Clinical use of tranexamic acid: evidences and controversies

A therapeutic assessment of tranexamic acid on functional recovery after rotator cuff repair surgery: A study of early and mid-term follow-up

Purpose

To perform therapeutic assessment of tranexamic acid on functional recovery after rotator cuff repair surgery in terms of early and mid-term follow up.

Methods

From December 2021 to April 2023, a total of 40 patients with rotator cuff injury were enrolled and randomly assigned to two groups with equal number of patients, and all patients received shoulder arthroscopic surgery before receiving either tranexamic acid or normal saline managements. Patients in the experimental group, group A, treated with 2g tranexamic acid (diluted with normal saline to 20ml) via intra-articular injection, while patients in the control group (group B) received 20ml normal saline management. The whole process was conducted in accordance with randomized double-blind controlled trials. Clinical outcomes were assessed preoperatively and postoperatively via American Shoulder and Elbow Surgeons (ASES) score, a UCLA shoulder rating, a CONSTANT score, and visual analog scale (VAS). Early and mid-term follow-up were performed at 1 week, 1 month, 3 months, and 6 months after surgery.

Results

The ASES score and CONSTANT score at 1 month, 3 months and 6 months after operation in the tranexamic acid group were higher than those in the normal saline group (p < 0.05). Meanwhile, the UCLA score at 3 months and 6 months after operation in the tranexamic acid group was higher than that in the normal saline group (p < 0.05). In addition, the muscle strength score and external rotation value at 6 months after operation in the tranexamic acid group and normal saline group were higher than those in the normal saline group (p < 0.05). There was no significant difference in the VAS score between the two groups at each observation cut-off point (p > 0.05).

Conclusions

Injection of tranexamic acid after rotator cuff repair surgery plays an positive role on the recovery of patients muscle strength and tone as well as shoulder flexibility. Therapeutic assessment demonstrates the favorable clinic efficacy either early or mid-term follow-up.

Perioperative patient blood management in one-stage bilateral calcar-guided short stem hip arthroplasty

BACKGROUND

Total hip arthroplasty is the standard treatment for end stage osteoarthritis of the hip joint. In Germany about 180.000 procedures are performed every year. While most surgeries are performed unilaterally there is an increasing number of single-stage bilateral (SSBL) hip arthroplasties performed. The goal of this study was to demonstrate the safety of SSBL-procedures in terms of blood loss and blood transfusion rates using specific perioperative protocols.

METHODS

Data were collected from 469 patients who underwent one-stage bilateral hip arthroplasty in a single institution, between 2020 and 2023. The current study included patients who were operated on using a minimal-invasive anterolateral approach with a cementless calcar-guided short stem hip prosthesis. The patient's age, sex, comorbidities, medication and preoperative laboratory parameters were gathered as well as the intraoperative blood loss, postoperative hemoglobin levels, blood transfusions and the perioperative administration of tranexamic acid.

RESULTS

Out of 469 patients who underwent SSBL hip arthroplasty, nine (1.9%) required blood transfusions after surgery. In total, 14 red blood cell concentrates (RBC) were transfused (0.029 RBCs per patient). The use of tranexamic acid significantly reduced the need for RBCs (p-value 0.018). Female sex, older age (> 76 years), low body mass index and body weight as well as lower preoperative hemoglobin levels were associated with an increased risk of RBC transfusion.

DISCUSSION

This study demonstrated that SSBL hip arthroplasty, when combined with a minimally invasive approach (anterolateral in supine position), cementless short stem implants, and optimized blood management (including the use of tranexamic acid), is a safe procedure in terms of blood loss and transfusion risk.

Topical tranexamic acid prevents scar tissue formation following craniectomy in a rat model

BACKGROUND

We carried out a study to assess the efficacy of tranexamic acid in preventing scar tissue in the craniectomy area in rats.

METHOD

Our study consisted of control and tranexamic acid groups with 10 subjects each. All subjects underwent bilateral frontoparietal craniectomy. After craniectomy, cotton pads were applied to the surgical sites. In the controls, the pads were soaked with saline and in the tranexamic acid group the pads were soaked with 30 mg/kg tranexamic acid. Rats were decapitated 30 days after surgery. The degree of scar formation was evaluated pathologically and by electron microscopy. In pathologic evaluation, dura mater thickness, scar tissue density, and arachnoid involvement were evaluated.

RESULTS

The outcomes demonstrated that no adhesions were present in the rats of the Tranexamic acid group, whereas the control group exhibited severe scar tissue [eight of ten rats (80%)] with adhesions. Additionally, comparison between the two groups showed that the dura mater thickness of tranexamic acid animals was thinner than that of the control group animals. Similarly, the intensity of scar tissue density and the intensity of arachnoid involvement were much better than the control group.

CONCLUSIONS

Scar tissue formation following craniectomies represents a significant adverse outcome that may lead to various complications. Intraoperative topical application of tranexamic acid has demonstrated potential efficacy in preventing scar formation in the craniectomy region in rat models.

Discovery of BT-114143, a Novel and Potent Phosphoric Acid-Containing Small-Molecule Plasminogen Activation Inhibitor for Hyperfibrinolysis

Fibrinolysis, the natural process of blood clot dissolution regulated by plasmin, plays a crucial role in preserving vascular health. Nevertheless, if this process becomes hyperactive, it can lead to severe bleeding episodes, particularly in instances of traumatic injuries. Conventional antifibrinolytics such as ε-aminocaproic acid (EACA) and tranexamic acid (TXA) exhibit limited impact attributed to their modest potency. The substantial dosage volume necessary for effectiveness, along with safety concerns, especially when administered in high doses, further constrains their usage. In response to these challenges, we have engineered BT-114143, an innovative plasminogen activation inhibitor featuring a phosphoric acid functional group. Crafted through structure-based drug design and nonclassical bioisosteres, BT-114143 has demonstrated significant antifibrinolytic activity and target selectivity in extensive preclinical studies. Presently, BT-114143 is in Phase Ib clinical trials in China (CTR20222910), representing a noteworthy progression in antifibrinolytic therapy.

Value of Q-switched 755-nm alexandrite laser combined with topical tranexamic acid in the treatment of melasma

OBJECTIVE

To explore the clinical value of Q-switched 755-nm alexandrite laser combined with topical tranexamic acid in treating melasma.

METHODS

A total of 121 melasma patients treated at AIST Medical Cosmetology Hospital from July 2022 to January 2024 were retrospectively included. They were divided into two groups: the Laser Treatment Group (LTG, n=61), receiving Q-switched 755-nm alexandrite laser combined with topical tranexamic acid, and the Control Treatment Group (CTG, n=60), receiving only topical tranexamic acid. Clinical efficacy, skin scores before and after treatment, laboratory indicators, melanin index, dermoscopic scores for pigmentation and vascular components, dermoscopic typing improvement, adverse reactions, and recurrence rates were compared.

RESULTS

The treatment efficacy rate was 93.44% in the LTG, significantly higher than 81.67% in the CTG (P<0.05). After treatment, the LTG showed significantly lower Melasma Area and Severity Index (MASI) scores, skin lesion color, and area scores compared to the CTG (all P<0.05). No significant differences were found in malondialdehyde (MDA) and superoxide dismutase (SOD) levels (both P>0.05). The LTG had a lower melanin index and dermoscopic scores for telangiectasia and perifollicular pigmentation than the CTG (all P<0.05). The incidence of adverse reactions in the LTG was 11.48%, significantly lower than 40.00% in the CTG (P<0.05). The LTG also had a lower recurrence rate of 1.64% at 6-month follow-up, compared to 10.00% in the CTG (P<0.05).

CONCLUSION

Q-switched 755-nm alexandrite laser combined with topical tranexamic acid is highly effective in treating melasma, improving clinical symptoms, reducing oxidative stress and inflammation, and yielding better results in vascular proliferation and pigmentation. The treatment also demonstrated a low recurrence rate, suggesting its potential for broader use.

Does Perioperative Subcutaneous Heparin or Intravenous Tranexamic Acid Affect the Rate of Vascular Complications in Anterior Lumbar Interbody Fusion Procedures?

Introduction Anterior lumbar interbody fusion (ALIF) is a surgical technique commonly used to treat degenerative disk disease in the lower lumbar spine. As the procedure commonly involves retraction of the iliac arteries and veins, potential complications include deep vein thrombosis (DVT) and hemorrhagic vessel injuries. The goal of this retrospective review is to assess whether the use of intraoperative intravenous tranexamic acid (TXA), subcutaneous heparin (SCH), or neither is associated with clinical complications and surgical outcomes. Methods All patients undergoing ALIF from 2015 to 2023 at a tertiary academic medical center were reviewed. Intraoperative use of prothrombotic or anticoagulant and short- and long-term outcomes were assessed. Results One hundred seventy-nine patients were included; there were 81 (45.3%) female patients and an average age of 58.96 ± 13.34 years. Twenty-eight patients received SCH, 34 patients received TXA, and 117 received neither. The use of perioperative SCH or TXA in ALIF procedures did not result in statistically significant differences in complication rates or pain scores. Statistically significant differences were found with the use of coagulative intervention and blood transfusions, with the TXA requiring the fewest transfusions and the no-intervention group requiring the most. Patients receiving TXA were more likely to be discharged home without the need for any other services. Although not statistically significant, there was a trend of decreasing estimated blood loss (EBL) between the coagulation intervention groups, with no intervention having the highest EBL, followed by SCH and TXA. Conclusion The use of perioperative coagulative intervention in ALIF procedures did not result in a significant change in complication rates, hospital stays, or pain outcomes. The TXA group had a trend toward lower blood loss, no patients requiring a blood transfusion, a higher likelihood of being discharged home without any supplemental services, and the best neurologic outcomes. As such, further large and prospective trials should be performed to study the effect of TXA in ALIF patients further to determine whether patients undergoing ALIFs would benefit from TXA administration.

Hemostatic effect of oxidized regenerated cellulose vs. topical tranexamic acid in total knee arthroplasty-a prospective randomized controlled trial

Aims

This study compared the hemostatic effects and complications of oxidized regenerated cellulose (ORC) and topical TXA in total knee arthroplasty (TKA), thus providing a reference for the use of ORC as an alternative hemostatic agent to TXA in TKA.

Methods

A total of 105 patients were included in this study and randomized into blank control, ORC, and TXA groups. The primary outcomes were total blood loss, hemoglobin drop (Hb drop), transfusion rates, and incidence of thrombosis. The secondary outcomes included operation time, tourniquet duration, coagulation parameters, inflammation markers, and complication rates.

Results

Total blood loss was 1,002.47 ± 308.58 ml and 964.68 ± 273.00 ml in the ORC and TXA groups, respectively, both significantly lower than that in the blank control group (1,168.94 ± 405.04 ml) (P 1 = 0.043 and P 2 = 0.014, respectively). Hb Drop was statistically insignificantly different between the ORC (36.03 ± 12.17 g/L) and TXA (34.32 ± 10.19 g/L) groups (P = 0.555). There was no statistically significant difference in transfusion rate, operation time, tourniquet duration, coagulation parameters, inflammation markers, and complication rates among the three groups.

Conclusion

In conclusion, our prospective randomized controlled trial (RCT) highlights that, oxidized regenerated cellulose (ORC) can reduce postoperative invisible blood loss in total knee arthroplasty and achieve a hemostatic effect similar to topical tranexamic acid (TXA). This provides a safe and effective hemostatic option for patients with severe underlying diseases or contraindications to tranexamic acid.

Clinical Trial registration

https://www.chictr.org.cn/bin/project/edit?pid=186370, identifier (ChiCTR2200066633).

Surgical options for Evans-Jensen type IV intertrochanteric femur fractures in the elderly over 65: a comparison between total hip arthroplasty and proximal femoral nail antirotation

BACKGROUND

Currently, there is no clear standard for the surgical options for Evans-Jensen Type IV intertrochanteric femur fractures in elderly patients over 65 years old. This study aims to retrospectively analyze and compare the early postoperative limb function and quality of life of patients treated with total hip arthroplasty (THA) and proximal femoral nail antirotation (PFNA) for this type of fracture. We hypothesize that there is no significant difference in complications and postoperative recovery between the two surgical methods.

METHODS

A retrospective analysis was conducted on patients over 65 years old with Evans-Jensen Type IV intertrochanteric femur fractures who were treated between 2020 and 2023. The patients were divided into two groups based on the treatment method: the PFNA group (20 cases) and the THA group (20 cases). General patient information, operative time, intraoperative blood loss, time to postoperative mobilization, time to weight-bearing on the affected limb, Harris hip scores at 1, 3, and 6 months postoperatively, excellent and good rates, SF-36 scores, and postoperative complications were recorded.

RESULTS

Compared to the PFNA group, the THA group had a longer operative time (86.7 ± 9.6 vs. 51.5 ± 5.3 min, p < 0.001) and more intraoperative blood loss (212.0 ± 35.5 vs. 76.5 ± 16.1 ml, p < 0.001). However, the THA group had an earlier time to first postoperative mobilization (3.1 ± 1.4 vs. 43.3 ± 13.09 days, p < 0.001) and earlier time to full weight-bearing on the affected limb (33.5 ± 3.1 vs. 77.9 ± 12.0 days, p < 0.001). The Harris hip scores and SF-36 scores at 1, 3, and 6 months postoperatively were higher in the THA group (p < 0.05 for all). There was no significant difference in the overall incidence of postoperative complications between the two groups (p = 0.41).

CONCLUSION

For elderly patients over 65 years old with Evans-Jensen Type IV intertrochanteric femur fractures, especially those with underlying diseases who cannot tolerate prolonged bed rest, hip replacement surgery (THA) may be preferred. Postoperative patients can begin rehabilitation exercises earlier, preventing the exacerbation of internal medical conditions. Early recovery of hip function on the affected side is faster, and the quality of life of patients is higher.

Tranexamic Acid Application in Facial Aesthetic Surgery: An Umbrella Review

Tranexamic acid (TXA) is an antifibrinolytic agent that is considered as one of the latest interventions currently being investigated in the field of facial aesthetic surgeries, as it is predicted to be effective in reducing intraoperative and postoperative complications of facial aesthetic surgeries. This review focuses on giving readers a comprehensive overview regarding the use of TXA in facial aesthetic surgeries. In this umbrella review, data were extracted from existing systematic reviews and meta-analysis that focused on the use of TXA in facial aesthetic surgeries. The authors searched PubMed, Embase, and Scopus databases. The data were extracted using a standard format, and the AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews) tool was used to assess the quality of the included reviews. In total, this study included 14 systematic reviews and meta-analyses all of which evaluated the effect of TXA on facial aesthetic surgeries, which included rhinoplasty, septorhinoplasty, rhytidectomy, and blepharoplasty. The majority of the included studies focused on reporting the effect of TXA on blood loss volume (BLV) and duration of surgery (DOS) as well as other postoperative complications. Eleven out of the 12 studies that focused on rhinoplasty showed that TXA used reduced BLV. In addition, in 8 studies that were focusing on DOS, the majority showed a reduction in DOS with TXA use. While in the case of septorhinoplasty, 3 studies revealed that TXA use decreased BLV. Moreover, in the case of rhytidectomy, 3 out of 6 systematic reviews showed reduction in BLV, while 2 reported reductions in DOS. Finally, the authors conclude that the use of TXA is indeed efficient in reducing BLV and DOS, in addition to some of the complications that can occur during or after facial aesthetic surgeries. However, in order to reach a final decision on the implication of the use of TXA in facial aesthetic surgeries, further studies should be established using a standardized protocol in assessing the desired outcomes.

Accidental Intrathecal Tranexamic Acid Injection During Caesarean Section: A Case Report

Background: Tranexamic acid (TXA) is increasingly used in the management of haemorrhage during and after delivery and haemorrhage caused by other medical conditions due to its efficacy and safety. However, increasing report of fatal complications from inadvertent intrathecal TXA injection remains a cause of concern. The aim of this case report is to demonstrate clinical presentation and predictors of accidental intrathecal injection of TXA within the structure and processes of care in a health facility. Case Description: A 37-year-old woman, multiparous woman presented with a diagnosis of obstructed labour and, therefore, was scheduled for emergency caesarean section. She was assigned the American Society of Anesthesiology II physical status. Spinal anaesthesia was performed at a sitting position through L4-L5 interspace using a 25-G spinal needle gauge. The anaesthetist injected 3 mL of an aesthetic agent that was prepared earlier as hyperbaric bupivacaine 0.5%. About 2 min after receiving the injection, the patient reported gluteal discomfort and itching and severe back pain. She subsequently developed progressive altered mentation followed by generalized tonic-clonic seizures. General anaesthesia was conducted with propofol (100 mg), pethidine (50 mg) and suxamethonium (100 mg). Episodes of tonic-clonic seizures continued despite treatment with multiple doses of diazepam (10 mg), propofol (100 mg) and phenytoin infusion (1 gm). Postoperatively, the patient was transferred to the intensive care unit with persistent tachycardia (125-138 beats per minute), hypertension (157/105-175/118 mmHg) and oxygen saturation of 90%-95%. She died due to cardiac arrest after 21 h of stay. Conclusion: Medication error such as accidental intrathecal injection of TXA continues to jeopardise the safety of surgery under spinal anaesthesia.

Impact of Tranexamic Acid on Bleeding Outcomes and Complication Rates in Facelift: A Systematic Review and Meta-analysis

BACKGROUND

Rhytidectomy poses a significant risk of bleeding. Several studies have reported the safety profile and efficacy of tranexamic acid (TXA), an antifibrinolytic agent, in minimizing perioperative sequelae, particularly hematoma and bleeding.

OBJECTIVES

The aim of this systematic review was to analyze the effect of TXA administration in facelift surgery, its effect with different routes of administration, and to compare different administration routes in reducing intraoperative blood loss, postoperative edema, and ecchymosis in rhytidectomy.

METHODS

A systematic literature search was conducted to identify studies that reported on TXA in facelift surgery. The primary outcomes of interest were intraoperative blood loss, time to achieve hemostasis, operation duration, and postoperative hematoma, edema, ecchymosis, drain output, and major and minor complications. Meta-analyses of hematoma, operation duration, drain output, and major and minor complications were performed, and the risk of bias was assessed with ROBINS-I for nonrandomized studies, and Cochrane's RoB 2.0, a tool for randomized controlled trials.

RESULTS

In total, 104 articles were included in the initial screening. Out of 388 participants 170 patients were administered TXA, predominantly female (over 91%), with ages from the late 50s to mid-60s. TXA administration varied, with subcutaneous injection being the most common method. The meta-analysis revealed that the pooled prevalence of minor and major hematoma in TXA recipients was remarkably low, with a significant reduction in the risk of minor hematoma (odds ratio [OR] = 0.18, 95% CI 0.05-0.62, P < .001) and no significant difference in major hematoma risk. Interestingly, TXA significantly reduced postoperative drainage compared to the controls (mean difference = -25.59, 95% CI, -30.4--20.77, P < .01). Additionally, neither minor nor major complications were significantly different between the TXA recipients and controls. Specifically, the pooled odds for the incidence of major complications were not significantly different (OR = 1.47, 95% CI, 0.23-9.19, P = .68), and similar results were found for minor complications (OR = 0.59, 95% CI, 0.23-1.48, P = .26).

CONCLUSIONS

TXA significantly reduces postoperative drain output and minor hematomas in facelift surgery without increasing major complications. It also reduces edema, ecchymosis, and intraoperative blood loss. However, further studies are required to explore the efficacy of TXA with different dosages and administration routes.

LEVEL OF EVIDENCE: 3

Tranexamic acid may benefit patients with preexisting thromboembolic risk undergoing total joint arthroplasty: a systematic review and meta-analysis

Purpose

This study sought to determine if the use of tranexamic acid (TXA) in preexisting thromboembolic risk patients undergoing total joint arthroplasty (TJA) was linked to an increased risk of death or postoperative complications.

Methods

We conducted a comprehensive search for studies up to May 2023 in PubMed, Web of Science, EMBASE, and the Cochrane Library. We included randomized clinical trials, cohort studies, and case-control studies examining the use of TXA during TJA surgeries on high-risk patients. The Cochrane Risk of Bias instrument was used to gauge the excellence of RCTs, while the MINORS index was implemented to evaluate cohort studies. We used mean difference (MD) and relative risk (RR) as effect size indices for continuous and binary data, respectively, along with 95% CIs.

Results

Our comprehensive study, incorporating data from 11 diverse studies involving 812 993 patients, conducted a meta-analysis demonstrating significant positive outcomes associated with TXA administration. The findings revealed substantial reductions in critical parameters, including overall blood loss (MD = -237.33; 95% CI (-425.44, -49.23)), transfusion rates (RR = 0.45; 95% CI (0.34, 0.60)), and 90-day unplanned readmission rates (RR = 0.86; 95% CI (0.76, 0.97)). Moreover, TXA administration exhibited a protective effect against adverse events, showing decreased risks of pulmonary embolism (RR = 0.73; 95% CI (0.61, 0.87)), myocardial infarction (RR = 0.47; 95% CI (0.40-0.56)), and stroke (RR = 0.73; 95% CI (0.59-0.90)). Importantly, no increased risk was observed for mortality (RR = 0.53; 95% CI (0.24, 1.13)), deep vein thrombosis (RR = 0.69; 95% CI (0.44, 1.09)), or any of the evaluated complications associated with TXA use.

Conclusion

The results of this study indicate that the use of TXA in TJA patients with preexisting thromboembolic risk does not exacerbate complications, including reducing mortality, deep vein thrombosis, and pulmonary embolism. Existing evidence strongly supports the potential benefits of TXA in TJA patients with thromboembolic risk, including lowering blood loss, transfusion, and readmission rates.

The effect of the use of tranexamic acid in percutaneous nephrolithotomy on blood loss and surgical visual clarity: a prospective, randomized, controlled and double-blind study

Tranexamic acid, once a randomly used antifibrinolytic agent, has been in standard protocols for many specific surgeries. Studies are still needed to standardize the dose and route of tranexamic acid administration, examine its possible contributions in urological surgery, and establish a protocol for its use. To contribute to this goal, we designed a prospective, randomized, double-blind study on 75 patients with 1 control and 2 study groups (n = 25) who underwent percutaneous nephrolithotomy. Group Tranexamic acid received 10 mg/kg intravenous tranexamic acid preoperatively. And Group Irrigation received the same amount in the initial irrigation fluid. Primarily, we observed the total amount of blood transfusion and the changes in hemoglobin and hematocrit values during 2 postoperative days. Distinctively, we intraoperatively monitored hemoglobin continuously as a saturation hemoglobin value to assess the timing of the effect of tranexamic acid. Secondarily, we questioned surgical visual clarity with a standard visual score to reveal its contribution to surgical practicality, operative time, and residual fragment quantity. Our results revealed a significant difference in the reduction of hemoglobin and hematocrit change and blood transfusion in both tranexamic acid groups concerning control, especially on the second day (p = 0.003, p = 0.002, p = 0.001). Likewise, surgical visual scores were significantly better in both tranexamic acid groups (p = 0.018). In conclusion, intravenous or local administration of tranexamic acid at a dose of 10 mg/kg will be sufficient to maintain perioperative stability in hemoglobin values, use fewer blood products and provide a better visual advantage for the surgeon intraoperatively.The trial registration number is NCT05947435, and the date of registration is 07/07/2023, retrospectively registered.

The effect of tranexamic acid on synovium of patients undergoing arthroplasty and anterior cruciate ligament reconstruction surgery

Preoperative hemorrhage can be reduced using anti-fibrinolytic medicine tranexamic acid (TXA). During surgical procedures, local administration is being used more and more frequently, either as an intra-articular infusion or as a perioperative rinse. Serious harm to adult soft tissues can be detrimental to the individual since they possess a weak ability for regeneration. Synovial tissues and primary fibroblast-like synoviocytes (FLS) isolated from patients were examined using TXA treatment in this investigation. FLS is obtained from rheumatoid arthritis (RA), osteoarthritis (OA), and anterior cruciate ligament (ACL)-ruptured patients. The in vitro effect of TXA on primary FLS was investigated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell viability assays for cell death, annexin V/propidium iodide (PI) staining for apoptotic rate, real-time PCR for p65 and MMP-3 expression, and enzyme-linked immunosorbent assay (ELISA) for IL-6 measurement. MTT assays revealed a significant decrease in cell viability in FLS of all groups of patients following treatment with 0.8-60 mg/ml of TXA within 24 h. There was a significant increase in cell apoptosis after 24 h of exposure to TXA (15 mg/ml) in all groups, especially in RA-FLS. TXA increases the expression of MMP-3 and p65 expression. There was no significant change in IL-6 production after TXA treatment. An increase in receptor activator of nuclear factor kappa-Β ligand (RANK-L) production was seen only in RA-FLS. This study demonstrates that TXA caused significant synovial tissue toxicity via the increase in cell death and elevation of inflammatory and invasive gene expression in FLS cells.

Enhanced recovery after surgery: a narrative review on patient blood management recommendations

This review aims to analyze and document the presence of patient blood management (PBM) recommendations in enhanced recovery after surgery (ERAS) guidelines. The aim of ERAS programs is to improve outcomes and optimize patient recovery by reducing the stress response to surgery. PBM programs pursue the objective of improving outcomes by boosting and conserving the patient's own blood. From the early development of ERAS, there was little attention paid to the three pillars of perioperative blood management. Preoperative anemia is an important risk factor in perioperative outcomes and should be diagnosed and treated. Bleeding and unnecessary transfusions should be avoided. We analyzed clinical guidelines for scheduled surgery in adults published by the ERAS Society between 2018 and 2022. The guidelines selected were searched for recommendations related to the three pillars of PBM. We selected 15 ERAS guidelines in programmed surgery in adults. Until 2018, none of the ERAS guidelines analyzed included any recommendations related to pillars I and III of PBM. In 2019, recommendations related to the three pillars of PBM were introduced in the ERAS clinical guidelines for colorectal surgery, gynecology/oncology surgery, and lung resection surgery. However, many ERAS guidelines for surgeries with a high risk of bleeding, such as cardiac surgery, contain no clear recommendations on the management of preoperative anemia. This review shows that the ERAS guidelines published to date make very few recommendations related to PBM. The authors emphasize the need to include the most efficient PBM recommendations in ERAS clinical guidelines, given improved outcomes with a good perioperative management of blood transfusion.