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Wilson M, Stuart S, Lassiter B, Parker T, Martin C, Healy R, Treager C, Sulava E, Gower L, Fernandez P, Friedrich E. Pharmacokinetics of Tranexamic Acid (TXA) Delivered by Expeditious Routes in a Swine Model of Polytrauma and Hemorrhagic Shock. PREHOSP EMERG CARE 2024:1-9. [PMID: 38634701 DOI: 10.1080/10903127.2024.2342025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/21/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE Hemorrhage is the leading cause of preventable death in civilian trauma centers and on the battlefield. One of the emerging treatment options for hemorrhage in austere environments is tranexamic acid (TXA). However, the landscape is not amenable to the current delivery standard. This study compared the pharmacokinetics of TXA via a standard 10-minute intravenous infusion (IV infusion), intravenous rapid push over 10 s (IV push), and intramuscular injection (IM) in a swine polytrauma and hemorrhagic shock model (trauma group) compared to uninjured controls (control group). METHODS Thirty swine were randomized to the trauma or control group. Following anesthesia, the trauma group experienced a simulated blast injury and 40% controlled hemorrhage. Subjects in both groups were then randomized to receive 1 g/10 mL TXA via IV infusion, IV push, or IM. Animals were monitored for four hours with serial blood sampling. Serum TXA concentrations were measured by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and analyzed. RESULTS The time to maximum TXA concentration (Tmax) was not affected by trauma in IV infusion or IV push, but was affected in the IM administration with Tmax significantly slower than the control group (p = 0.016). The minimum effective serum concentration of TXA (Ceff, 10 µg/mL) was reached in less than one minute with IV infusion and instantaneously with IV push. Despite lower bioavailability, the time to reach Ceff (Teff) was achieved via IM administration in less than 10 min for both groups (6.4 min trauma vs. 2.1 min control). CONCLUSIONS In austere prehospital environments, an alternative to intravenous infusion of a life-saving medication is desired. Administration of TXA via all three methods reached the level needed to cause substantial inhibition of fibrinolysis within 10 min. The IV push method showed similar pharmacokinetics to IV infusion of TXA but can be delivered quickly without sacrificing an access site for 10 min.
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Affiliation(s)
- Mallori Wilson
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Sean Stuart
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Timothy Parker
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Clyde Martin
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Robert Healy
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Christopher Treager
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Eric Sulava
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Lorie Gower
- General Dynamics Information Technology, Fairfax, Virginia
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Eisinger EC, Forsythe L, Joergensen S, Murali S, Cannon JW, Reilly PM, Kim PK, Kaufman EJ. Thromboembolic Complications Following Perioperative Tranexamic Acid Administration. J Surg Res 2024; 293:676-684. [PMID: 37839099 DOI: 10.1016/j.jss.2023.08.048] [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: 01/14/2023] [Revised: 07/25/2023] [Accepted: 08/27/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION The antifibrinolytic tranexamic acid (TXA) may reduce death in trauma; however, outcomes associated with TXA use in patients without proven hyperfibrinolysis remain unclear. We analyzed the associations of empirically administered TXA, hypothesizing that TXA use would correlate to lower transfusion totals but increased thromboembolic complications. METHODS This retrospective cohort study compared trauma patients started on massive transfusion protocol at a Level I trauma center from 2016 to 2021 who either did or did not receive TXA. Our primary outcome was in-hospital mortality. Venous thromboembolism (VTE; pulmonary embolism or deep vein thrombosis), transfusion volumes, and coagulation measures were considered secondarily. Descriptive statistics, univariate analyses, and multivariable logistic regression were used to evaluate differences in outcomes. RESULTS TXA patients presented with lower systolic blood pressure (100 versus 119.5 mmHg, P = 0.009), trended toward higher injury severity (ISS of 25 versus 20, P = 0.057), and were likelier to have undergone thoracotomy or laparotomy (89 versus 71%, P = 0.002). After adjusting for age, mechanism, presenting vitals, and operation, TXA was not significantly associated with mortality or VTE. TXA patients had larger volumes of packed red blood cells, platelets, and plasma transfused within 4- and 24-h (P ≤ 0.002). No differences in clot stability, captured via thromboelastography, were noted. CONCLUSIONS Despite no differences in mortality or VTE between patients who did and did not receive TXA, there were significant differences in transfusion totals. TXA patients had worse presenting physiology and likely had more severe bleeding. This absence of adverse outcomes supports TXA's safety. Nevertheless, further inquiry into the precise mechanism of TXA may help guide its empiric use, allowing for more targeted application.
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Affiliation(s)
- Ella C Eisinger
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Liam Forsythe
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Shyam Murali
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy W Cannon
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick M Reilly
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick K Kim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elinore J Kaufman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Hayakawa M, Tagami T, Kudo D, Ono K, Aoki M, Endo A, Yumoto T, Matsumura Y, Irino S, Sekine K, Ushio N, Ogura T, Nachi S, Irie Y, Hayakawa K, Ito Y, Okishio Y, Muronoi T, Kosaki Y, Ito K, Nakatsutsumi K, Kondo Y, Ueda T, Fukuma H, Saisaka Y, Tominaga N, Kurita T, Nakayama F, Shibata T, Kushimoto S. The Restrictive Red Blood Cell Transfusion Strategy for Critically Injured Patients (RESTRIC) trial: a cluster-randomized, crossover, non-inferiority multicenter trial of restrictive transfusion in trauma. J Intensive Care 2023; 11:34. [PMID: 37488591 PMCID: PMC10364403 DOI: 10.1186/s40560-023-00682-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND The efficacies of fresh frozen plasma and coagulation factor transfusion have been widely evaluated in trauma-induced coagulopathy management during the acute post-injury phase. However, the efficacy of red blood cell transfusion has not been adequately investigated in patients with severe trauma, and the optimal hemoglobin target level during the acute post-injury and resuscitation phases remains unclear. Therefore, this study aimed to examine whether a restrictive transfusion strategy was clinically non-inferior to a liberal transfusion strategy during the acute post-injury phase. METHODS This cluster-randomized, crossover, non-inferiority multicenter trial was conducted at 22 tertiary emergency medical institutions in Japan and included adult patients with severe trauma at risk of major bleeding. The institutions were allocated a restrictive or liberal transfusion strategy (target hemoglobin levels: 7-9 or 10-12 g/dL, respectively). The strategies were applied to patients immediately after arrival at the emergency department. The primary outcome was 28-day survival after arrival at the emergency department. Secondary outcomes included transfusion volume, complication rates, and event-free days. The non-inferiority margin was set at 3%. RESULTS The 28-day survival rates of patients in the restrictive (n = 216) and liberal (n = 195) strategy groups were 92.1% and 91.3%, respectively. The adjusted odds ratio for 28-day survival in the restrictive versus liberal strategy group was 1.02 (95% confidence interval: 0.49-2.13). Significant non-inferiority was not observed. Transfusion volumes and hemoglobin levels were lower in the restrictive strategy group than in the liberal strategy group. No between-group differences were noted in complication rates or event-free days. CONCLUSIONS Although non-inferiority of the restrictive versus liberal transfusion strategy for 28-day survival was not statistically significant, the mortality and complication rates were similar between the groups. The restrictive transfusion strategy results in a lower transfusion volume. TRIAL REGISTRATION NUMBER umin.ac.jp/ctr: UMIN000034405, registration date: 8 October 2018.
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Affiliation(s)
- Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8648, Japan.
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashi Kosugi Hospital, Kawasaki, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kota Ono
- Ono Biostat Consulting, Tokyo, Japan
| | - Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Akira Endo
- Department of Acute Critical Care and Disaster Medicine, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yosuke Matsumura
- Department of Intensive Care, Chiba Emergency Medical Centre, Chiba, Japan
| | - Shiho Irino
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Kazuhiko Sekine
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Noritaka Ushio
- Department of Emergency and Critical Care Medicine, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Takayuki Ogura
- Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Centre, Imperial Gift Foundation Saiseikai, Utsunomiya Hospital, Utsunomiya, Japan
| | - Sho Nachi
- Advanced Critical Care Centre, Gifu University Hospital, Gifu, Japan
| | - Yuhei Irie
- Department of Emergency and Critical Care Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Katsura Hayakawa
- Advanced Emergency and Critical Care Centre, Saitama Red Cross Hospital, Saitama, Japan
| | - Yusuke Ito
- Senri Critical Care Medical Centre, Saiseikai Senri Hospital, Suita, Japan
| | - Yuko Okishio
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, Wakayama, Japan
| | - Tomohiro Muronoi
- Department of Acute Care Surgery, Shimane University Faculty of Medicine, Izumo, Japan
| | - Yoshinori Kosaki
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kaori Ito
- Department of Surgery, Division of Acute Care Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Keita Nakatsutsumi
- Trauma and Acute Critical Care Centre, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Taichiro Ueda
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
| | - Hiroshi Fukuma
- Senshu Trauma and Critical Care Centre, Rinku General Medical Centre, Izumisano, Japan
| | - Yuichi Saisaka
- Emergency and Critical Care Centre, Kochi Health Sciences Centre, Kochi, Japan
| | - Naoki Tominaga
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Takeo Kurita
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Fumihiko Nakayama
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tama, Japan
| | - Tomotaka Shibata
- Advanced Trauma, Emergency and Critical Care Centre, Oita University Hospital, Yufu, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Alhenaki AM, Ali AS, Kadir B, Ahmed Z. Pre-hospital administration of tranexamic acid in trauma patients: A systematic review and meta-analysis. TRAUMA-ENGLAND 2022. [DOI: 10.1177/14604086211001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage-2 (CRASH-2) trial proved that tranexamic acid (TXA) is a time-dependent drug, having a better outcome if given within 1-hour of injury. In order to test this theory, studies have been conducted to examine the effect of TXA in the pre-hospital setting. We conducted a systematic search and meta-analysis to evaluate the role of TXA administration in the civilian pre-hospital setting on patient outcomes. Methods Embase, Medline, CINAHL and Cochrane were searched for randomized control trials (RCTs), retrospective, and prospective studies that examined the effect of TXA on patients in the pre-hospital setting versus a control group. Outcome measures were overall mortality rate and thromboembolic events. Two authors extracted the data independently. To appraise the included studies, we used the NIH quality assessment tool for cohort and cross-sectional studies. Results are presented as Risk Ratio (RR), a random-effect model was implemented, and the I2 test was used to assess heterogeneity. Results The search identified 1886 papers, but only five retrospective studies met the inclusion/exclusion criteria and were selected for further analysis. A meta-analysis confirmed that TXA reduced the overall mortality rate (pooled risk ratio of 0.74 (95% CI 0.45, 1.25)) and thromboembolic events (risk ratio of 0.71 (95% CI 0.35, 1.44)). Conclusion The pooled effects for both outcome measures favour the administration of TXA in the pre-hospital setting, although none of the findings reported a significant effect. Our study highlights the need for additional high-quality evidence to validate the significance of these findings. Level of evidence Level III, therapeutic study.
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Affiliation(s)
- Abdulrahman M Alhenaki
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ayesha S Ali
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Bryar Kadir
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Zubair Ahmed
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Surgical Reconstruction and Microbiology Research Centre, National Institute for Health Research, Queen Elizabeth Hospital, Birmingham, UK
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Karl V, Thorn S, Mathes T, Hess S, Maegele M. Association of Tranexamic Acid Administration With Mortality and Thromboembolic Events in Patients With Traumatic Injury: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e220625. [PMID: 35230436 PMCID: PMC8889461 DOI: 10.1001/jamanetworkopen.2022.0625] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Tranexamic acid is widely available and used off-label in patients with bleeding traumatic injury, although the literature does not consistently agree on its efficacy and safety. OBJECTIVE To examine the association of tranexamic acid administration with mortality and thromboembolic events compared with no treatment or with placebo in patients with traumatic injury in the literature. DATA SOURCES On March 23, 2021, PubMed, Embase, and the Cochrane Library were searched for eligible studies published between 1986 and 2021. STUDY SELECTION Randomized clinical trials and observational studies investigating tranexamic acid administration compared with no treatment or placebo among patients with traumatic injury and traumatic brain injury who were 15 years or older were included. Included studies were published in English or German. The electronic search yielded 1546 records, of which 71 were considered for full-text screening. The selection process was performed independently by 2 reviewers. DATA EXTRACTION AND SYNTHESIS The study followed the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted by 2 independent reviewers and pooled using the inverse-variance random-effects model. MAIN OUTCOMES AND MEASURES Outcomes were formulated before data collection and included mortality at 24 hours and 28 and 30 days (1 month) as well as the incidence of thromboembolic events and the amount of blood products administered. Owing to missing data, overall mortality was added and the amount of blood products administered was discarded. RESULTS Thirty-one studies with a total of 43 473 patients were included in the systematic review. The meta-analysis demonstrated that administration of tranexamic acid was associated with a significant decrease in 1-month mortality compared with the control cohort (risk ratio, 0.83 [95% CI, 0.71-0.97]; I2 = 35%). The results of meta-analyses for 24-hour and overall mortality and thromboembolic events were heterogeneous and could not be pooled. Further investigations on clinical heterogeneity showed that populations with trauma and trial conditions differed markedly. CONCLUSIONS AND RELEVANCE These findings suggest that tranexamic acid may be beneficial in various patient populations with trauma. However, reasonable concerns about potential thromboembolic events with tranexamic acid remain.
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Affiliation(s)
- Vivien Karl
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Cologne, Germany
| | - Sophie Thorn
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Emergency Medicine, Alfred Health, Melbourne, Australia
| | - Tim Mathes
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Cologne, Germany
- Institute for Medical Statistics, University Medical Centre, Göttingen, Germany
| | - Simone Hess
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Cologne, Germany
| | - Marc Maegele
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Cologne, Germany
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre, Witten/Herdecke University, Campus Cologne-Merheim, Cologne, Germany
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Walsh K, O'Keeffe F, Brent L, Mitra B. Tranexamic acid for major trauma patients in Ireland. World J Emerg Med 2022; 13:11-17. [PMID: 35003409 DOI: 10.5847/wjem.j.1920-8642.2022.003] [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: 11/10/2020] [Accepted: 05/26/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Clinical Randomisation of an Anti-fibrinolytic in Significant Hemorrhage-2 (CRASH-2) is the largest randomized control trial (RCT) examining circulatory resuscitation for trauma patients to date and concluded a statistically significant reduction in all-cause mortality in patients administered tranexamic acid (TXA) within 3 hours of injury. Since the publication of CRASH-2, significant geographical variance in the use of TXA for trauma patients exists. This study aims to assess TXA use for major trauma patients with hemorrhagic shock in Ireland after the publication of CRASH-2. METHODS A retrospective cohort study was conducted using data derived from the Trauma Audit and Research Network (TARN). All injured patients in Ireland between January 2013 and December 2018 who had evidence of hemorrhagic shock on presentation (as defined by systolic blood pressure [SBP] <100 mmHg [1 mmHg=0.133 kPa] and administration of blood products) were eligible for inclusion. Death at hospital discharge was the primary outcome. RESULTS During the study period, a total of 234 patients met the inclusion criteria. Among injured patients presenting with hemorrhagic shock, 133 (56.8%; 95% confidence interval [CI] 50.2%-63.3%) received TXA. Of patients that received TXA, a higher proportion of patients presented with shock index >1 (70.68% vs.57.43%) and higher Injury Severity Score (ISS >25; 49.62% vs. 23.76%). Administration of TXA was not associated with mortality at hospital discharge (odds ratio [OR] 0.86, 95% CI 0.31-2.38). CONCLUSIONS Among injured Irish patients presenting with hemorrhagic shock, TXA was administered to 56.8% of patients. Patients administered with TXA were on average more severely injured. However, a mortality benefit could not be demonstrated.
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Affiliation(s)
- Kieran Walsh
- National Trauma Research Institute, the Alfred Hospital, Melbourne 3004, Australia.,Critical Care Research, School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia.,Emergency & Trauma Centre, Alfred Health, Melbourne 3004, Australia
| | - Francis O'Keeffe
- National Trauma Research Institute, the Alfred Hospital, Melbourne 3004, Australia.,Emergency Department, Mater Misericordiae University Hospital, Dublin D07 R2WY, Ireland
| | - Louise Brent
- National Office for Clinical Audit, Ardilaun House, Dublin D02 VN51, Ireland
| | - Biswadev Mitra
- National Trauma Research Institute, the Alfred Hospital, Melbourne 3004, Australia.,Critical Care Research, School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia.,Emergency & Trauma Centre, Alfred Health, Melbourne 3004, Australia
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NAKAE R, MURAI Y, MORITA A, YOKOBORI S. Coagulopathy and Traumatic Brain Injury: Overview of New Diagnostic and Therapeutic Strategies. Neurol Med Chir (Tokyo) 2022; 62:261-269. [PMID: 35466118 PMCID: PMC9259082 DOI: 10.2176/jns-nmc.2022-0018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Coagulopathy is a common sequela of traumatic brain injury. Consumptive coagulopathy and secondary hyperfibrinolysis are associated with hypercoagulability. In addition, fibrinolytic pathways are hyperactivated as a result of vascular endothelial cell damage in the injured brain. Coagulation and fibrinolytic parameters change dynamically to reflect these pathologies. Fibrinogen is consumed and degraded after injury, with fibrinogen concentrations at their lowest 3-6 h after injury. Hypercoagulability causes increased fibrinolytic activity, and plasma levels of D-dimer increase immediately after traumatic brain injury, reaching a maximum at 3 h. Owing to disseminated intravascular coagulation in the presence of fibrinolysis, the bleeding tendency is highest within the first 3 h after injury, and often a condition called “talk and deteriorate” occurs. In neurointensive care, it is necessary to measure coagulation and fibrinolytic parameters such as fibrinogen and D-dimer routinely to predict and prevent the development of coagulopathy and its negative outcomes. Currently, the only evidence-based treatment for traumatic brain injury with coagulopathy is tranexamic acid in the subset of patients with mild-to-moderate traumatic brain injury. Coagulation and fibrinolytic parameters should be closely monitored, and treatment should be considered on a patient-by-patient basis.
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Affiliation(s)
- Ryuta NAKAE
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital
| | - Yasuo MURAI
- Department of Neurological Surgery, Nippon Medical School Hospital
| | - Akio MORITA
- Department of Neurological Surgery, Nippon Medical School Hospital
| | - Shoji YOKOBORI
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital
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Li SR, Guyette F, Brown J, Zenati M, Reitz KM, Eastridge B, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Zuckerbraun BS, Sperry JL. Early Prehospital Tranexamic Acid Following Injury Is Associated With a 30-day Survival Benefit: A Secondary Analysis of a Randomized Clinical Trial. Ann Surg 2021; 274:419-426. [PMID: 34132695 PMCID: PMC8480233 DOI: 10.1097/sla.0000000000005002] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We sought to characterize the timing of administration of prehospital tranexamic acid (TXA) and associated outcome benefits. BACKGROUND TXA has been shown to be safe in the prehospital setting post-injury. METHODS We performed a secondary analysis of a recent prehospital randomized TXA clinical trial in injured patients. Those who received prehospital TXA within 1 hour (EARLY) from time of injury were compared to those who received prehospital TXA beyond 1 hour (DELAYED). We included patients with a shock index of >0.9. Primary outcome was 30-day mortality. Kaplan-Meier and Cox Hazard regression were utilized to characterize mortality relationships. RESULTS EARLY and DELAYED patients had similar demographics, injury characteristics, and shock severity but DELAYED patients had greater prehospital resuscitation requirements and longer prehospital times. Stratified Kaplan-Meier analysis demonstrated significant separation for EARLY patients (N = 238, log-rank chi-square test, 4.99; P = 0.03) with no separation for DELAYED patients (N = 238, log-rank chi-square test, 0.04; P = 0.83). Stratified Cox Hazard regression verified, after controlling for confounders, that EARLY TXA was associated with a 65% lower independent hazard for 30-day mortality [hazard ratio (HR) 0.35, 95% confidence interval (CI) 0.19-0.65, P = 0.001] with no independent survival benefit found in DELAYED patients (HR 1.00, 95% CI 0.63-1.60, P = 0.999). EARLY TXA patients had lower incidence of multiple organ failure and 6-hour and 24-hour transfusion requirements compared to placebo. CONCLUSIONS Administration of prehospital TXA within 1 hour from injury in patients at risk of hemorrhage is associated with 30-day survival benefit, lower incidence of multiple organ failure, and lower transfusion requirements.
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Affiliation(s)
- Shimena R Li
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Francis Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Joshua Brown
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Mazen Zenati
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | | | - Brian Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT
| | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
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Nikolaou VS, Masouros P, Floros T, Chronopoulos E, Skertsou M, Babis GC. Single dose of tranexamic acid effectively reduces blood loss and transfusion rates in elderly patients undergoing surgery for hip fracture: a randomized controlled trial. Bone Joint J 2021; 103-B:442-448. [PMID: 33641430 DOI: 10.1302/0301-620x.103b3.bjj-2020-1288.r1] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AIMS The aim of this study was to investigate the hypothesis that a single dose of tranexamic acid (TXA) would reduce blood loss and transfusion rates in elderly patients undergoing surgery for a subcapital or intertrochanteric (IT) fracture of the hip. METHODS In this single-centre, randomized controlled trial, elderly patients undergoing surgery for a hip fracture, either hemiarthroplasty for a subcapital fracture or intramedullary nailing for an IT fracture, were screened for inclusion. Patients were randomly allocated to a study group using a sealed envelope. The TXA group consisted of 77 patients, (35 with a subcapital fracture and 42 with an IT fracture), and the control group consisted of 88 patients (29 with a subcapital fracture and 59 with an IT fracture). One dose of 15 mg/kg of intravenous (IV) TXA diluted in 100 ml normal saline (NS,) or one dose of IV placebo 100 ml NS were administered before the incision was made. The haemoglobin (Hb) concentration was measured before surgery and daily until the fourth postoperative day. The primary outcomes were the total blood loss and the rate of transfusion from the time of surgery to the fourth postoperative day. RESULTS Homogeneity with respect to baseline characteristics was ensured between groups. The mean total blood loss was significantly lower in patients who received TXA (902.4 ml (-279.9 to 2,156.9) vs 1,226.3 ml (-269.7 to 3,429.7); p = 0.003), while the likelihood of requiring a transfusion of at least one unit of red blood cells was reduced by 22%. Subgroup analysis showed that these differences were larger in patients who had an IT fracture compared with those who had a subcapital fracture. CONCLUSION Elderly patients who undergo intramedullary nailing for an IT fracture can benefit from a single dose of 15 mg/kg TXA before the onset of surgery. A similar tendency was identified in patients undergoing hemiarthroplasty for a subcapital fracture but not to a statistically significant level. Cite this article: Bone Joint J 2021;103-B(3):442-448.
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Affiliation(s)
- Vasileios S Nikolaou
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Themistoklis Floros
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Chronopoulos
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Maria Skertsou
- Department of Haematology, Konstandopoulio General Hospital, Athens, Greece
| | - George C Babis
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, Athens, Greece
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Hayakawa M, Tagami T, IIjima H, Kudo D, Sekine K, Ogura T, Yumoto T, Kondo Y, Endo A, Ito K, Matsumura Y, Kushimoto S. Restrictive transfusion strategy for critically injured patients (RESTRIC) trial: a study protocol for a cluster-randomised, crossover non-inferiority trial. BMJ Open 2020; 10:e037238. [PMID: 32895281 PMCID: PMC7478023 DOI: 10.1136/bmjopen-2020-037238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Resuscitation using blood products is critical during the acute postinjury period. However, the optimal target haemoglobin (Hb) levels have not been adequately investigated. With the restrictive transfusion strategy for critically injured patients (RESTRIC) trial, we aim to compare the restrictive and liberal red blood cell (RBC) transfusion strategies. METHODS AND ANALYSIS This is a cluster-randomised, crossover, non-inferiority trial of patients with severe trauma at 22 hospitals that have been randomised in a 1:1 ratio based on the use of a restrictive or liberal transfusion strategy with target Hb levels of 70-90 or 100-120 g/L, respectively, during the first year. Subsequently, after 1-month washout period, another transfusion strategy will be applied for an additional year. RBC transfusion requirements are usually unclear on arrival at the emergency department. Therefore, patients with severe bleeding, which could lead to haemorrhagic shock, will be included in the trial based on the attending physician's judgement. Each RBC transfusion strategy will be applied until 7 days postadmission to the hospital or discharge from the intensive care unit. The outcomes measured will include the 28-day survival rate after arrival at the emergency department (primary), the cumulative amount of blood transfused, event-free days and frequency of transfusion-associated lung injury and organ failure (secondary). Demonstration of the non-inferiority of restrictive transfusion will emphasise its clinical advantages. ETHICS AND DISSEMINATION The trial will be performed according to the Japanese and International Ethical guidelines. It has been approved by the Ethics Committee of each participating hospital and The Japanese Association for the Surgery of Trauma (JAST). Written informed consent will be obtained from all patients or their representatives. The results of the trial will be disseminated to the participating hospitals and board-certified educational institutions of JAST, submitted to peer-reviewed journals for publication, and presented at congresses. TRIAL REGISTRATION NUMBER UMIN Clinical Trials Registry; UMIN000034405. Registered 8 October 2018.
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Affiliation(s)
- Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | | | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University School of Medicine, Sendai, Miyagi, Japan
| | - Kazuhiko Sekine
- Department of Emergency and Critical Care Medicine, Saiseikai Central Hospital, Minato-ku, Tokyo, Japan
| | - Takayuki Ogura
- Department of Emergency Medicine & Critical Care Medicine, Advanced Medical Emergency and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Gunma, Japan
| | - Tetsuya Yumoto
- Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
| | - Akira Endo
- Trauma and Acute Critical Care Centre, Medical Hospital of Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Kaori Ito
- Department of Emergency Medicine, Division of Acute Care Surgery, Teikyo University School of Medicine Graduate School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Yosuke Matsumura
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Chiba, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University School of Medicine, Sendai, Miyagi, Japan
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Lins LAB, Miller PE, Samineni A, Watkins CJ, Matheney TH, Snyder BD, Shore BJ. The Use of Tranexamic Acid (TXA) in Neuromuscular Hip Reconstruction: Can We Alter the Need for Blood Transfusion? J Pediatr Orthop 2020; 40:e766-e771. [PMID: 32044813 DOI: 10.1097/bpo.0000000000001534] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Children with neuromuscular complex chronic conditions (NMCCC) frequently undergo hip reconstruction surgery requiring blood transfusion. The purpose of this study is to examine the efficacy of tranexamic acid (TXA) to reduce blood loss and transfusion requirement in NMCCC children undergoing hip reconstruction surgery. METHODS Children with NMCCC undergoing hip reconstruction surgery between 2013 and 2018 were identified. Two cohorts were identified: those who received TXA and those who did not. Patient and surgical characteristics between cohorts were used for propensity matching. Patients were matched on the basis of comorbid factors, bilateral involvement, pelvic osteotomy, open reduction, and surgeon. Comparative outcomes between cohorts were analyzed for intraoperative and postoperative blood loss and transfusion requirements and length of hospital stay (LOS). RESULTS A total of 166 patients underwent hip surgery at an average of 9.6 years (SD, 4.0). Propensity matching utilized 72% of the cohort including 47 TXA and 72 non-TXA subjects. There were no differences in patient or surgical characteristics across matched groups. Fifteen (15/47, 32%) TXA subjects required a postoperative blood transfusion compared with the 47% (34/72) of non-TXA subjects who required a transfusion and intraoperative transfusion rates were similar between the 2 groups. There was no significant difference in complication rate (TXA, 79%; non-TXA, 86%), reported estimated blood loss (median=200 mLfor both) or LOS (median=6 d for both). Hematocrit levels were slightly higher in TXA subjects intraoperatively (P=0.047), at the end of surgery (P=0.04), and for the overall lowest perioperative level (P=0.04). The overall percent loss of estimated blood volume was less for those who were given TXA compared with those who were not (P=0.001). CONCLUSIONS The use of TXA during hip reconstruction surgery in NMCCC children significantly reduced the percent loss of estimated blood volume and postoperative transfusion rate. Further prospective multicenter studies are needed to verify the positive effects and safety of TXA in the setting of hip reconstruction surgery in NMCCC children. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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Affiliation(s)
- Laura A B Lins
- Department of Orthopaedics, Boston Children's Hospital
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Colyn J Watkins
- Department of Orthopaedics, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | - Travis H Matheney
- Department of Orthopaedics, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | - Brian D Snyder
- Department of Orthopaedics, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | - Benjamin J Shore
- Department of Orthopaedics, Boston Children's Hospital
- Harvard Medical School, Boston, MA
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12
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Early Tranexamic Acid Administration After Traumatic Brain Injury Is Associated With Reduced Syndecan-1 and Angiopoietin-2 in Patients With Traumatic Intracranial Hemorrhage. J Head Trauma Rehabil 2020; 35:317-323. [PMID: 32881765 DOI: 10.1097/htr.0000000000000619] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To evaluate the effect of early tranexamic acid (TXA) administration on circulating markers of endotheliopathy. SETTING Twenty trauma centers in the United States and Canada. PARTICIPANTS Patients with moderate-to-severe traumatic brain injury (TBI) (MS-TBI) and intracranial hemorrhage who were not in shock (systolic blood pressure ≥90 mm Hg). DESIGN TXA (2 g) or placebo administered prior to hospital arrival, less than 2 hours postinjury. Blood samples and head computed tomographic scan collected upon arrival. Plasma markers measured using Luminex analyte platform. Differences in median marker levels evaluated using t tests performed on log-transformed variables. Comparison groups were TXA versus placebo and less than 45 minutes versus 45 minutes or more from time of injury to treatment administration. MAIN MEASURES Plasma levels of angiopoietin-1, angiopoietin-2, syndecan-1, thrombomodulin, thrombospondin-2, intercellular adhesion molecule 1, vascular adhesion molecule 1. RESULTS Demographics and Injury Severity Score were similar between the placebo (n = 129) and TXA (n = 158) groups. Levels of syndecan-1 were lower in the TXA group (median [interquartile range or IQR] = 254.6 pg/mL [200.7-322.0] vs 272.4 pg/mL [219.7-373.1], P = .05. Patients who received TXA less than 45 minutes postinjury had significantly lower levels of angiopoietin-2 (median [IQR] = 144.3 pg/mL [94.0-174.3] vs 154.6 pg/mL [110.4-209.8], P = .05). No differences were observed in remaining markers. CONCLUSIONS TXA may inhibit early upregulation of syndecan-1 and angiopoietin-2 in patients with MS-TBI, suggesting attenuation of protease-mediated vascular glycocalyx breakdown. The findings of this exploratory analysis should be considered preliminary and require confirmation in future studies.
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13
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Tranexamic acid administration is associated with an increased risk of posttraumatic venous thromboembolism. J Trauma Acute Care Surg 2020; 86:20-27. [PMID: 30239375 DOI: 10.1097/ta.0000000000002061] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is used as a hemostatic adjunct for hemorrhage control in the injured patient and reduces early preventable death. However, the risk of venous thromboembolism (VTE) has been incompletely explored. Previous studies investigating the effect of TXA on VTE vary in their findings. We performed a propensity matched analysis to investigate the association between TXA and VTE following trauma, hypothesizing that TXA is an independent risk factor for VTE. METHODS This retrospective study queried trauma patients presenting to a single Level I trauma center from 2012 to 2016. Our primary outcome was composite pulmonary embolism or deep vein thrombosis. Mortality, transfusion, intensive care unit and hospital lengths of stay were secondary outcomes. Propensity matched mixed effects multivariate logistic regression was used to determine adjusted odds ratio (aOR) and 95% confidence intervals (95% CI) of TXA on outcomes of interest, adjusting for prespecified confounders. Competing risks regression assessed subdistribution hazard ratio of VTE after accounting for mortality. RESULTS Of 21,931 patients, 189 pairs were well matched across propensity score variables (standardized differences <0.2). Median Injury Severity Score was 19 (interquartile range, 12-27) and 14 (interquartile range, 8-22) in TXA and non-TXA groups, respectively (p = 0.19). Tranexamic acid was associated with more than threefold increase in the odds of VTE (aOR, 3.3; 95% CI, 1.3-9.1; p = 0.02). Tranexamic acid was not significantly associated with survival (aOR, 0.86; 95% CI, 0.23-3.25; p = 0.83). Risk of VTE remained elevated in the TXA cohort despite accounting for mortality (subdistribution hazard ratio, 2.42; 95% CI, 1.11-5.29; p = 0.03). CONCLUSION Tranexamic acid may be an independent risk factor for VTE. Future investigation is needed to identify which patients benefit most from TXA, especially given the risks of this intervention to allow a more individualized treatment approach that maximizes benefits and mitigates potential harms. LEVEL OF EVIDENCE Therapeutic, level III.
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14
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Lohani KR, Kumar C, Kataria K, Srivastava A, Ranjan P, Dhar A. Role of tranexamic acid in axillary lymph node dissection in breast cancer patients. Breast J 2020; 26:1316-1320. [DOI: 10.1111/tbj.13810] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Kush Raj Lohani
- Department of Surgical Disciplines All India Institute of Medical Sciences (AIIMS) New Delhi India
| | - Chitresh Kumar
- Department of Surgical Disciplines All India Institute of Medical Sciences (AIIMS) New Delhi India
| | - Kamal Kataria
- Department of Surgical Disciplines All India Institute of Medical Sciences (AIIMS) New Delhi India
| | - Anurag Srivastava
- Department of Surgical Disciplines All India Institute of Medical Sciences (AIIMS) New Delhi India
| | - Piyush Ranjan
- Department of Surgical Disciplines All India Institute of Medical Sciences (AIIMS) New Delhi India
| | - Anita Dhar
- Department of Surgical Disciplines All India Institute of Medical Sciences (AIIMS) New Delhi India
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15
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Chen H, Chen M. The efficacy of tranexamic acid for brain injury: A meta-analysis of randomized controlled trials. Am J Emerg Med 2020; 38:364-370. [DOI: 10.1016/j.ajem.2019.158499] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 09/19/2019] [Accepted: 10/01/2019] [Indexed: 01/20/2023] Open
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16
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Hasegawa S, Sada R, Yaegashi M, Morimoto K, Mori T. 1g versus 2 g daily intravenous ceftriaxone in the treatment of community onset pneumonia - a propensity score analysis of data from a Japanese multicenter registry. BMC Infect Dis 2019; 19:1079. [PMID: 31878894 PMCID: PMC6933656 DOI: 10.1186/s12879-019-4552-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community-onset pneumonia (COP) is a combined concept of community acquired pneumonia and the previous classification of healthcare-associated pneumonia. Although ceftriaxone (CRO) is one of the treatment choices for COP, it is unclear whether 1 or 2 g CRO daily has better efficacy. We compared the effectiveness of 1 g with 2 g of CRO for COP treatment. We hypothesized that 1 g CRO would show non-inferiority over 2 g CRO. METHODS This study was an analysis of prospectively registered data of the patients with COP from four Japanese hospitals (the Adult Pneumonia Study Group-Japan: APSG-J). We included subjects who were initially treated solely with 1 or 2 g of CRO. The propensity score was estimated from the 33 pre-treatment variables, including age, sex, weight, pre-existing comorbidities, prescribed drugs, risk factors for aspiration pneumonia, vital signs, laboratory data, and a finding from chest xrays. The primary endpoint was the cure rate, for which a non-inferiority analysis was performed with a margin of 0.05. In addition, we performed three sensitivity analyses; using data limited to the group in which CRO solely was used until the completion of treatment, using data limited to inpatient cases, and performing a generalized linear mixed-effect logistic regression analysis to assess the primary outcome after adjusting for random hospital effects. RESULTS Of the 3817 adult subjects with pneumonia who were registered in the APSG-J study, 290 and 216 were initially treated solely with 1 or 2 g of CRO, respectively. Propensity score matching was used to extract 175 subjects in each group. The cure rate was 94.6 and 93.1% in the 1 and 2 g CRO groups, respectively (risk difference 1.5%; 95% confidence interval - 3.1 to 6.0; p = 0.009 for non-inferiority). The results of the sensitivity analyses were consistent with the primary result. CONCLUSIONS The propensity score-matched analysis of multicenter cohort data from Japan revealed that the cure rate for COP patients treated with 1 g daily CRO was non-inferior to that of patients treated with 2 g daily CRO.
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Affiliation(s)
- Shinya Hasegawa
- Department of Infectious Disease, Tokyo Metro Tama Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8524 Japan
- Department of General Internal Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602 Japan
| | - Ryuichi Sada
- Department of General Internal Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602 Japan
- Department of General Internal Medicine, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552 Japan
| | - Makito Yaegashi
- Department of General Internal Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602 Japan
| | - Konosuke Morimoto
- Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, 1-14 Bunkyo-cho, Nagasaki, Nagasaki 852-8521 Japan
| | - Takahiro Mori
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki, 305-8575 Japan
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki, 305-8575 Japan
- Department of General Internal Medicine, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Togane, Chiba, 283-8686 Japan
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Baugh CW, Levine M, Cornutt D, Wilson JW, Kwun R, Mahan CE, Pollack CV, Marcolini EG, Milling TJ, Peacock WF, Rosovsky RP, Wu F, Sarode R, Spyropoulos AC, Villines TC, Woods TD, McManus J, Williams J. Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel. Ann Emerg Med 2019; 76:470-485. [PMID: 31732375 DOI: 10.1016/j.annemergmed.2019.09.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/30/2019] [Accepted: 09/03/2019] [Indexed: 12/12/2022]
Abstract
Bleeding is the most common complication of anticoagulant use. The evaluation and management of the bleeding patient is a core competency of emergency medicine. As the prevalence of patients receiving anticoagulant agents and variety of anticoagulants with different mechanisms of action, pharmacokinetics, indications, and corresponding reversal agents increase, physicians and other clinicians working in the emergency department require a current and nuanced understanding of how best to assess, treat, and reverse anticoagulated patients. In this project, we convened an expert panel to create a consensus decision tree and framework for assessment of the bleeding patient receiving an anticoagulant, as well as use of anticoagulant reversal or coagulation factor replacement, and to address controversies and gaps relevant to this topic. To support decision tree interpretation, the panel also reached agreement on key definitions of life-threatening bleeding, bleeding at a critical site, and emergency surgery or urgent invasive procedure. To reach consensus recommendations, we used a structured literature review and a modified Delphi technique by an expert panel of academic and community physicians with training in emergency medicine, cardiology, hematology, internal medicine/thrombology, pharmacology, toxicology, transfusion medicine and hemostasis, neurology, and surgery, and by other key stakeholder groups.
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Affiliation(s)
| | - Michael Levine
- Department of Emergency Medicine, Keck School of Medicine at the University of Southern California, Los Angeles, CA
| | - David Cornutt
- Department of Emergency Medicine, Regional West Health Systems, Scottsbluff, NE
| | - Jason W Wilson
- Department of Emergency Medicine, Tampa General Hospital, Tampa, FL
| | - Richard Kwun
- Department of Emergency Medicine, Swedish/Mill Creek, Everett, WA
| | - Charles E Mahan
- Presbyterian Healthcare Services, University of New Mexico College of Pharmacy, Albuquerque, NM
| | - Charles V Pollack
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Evie G Marcolini
- Department of Medicine, Section of Emergency Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
| | | | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
| | - Rachel P Rosovsky
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Fred Wu
- Department of Emergency Medicine, University of California San Francisco-Fresno, Fresno, CA
| | - Ravi Sarode
- Department of Pathology and Internal Medicine (Hematology/Oncology), University of Texas Southwestern Medical Center, Dallas, TX
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Todd C Villines
- Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | | | - John McManus
- Department of Emergency Medicine, Augusta University, Augusta, GA
| | - James Williams
- Department of Emergency Medicine, Covenant Medical Center, Lubbock, TX.
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Richards JE, Samet RE, Koerner AK, Grissom TE. Tranexamic Acid in the Perioperative Period: Yes, No, Maybe? Adv Anesth 2019; 37:87-110. [PMID: 31677661 DOI: 10.1016/j.aan.2019.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Justin E Richards
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Ron E Samet
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - A Kennedy Koerner
- Department of Anesthesiology, University of Maryland School of Medicine, Center for the Sustainment of Trauma and Readiness Skills (CSTARS)-Baltimore, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA.
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Grissom TE. Walking the Tightrope of Bleeding Control. Anesth Analg 2019; 129:644-646. [DOI: 10.1213/ane.0000000000004320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Severely injured trauma patients with admission hyperfibrinolysis: Is there a role of tranexamic acid? Findings from the PROPPR trial. J Trauma Acute Care Surg 2019; 85:851-857. [PMID: 29985230 DOI: 10.1097/ta.0000000000002022] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Administration of tranexamic acid (TXA) in coagulopathy of trauma gained popularity after the CRASH-2 trial. The aim of our analysis was to analyze the role of TXA in severely injured trauma patients with admission hyperfibrinolysis. METHODS We reviewed the prospectively collected Pragmatic, Randomized Optimal Platelet and Plasma Ratios database. We included patients with admission hyperfibrinolysis (Ly30 >3%) on thromboelastography. Patients were stratified into two groups (TXA and No-TXA) and were matched in 1:2 ratio using propensity score matching for demographics, admission vitals, and injury severity. Primary outcome measures were 6-, 12-, and 24-hour and 30-day mortality; 24-hour transfusion requirements; time to achieve hemostasis; and rebleeding after hemostasis requiring intervention. Secondary outcome measures were thrombotic complications. RESULTS We analyzed 680 patients. Of those, 118 had admission hyperfibrinolysis, and 93 patients (TXA: 31 patients; No-TXA: 62 patients) were matched. Matched groups were similar in age (p = 0.33), gender (p = 0.84), race (p = 0.81), emergency department (ED) Glasgow Coma Scale (p = 0.34), ED systolic blood pressure (p = 0.28), ED heart rate (p = 0.43), mechanism of injury (p = 0.45), head Abbreviated Injury Scale score (p = 0.68), injury severity score (p = 0.56), and blood products ratio (p = 0.44). Patients who received TXA had a lower 6-hour mortality rate (34% vs. 13%, p = 0.04) and higher 24-hour transfusion of plasma (15 vs. 10 units, p = 0.03) compared with the No-TXA group. However, there was no difference in 12-hour (p = 0.24), 24-hour (p = 0.25), and 30-day mortality (p = 0.82). Similarly, there was no difference in 24-hour transfusion of RBC (p = 0.11) or platelets (p = 0.13), time to achieve hemostasis (p = 0.65), rebleeding requiring intervention (p = 0.13), and thrombotic complications (p = 0.98). CONCLUSION Tranexamic acid was associated with increased 6-hour survival but does not improve long-term outcomes in severely injured trauma patients with hemorrhage who develop hyperfibrinolysis. Moreover, TXA administration was not associated with thrombotic complications. Further randomized clinical trials will identify the subset of trauma patients who may benefit from TXA. LEVEL OF EVIDENCE Therapeutic study, level III.
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Benipal S, Santamarina JL, Vo L, Nishijima DK. Mortality and Thrombosis in Injured Adults Receiving Tranexamic Acid in the Post-CRASH-2 Era. West J Emerg Med 2019; 20:443-453. [PMID: 31123544 PMCID: PMC6526890 DOI: 10.5811/westjem.2019.4.41698] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/10/2019] [Accepted: 04/08/2019] [Indexed: 12/13/2022] Open
Abstract
Introduction The CRASH-2 trial demonstrated that tranexamic acid (TXA) reduced mortality with no increase in adverse events in severely injured adults. TXA has since been widely used in injured adults worldwide. Our objective was to estimate mortality and adverse events in adults with trauma receiving TXA in studies published after the CRASH-2 trial. Methods We systematically searched PubMed, Embase, MicroMedex, and ClinicalTrials.gov for studies that included injured adults who received TXA and reported mortality and/or adverse events. Two reviewers independently assessed study eligibility, abstracted data, and assessed the risk of bias. We conducted meta-analyses using random effects models to estimate the incidence of mortality at 28 or 30 days and in-hospital thrombotic events. Results We included 19 studies and 13 studies in the systematic review and meta-analyses, respectively. The pooled incidence of mortality at 28 or 30 days (five studies, 1538 patients) was 10.1% (95% confidence interval [CI], 7.8–12.4%) (vs 14.5% [95% CI, 13.9–15.2%] in the CRASH-2 trial), and the pooled incidence of in-hospital thrombotic events (nine studies, 1656 patients) was 5.9% (95% CI, 3.3–8.5%) (vs 2.0% [95% CI, 1.8–2.3%] in the CRASH-2 trial). Conclusion Compared to the CRASH-2 trial, adult trauma patients receiving TXA identified in our systematic review had a lower incidence of mortality at 28 or 30 days, but a higher incidence of in-hospital thrombotic events. Our findings neither support nor refute the findings of the CRASH-2 trial but suggest that incidence rates in adults with trauma in settings outside of the CRASH-2 trial may be different than those observed in the CRASH-2 trial.
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Affiliation(s)
- Simranjeet Benipal
- Universtiy of California, Davis Medical Center, Department of Emergency Medicine, Sacramento, California
| | - John-Lloyd Santamarina
- Universtiy of California, Davis Medical Center, Department of Emergency Medicine, Sacramento, California
| | - Linda Vo
- Universtiy of California, Davis Medical Center, Department of Emergency Medicine, Sacramento, California
| | - Daniel K Nishijima
- Universtiy of California, Davis Medical Center, Department of Emergency Medicine, Sacramento, California
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22
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Abstract
BACKGROUND Tranexamic acid (TXA) use in severe trauma remains controversial notably because of concerns of the applicability of the CRASH-2 study findings in mature trauma systems. The aim of our study was to evaluate the outcomes of TXA administration in severely injured trauma patients managed in a mature trauma care system. METHODS We performed a retrospective study of data prospectively collected in the TraumaBase registry (a regional registry collecting the prehospital and hospital data of trauma patients admitted in six Level I trauma centers in Paris Area, France). In hospital mortality was compared between patients having received TXA or not in the early phase of resuscitation among those presenting an unstable hemodynamic state. Propensity score for TXA administration was calculated and results were adjusted for this score. Hemodynamic instability was defined by the need of packed red blood cells (pRBC) transfusion and/or vasopressor administration in the emergency room (ER). RESULTS Among patients meeting inclusion criteria (n = 1,476), the propensity score could be calculated in 797, and survival analysis could be achieved in 684 of 797. Four hundred seventy (59%) received TXA, and 327 (41%) did not. The overall hospital mortality rate was 25.7%. There was no effect of TXA use in the whole population but mortality was lowered by the use of TXA in patients requiring pRBC transfusion in the ER (hazard ratio, 0.3; 95% confidence interval, 0.3-0.6). CONCLUSION The use of TXA in the management of severely injured trauma patients, in a mature trauma care system, was not associated with reduction in the hospital mortality. An independent association with a better survival was found in a selected population of patients requiring pRBC transfusion in the ER. LEVEL OF EVIDENCE Therapeutic study, level III.
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23
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Neeki MM, Dong F, Toy J, Vaezazizi R, Powell J, Wong D, Mousselli M, Rabiei M, Jabourian A, Niknafs N, Burgett-Moreno M, Vara R, Kissel S, Luo-Owen X, O'Bosky KR, Ludi D, Sporer K, Pennington T, Lee T, Borger R, Kwong E. Tranexamic Acid in Civilian Trauma Care in the California Prehospital Antifibrinolytic Therapy Study. West J Emerg Med 2018; 19:977-986. [PMID: 30429930 PMCID: PMC6225940 DOI: 10.5811/westjem.2018.8.39336] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/31/2018] [Accepted: 08/03/2018] [Indexed: 12/13/2022] Open
Abstract
Introduction Hemorrhage is one of the leading causes of death in trauma victims. Historically, paramedics have not had access to medications that specifically target the reversal of trauma-induced coagulopathies. The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to evaluate the safety and efficacy of tranexamic acid (TXA) use in the civilian prehospital setting in cases of traumatic hemorrhagic shock. Methods The Cal-PAT study is a multi-centered, prospective, observational cohort study with a retrospective comparison. From March 2015 to July 2017, patients ≥ 18 years-old who sustained blunt or penetrating trauma with signs of hemorrhagic shock identified by first responders in the prehospital setting were considered for TXA treatment. A control group was formed of patients seen in the five years prior to data collection cessation (June 2012 to July 2017) at each receiving center who were not administered TXA. Control group patients were selected through propensity score matching based on gender, age, Injury Severity Scores, and mechanism of injury. The primary outcome assessed was mortality recorded at 24 hours, 48 hours, and 28 days. Additional variables assessed included total blood products transfused, the hospital and intensive care unit length of stay, systolic blood pressure taken prior to TXA administration, Glasgow Coma Score observed prior to TXA administration, and the incidence of known adverse events associated with TXA administration. Results We included 724 patients in the final analysis, with 362 patients in the TXA group and 362 in the control group. Reduced mortality was noted at 28 days in the TXA group in comparison to the control group (3.6% vs. 8.3% for TXA and control, respectively, odds ratio [OR]=0.41 with 95% confidence interval [CI] [0.21 to 0.8]). This mortality difference was greatest in severely injured patients with ISS >15 (6% vs 14.5% for TXA and control, respectively, OR=0.37 with 95% CI [0.17 to 0.8]). Furthermore, a significant reduction in total blood product transfused was observed after TXA administration in the total cohort as well as in severely injured patients. No significant increase in known adverse events following TXA administration were observed. Conclusion Findings from the Cal-PAT study suggest that TXA use in the civilian prehospital setting may safely improve survival outcomes in patients who have sustained traumatic injury with signs of hemorrhagic shock.
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Affiliation(s)
- Michael M Neeki
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.,California University of Sciences and Medicine, Colton, California
| | - Fanglong Dong
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California
| | - Jake Toy
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California
| | - Reza Vaezazizi
- Inland Counties Emergency Medical Agency, San Bernardino, California.,Riverside County Emergency Services Agency, Riverside, California
| | - Joe Powell
- City of Rialto Fire Department, Rialto, California
| | - David Wong
- Arrowhead Regional Medical Center, Department of Surgery, Colton, California.,California University of Sciences and Medicine, Colton, California
| | - Michael Mousselli
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California
| | - Massoud Rabiei
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California
| | - Alex Jabourian
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California
| | - Nichole Niknafs
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California
| | | | - Richard Vara
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California
| | - Shanna Kissel
- Riverside County Emergency Services Agency, Riverside, California
| | - Xian Luo-Owen
- Loma Linda University Medical Center, Department of General Surgery, Loma Linda, California
| | - Karen R O'Bosky
- Loma Linda University Medical Center, Department of General Surgery, Loma Linda, California
| | - Daniel Ludi
- Riverside University Health System Medical Center, Department of Surgery, Moreno Valley, California
| | - Karl Sporer
- Alameda County Emergency Medical Services Agency, San Leandro, California
| | - Troy Pennington
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.,California University of Sciences and Medicine, Colton, California
| | - Tommy Lee
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.,California University of Sciences and Medicine, Colton, California
| | - Rodney Borger
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.,California University of Sciences and Medicine, Colton, California
| | - Eugene Kwong
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.,California University of Sciences and Medicine, Colton, California
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24
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Increased risk of fibrinolysis shutdown among severely injured trauma patients receiving tranexamic acid. J Trauma Acute Care Surg 2018; 84:426-432. [DOI: 10.1097/ta.0000000000001792] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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25
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Yuan X, Wang J, Wang Q, Zhang X. Synergistic effects of intravenous and intra-articular tranexamic acid on reducing hemoglobin loss in revision total knee arthroplasty: a prospective, randomized, controlled study. Transfusion 2018; 58:982-988. [PMID: 29399799 DOI: 10.1111/trf.14477] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 11/15/2017] [Accepted: 11/15/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Xiangwei Yuan
- Department of Orthopaedics; Shanghai Sixth People's Hospital, Shanghai Jiao Tong University; Shanghai China
| | - Jiaxing Wang
- Department of Orthopaedics; Shanghai Sixth People's Hospital, Shanghai Jiao Tong University; Shanghai China
| | - Qiaojie Wang
- Department of Orthopaedics; Shanghai Sixth People's Hospital, Shanghai Jiao Tong University; Shanghai China
| | - Xianlong Zhang
- Department of Orthopaedics; Shanghai Sixth People's Hospital, Shanghai Jiao Tong University; Shanghai China
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Primary lower limb joint replacement and tranexamic acid: an observational cohort study. Arthroplast Today 2018; 4:330-334. [PMID: 30186916 PMCID: PMC6123173 DOI: 10.1016/j.artd.2017.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/05/2017] [Accepted: 12/06/2017] [Indexed: 12/25/2022] Open
Abstract
Background This work aimed to evaluate the efficacy and safety of routine tranexamic acid (TXA) use in elective orthopaedic lower limb joint replacement surgery. Methods This retrospective cohort study included all primary hip or knee replacement procedures by a single surgeon over a 6-year period. TXA was introduced during the study period as part of an enhanced recovery after surgery strategy. Results Of the 673 procedures, 446 cases (66.3%) received TXA. The median length of stay was 5 days (2-69) and 6 days (3-28) for the TXA and control groups, respectively (P < .001). Blood transfusion was required for 28 (6.3%) of the TXA cases versus 40 (17.6%) controls (P < .001). Complication rates were similar irrespective of TXA status. At multivariate analysis, TXA was significantly and independently associated with fewer blood transfusions (hazard ratio 0.309, 95% confidence interval: 0.168-0.568, P < .001), with a number needed to treat of 9 cases. TXA use was estimated to save between £67.89 and £155.90 per case. Conclusions Routine prophylactic TXA administration for elective primary hip and knee replacement reduces the likelihood of postoperative transfusion with a number needed to treat of 9. Cost savings may be as high as £155.90 per case, and no safety concerns were noted.
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Hassen GW, Clemons P, Kaplun M, Kalantari H. Is topical tranexamic acid a better alternative for selected cases of anterior epistaxis management in the ED? Am J Emerg Med 2018; 36:734.e1-734.e2. [PMID: 29310981 DOI: 10.1016/j.ajem.2018.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/03/2018] [Indexed: 11/18/2022] Open
Abstract
Epistaxis is a well-known problem that is mostly self-limited. In certain cases it requires packing or cauterization. Tranexamic acid has been tried and has shown promising results. Here we report a case of prolonged epistaxis in a patient on dual anti-platelet agent therapy.
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Affiliation(s)
- Getaw Worku Hassen
- NYU Langone Hospital-Brooklyn, Department of Emergency Medicine, Brooklyn, NY, United States; NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, New York, NY, United States.
| | - Paula Clemons
- NYU Langone Hospital-Brooklyn, Department of Emergency Medicine, Brooklyn, NY, United States
| | - Michelle Kaplun
- NYU Langone Hospital-Brooklyn, Department of Clinical Pharmacy, Brooklyn, NY, United States
| | - Hossein Kalantari
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, New York, NY, United States
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