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Mergoum AM, Mergoum AS, Larson NJ, Dries DJ, Cook A, Blondeau B, Rogers FB. Tranexamic Acid Use in the Surgical Arena: A Narrative Review. J Surg Res 2024; 302:208-221. [PMID: 39106732 DOI: 10.1016/j.jss.2024.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/02/2024] [Accepted: 07/07/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION Tranexamic acid (TXA) is a potent antifibrinolytic drug that inhibits the activation of plasmin by plasminogen. While not a new medication, TXA has quickly gained traction across a variety of surgical subspecialties to prevent and treat bleeding. Knowledge on the use of this drug is essential for the modern surgeon to continue to provide excellent care to their patients. METHODS A comprehensive review of the PubMed database was conducted of articles published within the last 10 y (2014-2024) relating to TXA and its use in various surgical subspecialties. Seminal studies regarding the use of TXA older than 10 y were included from the author's archives. RESULTS Indications for TXA are not limited to trauma alone, and TXA is utilized across a variety of surgical subspecialties from neurosurgery to hepatic surgery to control hemorrhage. Overall, TXA is well tolerated with common dose-dependent adverse effects, including headache, nasal symptoms, dizziness, nausea, diarrhea, and fatigue. More severe adverse events are rare and easily mitigated by not exceeding a dose of 50 mg/kg. CONCLUSIONS The administration of TXA as an adjunct to treat trauma saves lives. The ability of TXA to induce seizures is dose dependent with identifiable risk factors, making this serious adverse effect predictable. As for the potential for TXA to cause thrombotic events, uncertainty remains. If this association is proven to be real, the risk will likely be small, since the use of TXA is still advantageous in most situations because of its efficacy for a more common concern, bleeding.
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Affiliation(s)
| | - Adel S Mergoum
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | - Alan Cook
- Department of Surgery, University of Texas at Tyler School of Medicine, Tyler, Texas
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
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Karageorgos S, Ren D, Ranaweera M, Casey S, Solan T, Hibberd O, Hall D. Fifteen-minute consultation: a guide to paediatric major haemorrhage. Arch Dis Child Educ Pract Ed 2024:edpract-2024-327224. [PMID: 38914447 DOI: 10.1136/archdischild-2024-327224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/25/2024] [Indexed: 06/26/2024]
Abstract
Major trauma is a principal cause of morbidity and mortality in children. Severe haemorrhage is the second-leading cause of death in paediatric trauma, preceded by traumatic brain injury. Major haemorrhage protocols (MHPs), also known as 'code red' and 'massive transfusion protocols', are used to make large volumes of blood products rapidly available. Most recommendations for paediatric MHPs are extrapolated from adult data because of a lack of large, high-quality, prospective paediatric studies. However, applying adult data in a paediatric context requires caution due to differences in injury mechanisms and physiological responses between adults and children. Since major haemorrhage is a high-acuity low-occurrence event, MHP requires effective training, collaboration and communication among a large multidisciplinary team.In this 15-minute consultation, we provide an evidence-based synthesis of the management principles of paediatric major haemorrhage.
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Affiliation(s)
- Spyridon Karageorgos
- Aghia Sophia Children's Hospital, Athens, Greece
- Blizard Institute, Queen Mary University of London Faculty of Medicine and Dentistry, London, UK
| | - Dennis Ren
- Blizard Institute, Queen Mary University of London Faculty of Medicine and Dentistry, London, UK
- Division of Emergency Medicine, Children's National Hospital, Washington, Columbia, USA
| | - Melanie Ranaweera
- Blizard Institute, Queen Mary University of London Faculty of Medicine and Dentistry, London, UK
| | - Sean Casey
- Blizard Institute, Queen Mary University of London Faculty of Medicine and Dentistry, London, UK
- Department of Paediatrics, Children's Health Ireland, Dublin, Ireland
| | - Tom Solan
- Blizard Institute, Queen Mary University of London Faculty of Medicine and Dentistry, London, UK
- Emergency Department, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Owen Hibberd
- Blizard Institute, Queen Mary University of London Faculty of Medicine and Dentistry, London, UK
- Emergency and Urgent Care Research in Cambridge (EURECA), PACE Section, Department of Medicine, Cambridge University, Cambridge, UK
| | - Dani Hall
- Blizard Institute, Queen Mary University of London Faculty of Medicine and Dentistry, London, UK
- Department of Paediatric Emergency Medicine, Children's Health Ireland at Crumlin, Dublin, Ireland
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Ciorba MC, Maegele M. Polytrauma in Children. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:291-297. [PMID: 38471125 PMCID: PMC11381203 DOI: 10.3238/arztebl.m2024.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Inadequate clinical experience still causes uncertainty in the acute diagnostic evaluation and treatment of polytrauma in children (with or without coagulopathy). This review deals with the main aspects of the acute care of severely injured children in the light of current guidelines and other relevant literature, in particular airway control, volume and coagulation management, acute diagnostic imaging, and blood coagulation studies in the shock room. METHODS This review is based on literature retrieved by a selective search in PubMed, Medline (OVIDSP), the Cochrane Central Register of Controlled Trials, and Epistemonikos covering the period January 2001 to August 2023. Review articles and the updated S2k clinical practice guideline on polytrauma management in childhood were considered. RESULTS Most accidents in childhood occur at home and in the child's free time, with varying mechanisms and patterns of injury depending on age. The outcome of treatment depends largely on the presence or absence or traumatic brain injury, which affects 66% of children with polytrauma and is thus the most common type of injury in this group, and of hemorrhagic shock with or without coagulopathy. Acute care follows the ABCDE algorithms with attention to special features in children, including age-specific reference values. According to a registry study, coagulopathy and hypovolemic shock are associated with 22% and 17% mortality, respec - tively. Treatment in a pediatric trauma reference center of the trauma network is recommended. Computed tomography (CT) should be carried out in children in accordance with defined criteria (PECARN), as a team decision and with the use of age-specific low-dose CT protocols. In children as in adults, viscoelasticity-based point-of-care tests enable the prompt diagnosis of relevant coagulopathies and their treatment in consideration of age-specific target values. The administration of tranexamic acid remains controversial. CONCLUSION 4% of polytrauma patients are children. Because children differ from adults both anatomically and physiologically, the diagnostic evaluation and management of polytrauma in children presents a special challenge. The evidence base for pediatric polytrauma management is still inadequate; current recommendations are based on consensus, in consideration of the special features of children compared to adults.
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Affiliation(s)
- Monica Christine Ciorba
- Department of Orthopedics, Trauma Surgery and Sports Traumatology, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany; Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Campus, Cologne, Germany
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Arsenault V, Lieberman L, Akbari P, Murto K. Canadian tertiary care pediatric massive hemorrhage protocols: a survey and comprehensive national review. Can J Anaesth 2024; 71:453-464. [PMID: 38057534 DOI: 10.1007/s12630-023-02641-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/27/2023] [Accepted: 07/09/2023] [Indexed: 12/08/2023] Open
Abstract
PURPOSE Hemorrhage is the leading cause of pediatric death in trauma and cardiac arrest during surgery. Adult studies report improved patient outcomes using massive hemorrhage protocols (MHPs). Little is known about pediatric MHP adoption in Canada. METHODS After waived research ethics approval, we conducted a survey of Canadian pediatric tertiary care hospitals to study MHP activations. Transfusion medicine directors provided hospital/patient demographic and MHP activation data. The authors extracted pediatric-specific MHP data from requested policy/procedure documents according to seven predefined MHP domains based on the literature. We also surveyed educational and audit tools. The analysis only included MHPs with pediatric-specific content. RESULTS The survey included 18 sites (100% response rate). Only 13/18 hospitals had pediatric-specific MHP content: eight were dedicated pediatric hospitals, two were combined pediatric/obstetrical hospitals, and three were combined pediatric/adult hospitals. Trauma was the most common indication for MHP activation (54%), typically based on a specific blood volume anticipated/transfused over time (10/13 sites). Transport container content was variable. Plasma and platelets were usually not in the first container. There was little emphasis on balanced plasma/platelet to red-blood-cell ratios, and most sites (12/13) rapidly incorporated laboratory-guided goal-directed transfusion. Transfusion thresholds were consistent with recent guidelines. All protocols used tranexamic acid and eight sites used an audit tool. DISCUSSION/CONCLUSION Pediatric MHP content was highly variable. Activation demographics suggest underuse in nontrauma settings. Our findings highlight the need for a consensus definition for pediatric massive hemorrhage, a validated pediatric MHP activation tool, and prospective assessment of blood component ratios. A national pediatric MHP activation repository would allow for quality improvement metrics.
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Affiliation(s)
- Valérie Arsenault
- Division of Transfusion Medicine, Department of Laboratory Medicine, University of Montreal, Montreal, QC, Canada
- Centre Hospitalier Universitaire (CHU) Sainte-Justine, Mother and Child Hospital of Montreal, Montreal, QC, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Pegah Akbari
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Kimmo Murto
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada.
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd., Ottawa, ON, K1H 8L1, Canada.
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Faraoni D, Fenger-Eriksen C. Dosing of tranexamic acid in trauma. Curr Opin Anaesthesiol 2024; 37:125-130. [PMID: 38390911 DOI: 10.1097/aco.0000000000001357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW Tranexamic acid is routinely used as part of the management of traumatic bleeding. The dose recommendation in trauma was extrapolated from other clinical settings and the results of pragmatic randomized trials rather than pharmaco-kinetic and -dynamic evaluations. The review addresses current evidence on dosing of tranexamic acid in traumatized patients with a focus on efficacy, safety and risk-benefit profile. RECENT FINDINGS A majority, but not all, of existing randomized clinical trials reports a reduction in mortality and/or blood loss with tranexamic acid administration. Increasing dose above the general recommendation (1 g bolus + 1 g infusion/8 h intravenously) has not been shown to further increase efficacy and could potentially increase side effects. SUMMARY The benefit of tranexamic acid as adjuvant therapy in the management of bleeding trauma patients on mortality and transfusion requirements is clear and well documented, being most effective if given early and to patients with clinical signs of hemorrhagic shock. Recent reports suggest that in some patients presenting with a shutdown of their fibrinolytic pathway the administration of tranexamic acid could be associated with an increased risk of thromboembolic events and poor outcomes. A more personalized approach based on bedside assessment of fibrinolytic activation and pharmacokinetic-based dose regimen should be developed moving forward.
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Affiliation(s)
- David Faraoni
- Arthur S. Keats Division of Pediatric. Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Christian Fenger-Eriksen
- Department of Anesthesiology and Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Franchini M, Focosi D, Zaffanello M, Mannucci PM. Efficacy and safety of tranexamic acid in acute haemorrhage. BMJ 2024; 384:e075720. [PMID: 38176733 DOI: 10.1136/bmj-2023-075720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy
| | - Marco Zaffanello
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Georgette N, Lipton G, Li J. Balanced resuscitation: application to the paediatric trauma population. Curr Opin Pediatr 2023; 35:303-308. [PMID: 36762640 DOI: 10.1097/mop.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Trauma is the leading cause of death in children over 5 years old. Early mortality is associated with trauma-induced coagulopathy (TIC), with balanced resuscitation potentially mitigating the effects of TIC. We review TIC, balanced resuscitation and the best evidence for crystalloid fluid versus early blood products, massive transfusion protocol (MTP) and the optimal ratio for blood products. RECENT FINDINGS Crystalloid fluids have been associated with adverse events in paediatric trauma patients. However, the best way to implement early blood products remains unclear; MTP has only shown improved time to blood products without clear clinical improvement. The indications to start blood products are also currently under investigation with several scoring systems and clinical indications being studied. Current studies on the blood product ratio suggest a 1 : 1 ratio for plasma:pRBC is likely ideal, but prospective studies are needed to further support its use. SUMMARY Balanced resuscitation strategies of minimal crystalloid use and early administration of blood products are associated with improved morbidity in paediatric trauma patients but unclear mortality benefit. Current evidence suggests that the utilization of MTPs with 1 : 1 plasma:pRBC ratio may improve morbidity, but more research is needed.
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Affiliation(s)
- Nathan Georgette
- Boston Children's Hospital, Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Borgman MA, Nishijima DK. Tranexamic acid in pediatric hemorrhagic trauma. J Trauma Acute Care Surg 2023; 94:S36-S40. [PMID: 36044459 DOI: 10.1097/ta.0000000000003775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT There is strong evidence in adult literature that tranexamic acid (TXA) given within 3 hours from injury is associated with improved outcomes. The evidence for TXA use in injured children is limited to retrospective studies and one prospective observational trial. Two studies in combat settings and one prospective civilian US study have found association with improved mortality. These studies indicate the need for a randomized controlled trial to evaluate the efficacy of TXA in injured children and to clarify appropriate timing, dose and patient selection. Additional research is also necessary to evaluate trauma-induced coagulopathy in children. Recent studies have identified three distinct fibrinolytic phenotypes following trauma (hyperfibrinolysis, physiologic fibrinolysis, and fibrinolytic shutdown), which can be identified with viscohemostatic assays. Whether viscohemostatic assays can appropriately identify children who may benefit or be harmed by TXA is also unknown.
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Affiliation(s)
- Matthew A Borgman
- From the Brooke Army Medical Center (M.A.B.), Uniformed Services University, Ft. Sam Houston, Texas; and UC Davis Medical Center (D.K.N.), University of California, Sacramento, California
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Russell RT, Bembea MM, Borgman MA, Burd RS, Gaines BA, Jafri M, Josephson CD, Leeper CM, Leonard JC, Muszynski JA, Nicol KK, Nishijima DK, Stricker PA, Vogel AM, Wong TE, Spinella PC. Pediatric traumatic hemorrhagic shock consensus conference research priorities. J Trauma Acute Care Surg 2023; 94:S11-S18. [PMID: 36203242 PMCID: PMC9805504 DOI: 10.1097/ta.0000000000003802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Traumatic injury is the leading cause of death in children and adolescents. Hemorrhagic shock remains a common and preventable cause of death in the pediatric trauma patients. A paucity of high-quality evidence is available to guide specific aspects of hemorrhage control in this population. We sought to identify high-priority research topics for the care of pediatric trauma patients in hemorrhagic shock. METHODS A panel of 16 consensus multidisciplinary committee members from the Pediatric Traumatic Hemorrhagic Shock Consensus Conference developed research priorities for addressing knowledge gaps in the care of injured children and adolescents in hemorrhagic shock. These ideas were informed by a systematic review of topics in this area and a discussion of these areas in the consensus conference. Research priorities were synthesized along themes and prioritized by anonymous voting. RESULTS Eleven research priorities that warrant additional investigation were identified by the consensus committee. Areas of proposed study included well-designed clinical trials and evaluations, including increasing the speed and accuracy of identifying and treating hemorrhagic shock, defining the role of whole blood and tranexamic acid use, and assessment of the utility and appropriate use of viscoelastic techniques during early resuscitation. The committee recommended the need to standardize essential definitions, data elements, and data collection to facilitate research in this area. CONCLUSION Research gaps remain in many areas related to the care of hemorrhagic shock after pediatric injury. Addressing these gaps is needed to develop improved evidence-based recommendations for the care of pediatric trauma patients in hemorrhagic shock.
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Affiliation(s)
- Robert T. Russell
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham, AL
| | - Melania M. Bembea
- Division of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew A. Borgman
- Department of Pediatrics, Brooke Army Medical Center, Uniformed Services University
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Barbara A. Gaines
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC Children’s Hospital, Pittsburgh, PA
| | - Mubeen Jafri
- Division of Pediatric Surgery, Doernbecher Children’s Hospital, Oregon Health and Science University, Portland, OR
| | - Cassandra D. Josephson
- Department of Oncology, Sydney Kimmel Cancer Center, Johns Hopkins University School of Medicine, Baltimore MD, and Cancer and Blood Disorders Institute, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Christine M. Leeper
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Julie C. Leonard
- Department of Pediatrics, Division of Emergency Medicine, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Jennifer A. Muszynski
- Division of Critical Care Medicine, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Kathleen K. Nicol
- Department of Pathology and Laboratory Medicine, The Ohio State University College of Medicine Nationwide Children’s Hospital, Columbus, OH
| | - Daniel K. Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Paul A. Stricker
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Adam M. Vogel
- Divisions of Pediatric Surgery and Critical Care, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Trisha E. Wong
- Division of Pediatric Hematology and Oncology and Department of Pathology, Oregon Health and Science University, Portland, OR
| | - Philip C. Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center. Pittsburgh, PA
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Fu Z, Liu L, Chen J, Ning N. Comment on “Effectiveness and safety of tranexamic acid in pediatric trauma: A systematic review and meta-analysis”. Am J Emerg Med 2022; 59:184-185. [DOI: 10.1016/j.ajem.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 05/03/2022] [Indexed: 10/18/2022] Open
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