Efficacy of topical tranexamic acid in epistaxis: A systematic review and meta-analysis

Reducing Surgery for Pediatric Posttonsillectomy Hemorrhage Using Tranexamic Acid: A Quality Improvement Initiative

OBJECTIVE

Evaluate the use of tranexamic acid (TXA) and observation as a management option for pediatric patients presenting with posttonsillectomy hemorrhage (PTH).

STUDY DESIGN

Retrospective analysis of a prospectively implemented quality improvement initiative with a historical control comparison group.

SETTING

Tertiary children's hospital.

METHODS

Patients <18 years of age who underwent adenotonsillectomy (AT) and returned to the Emergency Department for PTH were included. Patients who were stable without large volume or active bleeding were given intravenous TXA and admitted for overnight observation. Data were compared in a before-and-after analysis: preprotocol (April 2022 to March 2023) versus postprotocol (April 2023 to March 2024). For cost-effectiveness analysis, we analyzed aggregated claims data from a commercial claims database.

RESULTS

Preprotocol 1800 adenotonsillectomies were performed, and 40 procedures were performed for control of hemorrhage (2.2 per 100 AT). Postprotocol 2356 adenotonsillectomies were performed, and 30 procedures were performed to control hemorrhage (1.3 per 100 AT) showing a significant reduction in return to the operating room (relative risk [RR] = 0.59, 95% confidence interval [CI] [0.358, 0.916], P-value .020). There were no reported adverse events attributable to TXA. An estimated 21 surgeries were avoided, and 26 additional patients were observed in the hospital during the postprotocol period, for an estimated net cost savings of $174,970.

CONCLUSION

The implementation of a standardized TXA protocol significantly reduced the need for return to the operating room for PTH in pediatric patients, without complications and with net cost savings to the health care system.

Is Topical Tranexamic Acid Effective in Treating Epistaxis?

Topical tranexamic acid is used to treat epistaxis. We reviewed the evidence for this practice, and found based on the current literature, it may be a useful adjunct in managing epistaxis.

Appropriate dose of tranexamic acid in the topical treatment of anterior epistaxis, 500 mg vs 1000 mg: A double-blind randomized controlled trial

AIMS

Patients with epistaxis typically visit the emergency department for initial treatment. According to recent studies, tranexamic acid (TXA) is effective in the treatment of epistaxis. This study compared the therapeutic superiority of saline to that of 500 and 1000 mg doses of topical TXA for the treatment of anterior epistaxis. Materials and methods: This phase 4 clinical trial was a randomized, controlled, and double-blind trial. A total of 152 patients were divided into three groups. Group 1 was treated with 1000 mg TXA, Group 2 with 500 mg TXA, and Group 3 with saline. Results: Based on multinomial logistic regression analysis, the bleeding frequency at the 5th minute was 2.9 times and rebleeding status was 4.3 times less in Group 1 (1000 mg TXA) than in Group 3 (saline). There were no differences between the three groups in terms of side effects or salvage therapy. Conclusion: In addition to its superiority in treatment, 1000 mg of TXA is recommended because of the decreased rate of recurrent bleeding and low incidence of side effects.

Topical Tranexamic Acid to Control Vaginal Laceration Bleeding after Sexual Assault

BACKGROUND

Sexual assault survivors may sustain vaginal trauma that requires intervention in the emergency department, or operating room.

CASE REPORT

We describe the case of a 16-year-old female who was referred to the emergency department for evaluation of continued bleeding from a vaginal laceration following sexual assault 38 h prior. The bleeding limited the medical forensic medical examination, but she was hemodynamically stable. After the application of tranexamic acid (TXA)-soaked gauze, the patient's bleeding was controlled and the wound was able to be evaluated and the examination completed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is the first case in the literature that describes the use of topical TXA in a patient to achieve hemostasis in a vaginal laceration sustained from sexual violence.

When to use tranexamic acid for the treatment of major bleeding?

Tranexamic acid (TXA) is an antifibrinolytic agent originally developed for the management of bleeding in the setting of postpartum hemorrhage (PPH). Over the last 15 years, there has been accumulating evidence on the use of TXA for the treatment of active bleeding in a variety of clinical contexts. Clinical trials have shown that the efficacy and safety of TXA for the treatment of bleeding differ according to the clinical context in which it is being administered, timing of administration, and dose. Early administration is important for efficacy, particularly in trauma and PPH. Further studies are needed to understand the mechanisms by which TXA provides benefit, optimal modes of administration and dosing, and its effect in some clinical settings, such as spontaneous intracerebral hemorrhage. There is no evidence that TXA increases the risk of thrombotic events in patients with major bleeding overall. However, there is evidence of increased risk of venous thrombosis in patients with gastrointestinal bleeding. There is also evidence of increased risk of seizures with the use of higher doses. This review summarizes the current evidence for the use of TXA for patients with active bleeding and highlights the importance of generating evidence of efficacy and safety of hemostatic interventions specific to the bleeding contexts-as findings from 1 clinical setting may not be generalizable to other contexts-and that of individual patient assessment for bleeding, thrombotic, and other risks, as well as important logistical and other practical considerations, to optimize care and outcomes in these settings.

Topical Tranexamic Acid: Risks, Benefits and Novel Complications in Aesthetic Plastic Surgery

Antifibrinolytics, particularly tranexamic acid (TXA), are agents used to reduce bleeding. TXA is a synthetic reversible competitive inhibitor to the lysine receptor found on plasminogen. By reversibly binding to this site, it leads to plasminogen being unable to bind to fibrin and so prevents fibrinolysis, this stabilizes the clot and thus prevents hemorrhage. (Pekrul in Der Anaesth 70:515-521, 2021) It can be used either intravenously or topically but has never entered mainstream use in plastic surgery. (Pekrul in Der Anaesth 70:515-521, 2021) This is most likely due to understandable fears of thromboembolic events. On the other hand, the tempting benefits are reduced bleeding (perioperatively) decreased bruising and swelling, and thus increased aesthetic, important for obvious reasons. A review of the literature was done to go deeper on this issue, examining topical use in aesthetic surgery. Clear benefit was shown in the literature, it could be postulated that it would not be unwise to consider more research on topical use of TXA in certain cases, the benefits could greatly outweigh the risks. Old fears and conceptions, unsupported by the literature at the time of writing, should not hold back further research, and the benefits shown could even potentially justify the topical use of these agents in the near future. Further studies evaluating the utility of TXA in Panniculectomy and Abdominoplasty surgery should be performed especially, since only one was found which reported no significant benefit. Minor complications were present, such as minor delayed post-auricular skin healing, temporary unilateral marginal mandibular neuropraxia and increased cumulative seroma volume. These were novel findings and could warrant further investigation as well. After performing a review of the literature, it was seen that topical TXA generally adds benefit in aesthetic plastic surgery, with no particularly significant complications. We would like to bring more attention to the issue and support more studies on TXA use. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Comparative effectiveness of various noninvasive local treatments in patients with epistaxis: A systematic review and network meta-analysis

BACKGROUND

The best initial strategy for managing epistaxis is unclear. We performed a systematic review and network meta-analysis (NMA) to compare the effectiveness of various noninvasive treatments for patients with epistaxis.

METHODS

We searched PubMed, Embase, and the Cochrane Library from inception to September 2022 without language restrictions. Randomized controlled trials (RCTs) assessing immediate hemostasis, 2-day and 7-day rebleeding outcomes, as well as the use of noninvasive interventions for the treatment of epistaxis were selected. Frequentist NMA was performed.

RESULTS

The systematic review included 20 RCTs (2994 participants) involving 12 different interventions. The NMA demonstrated that topical treatment with tranexamic acid (TXA) significantly reduced the odds of 2-day rebleeding compared with the control conservative treatment (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.21-0.61) and traditional anterior nasal packing (OR 0.45, 95% CI 0.26-0.76). The sensitivity analysis yielded robust results, and the overall evidence was high. Topical TXA significantly reduced the odds of 7-day rebleeding compared with traditional nasal packing (OR 0.33, 95% CI 0.15-0.70), with moderate evidence owing to the heterogeneous results. Despite the significant effects of topical TXA on achieving immediate hemostasis and Rapid Rhino nasal packing on preventing 2-day rebleeding compared to the control and traditional nasal packing, the evidence is low to very low due to heterogeneity, inconsistency, and within-study bias.

CONCLUSIONS

In the treatment of epistaxis, topical TXA may be superior to conservative treatment or traditional nasal packing, particularly in preventing 2-day rebleeding.

Epistaxis Treatment Options: Literature Review

Epistaxis means bleeding from nostrils, nasal cavity or nasopharynx. To summarize the available epistaxis treatment options. Methods: 61 articles published in the last 20 years were included. Duplicate records, irrelevant and inaccessible ones were excluded.  Epistaxis can be treated with first aid measures such as external pressure and ice packing and applying topical agents, e.g. oxymetazoline that stops 65-75% of nosebleeds in A&E. Also, with electrocautery which is more effective and has fewer recurrences (14.5% vs. 35.1%) than chemical cauterization and applying tranexamic acid that promotes hemostasis in 78% of patients, versus 35% and 31% respectively in patients treated with oxymetazoline and nasal packing. Furthermore, nasal packing can be applied with non-absorbable materials, e.g. petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel), Foley catheter, balloons (Rapid-Rhino), absorbable materials, e.g. nasal tampon (Nasopore), and with newer hemostatic materials which are more effective and with fewer complications, e.g. hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan) and fibrin glue. Moreover, epistaxis can be achieved with endoscopic ligation of arteries, mainly SPA, which is more effective than conventional nasal packing (97% vs. 62%), and with endoscopic cauterization which is more effective than ligation. Finally, for intractable cases embolization can be applied using gelatin sponge, foam, PVA and coils with 80% success rate and comparable efficacy and complications to surgical methods. Epistaxis can be dealt with various methods depending on patient's history and available resources. Newer hemostatic agents in combination with endoscopic methods have advantages over traditional methods.

Risk Factors for Severe Clinical Course in Epistaxis Patients

Purpose: Epistaxis is a common medical emergency that may require admission to the emergency department (ED) and treatment by an otolaryngologist. Currently, there are no widely accepted indications for hospitalization, and the decision is based on personal experience. Methods: A retrospective study of 1171 medical records of patients with epistaxis treated at our tertiary medical center ED from 2013 to 2018 with no age limit. The presence of recurrent epistaxis, a posterior source of bleeding, the need for hospitalization, the need for blood transfusion, or surgical intervention defined severe clinical course. Results: The 1171 admissions included 230 recurrent admissions for a total of 941 patients (60% males) who were treated by an otolaryngologist. The average age was 57.6 in the adult population (>15) and 6.6 in the pediatric population (≤15). Of all patients, 39% had hypertension; 39% took antiplatelet/anticoagulation therapy; 63% came during winter-a significant risk factor; 34 (2.9%) had reduced hemoglobin levels of >1gr%, but only 7 received a blood transfusion; 131 (11%) were hospitalized, and 21 (1.8%) required surgical control of the bleeding. Age (OR 1.02; CI 1.01-1.023), male sex (OR 2.07; CI 1.59-2.69), hypertension (OR 1.76; CI 1.27-2.45), and antiplatelet/anticoagulation therapy (OR 2.53; CI 1.93-3.33, OR 1.65; CI 1.11-2.44, respectively), were significantly correlated with severe clinical course. Conclusion: Epistaxis is significantly more common and severe in older male patients with hypertension or antiplatelet/anticoagulation therapy. However, few need a blood transfusion or surgical intervention. In borderline cases with no definitive indication for hospitalization, we suggest adopting these factors as indications for hospitalization due to their marked influence on the clinical course. Routine coagulation tests are indicated in patients treated with warfarin or combined antiplatelet + anticoagulation therapy.

Acute Hemorrhage on the Playing Field

Acute hemorrhage in sport is a common issue for the sideline professional. The severity of bleeding ranges from mild to severe and life- or limb-threatening. The mainstay of management of acute hemorrhage is achieving hemostasis. Hemostasis is frequently accomplished via direct pressure but may require more invasive management including tourniquet use or pharmacologic management. With concerns for internal bleeding, dangerous mechanism of injury, or signs of shock, prompt activation of the emergency action plan is required.

EFFECT OF IRRIGATION FLUID COMPOSITION ON HEMOSTASIS IN MOUSE BLEEDING MODELS

ABSTRACT

Introduction: Intraoperative irrigation, usually with normal saline (NS), aids in bleeding identification and management. We investigated the effect of different irrigation fluids, with additives, on hemostasis using two bleeding models. Methods: C57BL/6 J mice were subjected to a tail bleed model or uncontrolled abdominal hemorrhage via liver laceration followed by abdominal cavity irrigation. We compared NS, lactated Ringer's (LR), and PlasmaLyte. We examined NS and LR at different temperatures. Normal saline or LR with calcium (Ca 2+ ) or tranexamic acid (TXA) was studied. Results: Compared with room temperature (RT), increasing the temperature of the irrigation fluid to 37°C and 42°C reduced tail vein bleeding times substantially in both NS and LR (all P < 0.001), with no significant differences between the two fluids. At RT, LR, but not PlasmaLyte, substantially reduced bleeding times in comparison to NS ( P < 0.0001). Liver injury blood loss was lower with LR ( P < 0.01). Normal saline supplemented with 2.7 mEq/L of Ca 2+ decreased bleeding time and blood loss volume ( P < 0.001 and P < 0.01, respectively) to similar levels as LR. Normal saline with 150 mg/mL of TXA markedly reduced bleeding time ( P < 0.0001), and NS with 62.5 mg/mL TXA decreased blood loss ( P < 0.01). Conclusion: Whereas Ca 2+ - and TXA-supplemented NS reduced bleeding, LR remained superior to all irrigation fluid compositions. As LR contains Ca 2+ , and Ca 2+ -supplemented NS mirrored LR in response, Ca 2+ presence in the irrigation fluid seems key to improving solution's hemostatic ability. Because warming the fluids normalized the choice of agents, the data also suggest that Ca 2+ -containing fluids such as LR may be more suitable for hemostasis when used at RT.

Tranexamic acid administration practice in otolaryngology head & neck surgery; international survey

PURPOSE

Tranexamic acid (TXA) is a potent pro-coagulation drug. Pre-operative, preventive TXA administration and TXA use for active bleeding are established treatments in many medical situations; yet, less is known about its use in otolaryngology head and neck surgery practice. The primary study goals were: MATERIALS AND METHODS: This is an international survey exploring TXA administration strategy. The electronic, anonymous, questionnaire was emailed to all registered Israeli and American Otolaryngology Head and Neck Surgery (OHNS) physicians, investigating TXA administration: RESULTS: Overall, 317 otolaryngologists participated in the study. TXA was administered to 40.5 % of the pediatric population and 50 % of the adult patients when needed. Epistaxis was the most common indication for TXA administration (48-55 %). A small number of otolaryngologists, 4-13 %, recommended preventive TXA for various operations. More surgeons include TXA in their practice and adjusted the dose according to renal function in academic compared to non-academic medical centers and among otolaryngologists practicing in Israel compared to the United States.

CONCLUSIONS

TXA is provided by many otolaryngologists to treat active epistaxis but to a substantially lesser extent as a preventive measure. TXA is given to children and adults, some with substantial comorbidities. Treatment is more common among surgeons working in academic institutes and medical centers in Israel.