groups for whom safety information regarding TXA is lacking due to common exclusion from perioperative TXA trials.

STUDY DESIGN AND METHODS

A systematic review searching the databases Medline, EMBASE, CENTRAL, and Clinicaltrials.gov was performed. Randomized controlled trials (RCTs) administering systemic TXA perioperatively to elective or emergent surgery patients were eligible. Our primary outcome was to describe exclusion criteria of RCTs, and the secondary outcome was TXA safety. A descriptive synthesis of exclusion criteria was performed, and TXA safety was assessed by meta-analysis.

RESULTS

A total of 268 eligible RCTs were included. Meta-analysis showed that systemic TXA did not increase risk of adverse events compared to placebo or no intervention (relative risk, 1.05; 95% confidence interval, 0.99-1.12). Patient groups commonly excluded from perioperative TXA trials, and thus potentially lacking TXA safety data, were those with major comorbidities, a history of thromboembolism, medication use affecting coagulation, TXA allergy, and coagulopathy. Exclusion of patients with major comorbidities may not be necessary; we showed that the risk of adverse events was similar in studies that excluded patients with major comorbidities and those that did not.

CONCLUSION

Sufficient evidence exists to develop perioperative guidelines for TXA use in many populations. Further studies evaluating perioperative TXA use in patients with a history of thromboembolism are warranted.

Single intravenous bolus versus perioperative continuous infusion of tranexamic acid to reduce blood loss in abdominal oncosurgical procedures: A prospective randomized double-blind clinical study

Background and Aims:

Intraoperative use of a single bolus dose of tranexamic acid may not be sufficient to prevent bleeding in the early postoperative period. The present study was carried out to compare the effect of two dose regimens of tranexamic acid in reducing perioperative blood loss and the amount of allogenic blood transfusion in abdominal tumor surgery.

Material and Methods:

In this prospective, controlled, and double-blind investigation, 60 patients electively posted for abdominal oncosurgical procedures were randomly assigned to receive a single bolus dose of tranexamic acid (10 mg/kg) (Group A), a bolus dose of tranexamic acid (10 mg/kg) followed by infusion (1 mg/kg/h) till 4 h postoperatively (Group B), and a bolus followed by infusion of normal saline (group C). Total intraoperative blood loss, amount of allogenic blood transfusion, postoperative drain collections, and hemoglobin and hematocrit levels were recorded at different time intervals. Data obtained after comparing three groups were analyzed by analysis of variance test for variables following normal distribution, Kruskal–Wallis test for nonparametric data, and post-hoc Tukey–Kramer test for intergroup analysis. A probability value of less than 5% was considered significant.

Results:

There was no significant difference in intraoperative blood loss in all the three groups. Both the tranexamic acid groups showed reduction in postoperative blood collection in drain at 6 h and 24 h in comparison to the control group (P < 0.001). There was also a significant difference in the amount of blood in postoperative drain at 24 h within the tranexamic acid groups, where lesser collection was seen in the infusion group (P = 0.007). Hemoglobin and hematocrit levels measured at different postoperative time intervals showed a significant reduction from the baseline in the control group compared to the tranexamic acid groups together.

Conclusion:

Tranexamic acid causes more effective reduction in post-operative blood loss when used as a bolus followed by an infusion continued in the postoperative period in comparison to its use as a single intravenous bolus in abdominal tumor surgery.

Efficacy of tranexamic acid in reducing blood loss and blood transfusion in idiopathic scoliosis: a systematic review and meta-analysis

Background

Tranexamic acid is a synthetic lysine-analogue antifibrinolytic that competitively inhibits the activation of plasminogen to plasmin, it is a well-documented blood sparing agent. However, its routine use in idiopathic scoliosis surgery is poorly documented. The objective of this meta-analysis was to determine TXA's efficacy in reducing blood loss and blood transfusion in idiopathic scoliosis surgery.

Methods

Five databases (Medline, PubMed, Web of Science, Embase and The Cochrane Central Register of Controlled Trials) were searched to identify the relevant randomized controlled trials (RCTs), prospective cohort control (PCC), and retrospective controlled trails regarding the TXA efficacy in idiopathic scoliosis surgery. Mean differences (MDs) of blood loss and blood transfusions in TXA-treated group compared to control and/or placebo group were extracted and combined using random-effect meta-analysis model.

Results

A total of seven studies comprising 426 patients were included in the meta-analysis according to the pre-defined selection criteria. TXA-treated group had an overall significantly (P<0.005) less volume of blood loss [ES (MD) =727.71 mL; CI, 281.86-1,173.56 mL]. Six studies comprising 346 patients TXA-treated group had an overall significantly {P<0.001 less transfusion volume [ES (MD) =268.30 mL; CI, 105.19-431.44 mL]}.

Conclusions

Patients treated with TXA had a significantly lower blood loss and lower rates of allogeneic blood transfusion than the control group. Further investigation is required regarding the safety of TXA before it can be generalized in the use of idiopathic scoliosis surgery.

Effectiveness of tranexamic acid for decreasing bleeding in prostate surgery: a systematic review and meta-analysis

Introduction

The objective of this study was to determine the effectiveness of tranexamic acid in decreasing bleeding in patients undergoing prostate surgery.

Material and methods

All clinical experiments were included without language restrictions. The inclusion criteria were as follows: men over 18 years of age who underwent prostate surgery (transurethral, prostate adenectomy, and radical prostatectomy) and received tranexamic acid prior to prostate surgery as a preventive measure for perioperative hemorrhage. Prophylactic tranexamic acid vs. no intervention or placebo were compared. The primary outcomes were as follows: 1) intraoperative blood loss and 2) the need for red blood cell transfusion. A systematic search was performed in MEDLINE, EMBASE, CENTRAL and LILACS. Other sources were used to discover published and unpublished literature sources. The statistical analysis was performed in Review Manager v.5.3.

Results

Four studies were included with a total of 436 patients. Three of the four studies had small sample sizes. There was a low risk of attrition bias and reporting bias. Unclear risk of selection bias, performance bias, or detection bias was presented. A mean difference (MD) of -174.49 [95% CI (-248.43 to -100.56)] was found for perioperative blood loss (the primary outcome). At the end of the procedure, the hemoglobin concentration had a MD of -1.19 [95% CI (-4.37 to 1.99)].

Conclusions

Tranexamic acid is effective at preventing perioperative blood loss compared with the placebo in patients undergoing transurethral resection of the prostate (TURP). However, this treatment was not effective neither at preventing the need for transfusions nor at increasing hemoglobin values at the end of the procedure.

Efficacy of tranexamic acid for the prevention of bleeding in patients with von Willebrand disease and Glanzmann thrombasthenia: a controlled, before and after trial

INTRODUCTION

Reducing bleeding episodes is very important in haematology disorders like von Willebrand disease (VWD) and Glanzmann thrombasthenia (GT). Replacement factors are very expensive although prophylactic drugs are affordable.

OBJECTIVE

To study the prophylactic effects of tranexamic acid (TXA) for reduction of bleeding episodes in patients with VWD and GT in non-invasive conditions.

METHODS

A controlled, double-blind before and after single-centre trial was performed in Amir-Kabir Hospital (Arak, Iran). The study was done on 17 patients with VWD and three patients with GT with minimum age of 2 years. Patients were received placebo for 6 months to evaluate the frequency and severity of bleeding and also to record the frequency of use of factor concentrates and platelet transfusion. After that, patients were given oral single dose of TXA 25 mg kg(-1) day(-1) for 6 months. The mentioned outcomes were studied and compared between two phases of study. Safety assessment was done in all patients.

RESULTS

Tranexamic acid caused a significant reduction in number of Grade 1 and Grade 2 bleeding episodes in VWD patients (P < 0.001 and P < 0.01 respectively). In addition, TXA therapy was associated with significant decrease in the use of factor concentrates (P < 0.05). Number of bleeding episodes decreased in GT patients who used TXA; however, difference between two phases of studies was not significant (P = 0.1). TXA had no effect in the frequency of platelet transfusions in GT patients. TXA therapy was associated with headache, back pain and musculoskeletal pain. No case of allergy or thromboembolic events was seen following treatment.

CONCLUSIONS

The results suggest that TXA is safe and effective to reduce bleeding and use of factor concentrates in VWD patients. In addition, TXA therapy can decrease bleeding in GT patients.

Does the preoperative administration of tranexamic acid reduce perioperative blood loss and transfusion requirements after head neck cancer surgery? A randomized, controlled trial

Background:

Head and neck cancer (HNC) surgery is associated with high intraoperative blood loss which may require urgent blood transfusion. Many strategies have been recommended to decrease the need for allogenic transfusion. Use of perioperative tranexamic acid (TA) has a promising role.

Aims:

This study was to evaluate the effectiveness of single preoperative bolus dose of TA on blood loss prevention and red blood cell transfusion in patients undergoing HNC surgery.

Study Design:

A prospective, double-blind, and randomized controlled study.

Materials and Methods:

From 2007 July to 2010 January; 80 patients, aged (35–55), of American Society of Anesthesiologists II-III scheduled for unilateral HNC surgeries were randomly received either TA (Group T) in a dose of 20 mg/kg diluted to 25 cc with normal saline or an equivalent volume of normal saline (Group C) in a tertiary care hospital. Hemoglobin (Hb) concentration, platelet count, packed cell volume, fibrinogen level, D-dimer level were measured pre- and post-operatively.

Results:

Saline (C) Group required more blood, colloid, crystalloid for blood loss. In Group T, 32 patients did not require transfusion of any blood products compared to five patients in Group C (P < 0.0001) and only eight units of blood was transfused in Group T, whereas a total of 42 units of blood was transfused in Group C. Even after numerous transfusions, Hb% after 6 h and 24 h in Group C were significantly low in comparison with Group T (P < 0.05).

Conclusion:

Thus, TA significantly reduces blood loss and chances of colloid, blood, and crystalloid transfusion caused by HNC surgery.