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El Halawany M, Khashaba M, AbouGhaly MHH, Latif R. Tranexamic acid loaded in a physically crosslinked trilaminate dressing for local hemorrhage control: Preparation, characterization, and in-vivo assessment using two different animal models. Int J Pharm 2024; 659:124219. [PMID: 38734277 DOI: 10.1016/j.ijpharm.2024.124219] [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: 02/26/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/13/2024]
Abstract
This work aimed at formulating a trilaminate dressing loaded with tranexamic acid. It consisted of a layer of 3 % sodium hyaluronate to initiate hemostasis. It was followed by a mixed porous layer of 5 % polyvinyl alcohol and 2 % kappa-carrageenan. This layer acted as a drug reservoir that controlled its release. The third layer was 5 % ethyl cellulose backing layer for unidirectional release of tranexamic acid towards the wound. The 3 layers were physically crosslinked by hydrogen bonding as confirmed by Infrared spectroscopy. Swelling and release studies were performed, and results proposed that increasing number of layers decreased swelling properties and sustained release of tranexamic acid for 8 h. In vitro blood coagulation study was performed using human blood and showed that the dressing significantly decreased coagulation time by 70.5 % compared to the negative control. In vivo hemostatic activity was evaluated using tail amputation model in Wistar rats. Statistical analysis showed the dressing could stop bleeding in a punctured artery of the rat tail faster than the negative control by 59 %. Cranial bone defect model in New Zealand rabbits was performed to check for bone hemostasis and showed significant decrease in the hemostatic time by 80 % compared to the control.
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Affiliation(s)
- Mai El Halawany
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Kasr El-Ainy Street, Cairo 11562, Egypt.
| | - Mohamed Khashaba
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Cairo University, 12 Saray El Manial Street, Cairo 11562, Egypt
| | - Mohamed H H AbouGhaly
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Kasr El-Ainy Street, Cairo 11562, Egypt; Department of Pharmaceutics and Industrial Pharmacy, School of Pharmacy, Newgiza University, Km. 22 Cairo-Alex Road, Giza P.O. Box 12577, Egypt
| | - Randa Latif
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Kasr El-Ainy Street, Cairo 11562, Egypt
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Leite F, Benites BD, da Silva RL, Soriano S, Alves SDOC, Rizzo SRCP, Rabello G, Junior DML. Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Assessment and management of coagulation in the preoperative period. Hematol Transfus Cell Ther 2024; 46 Suppl 1:S24-S31. [PMID: 38521626 PMCID: PMC11069057 DOI: 10.1016/j.htct.2024.02.005] [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: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 03/25/2024] Open
Abstract
Managing coagulation disorders and potential bleeding risks, especially in the context of anticoagulant medications, is of immense value both clinically and prior to surgery. Coagulation disorders can lead to bleeding complications, affecting patient safety and surgical outcomes. The use of Patient Blood Management protocols offers a comprehensive, evidence-based approach that effectively addresses these challenges. The problem is to find a delicate balance between preventing thromboembolic events (blood clots) and reducing the risk of bleeding. Anticoagulant medications, although crucial to preventing clot formation, can increase the potential for bleeding during surgical procedures. Patient blood management protocols aim to optimize patient outcomes by minimizing blood loss and unnecessary transfusions.
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Affiliation(s)
- Flavia Leite
- Hemocentro de Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil
| | - Bruno Deltreggia Benites
- Centro de Hematologia e Hemoterapia da Universidade Estadual de Campinas (Hemocentro UNICAMP), Campinas, SP, Brazil
| | - Roberto Luiz da Silva
- Instituto Brasileiro de Controle do Câncer (IBCC), São Paulo, SP, Brazil; Hospital São Camilo Pompéia, São Paulo, SP, Brazil
| | - Selma Soriano
- Hemocentro Coordenador do Estado do Pará (Fundação HEMOPA), Belém, PA, Brazil
| | | | | | - Guilherme Rabello
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Incor - HCFMUSP), São Paulo, SP, Brazil.
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Kowalczyk JJ, Cecconi M, Butwick AJ. Evaluating tranexamic acid for the prevention and treatment of obstetric hemorrhage. Curr Opin Obstet Gynecol 2024; 36:88-96. [PMID: 38170626 DOI: 10.1097/gco.0000000000000935] [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: 01/05/2024]
Abstract
PURPOSE OF REVIEW Tranexamic acid (TXA) has emerged as a promising pharmacological adjunct to treat and prevent postpartum hemorrhage (PPH). We provide an overview of TXA, including its pharmacology, key findings of randomized trials and observational studies, and critical patient safety information. RECENT FINDINGS Pharmacokinetic data indicate that TXA infusions result in peak plasma concentration within 3 min (range: 1-6.6 min). Ex-vivo pharmacodynamic data suggest that low-dose TXA (5 mg/kg) inhibits maximum lysis for at least 1 h. In predominantly developing countries, TXA has demonstrated a 19% reduction in the risk of bleeding-related death among patients with PPH. Based on high-quality randomized trials, TXA prophylaxis does not effectively reduce the risk of PPH during vaginal delivery and is likely ineffective in reducing the PPH risk during cesarean delivery. TXA exposure does not increase the risk of maternal thrombotic events. Maternal deaths have occurred from accidental intrathecal TXA injection from look-alike medication errors. SUMMARY TXA has shown promise as an important adjunct for PPH treatment, especially in low-resource settings. However, TXA is not recommended as PPH prophylaxis during vaginal or cesarean delivery. Patient safety initiatives should be prioritized to prevent maternal death from accidental intrathecal TXA injection.
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Affiliation(s)
- John J Kowalczyk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maurizio Cecconi
- Biomedical Sciences Department, Humanitas University
- Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
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Piette N, Beck F, Carella M, Hans G, Maesen D, Kurth W, Lecoq JP, Bonhomme VL. Oral as compared to intravenous tranexamic acid to limit peri-operative blood loss associated with primary total hip arthroplasty: A randomised noninferiority trial. Eur J Anaesthesiol 2024; 41:217-225. [PMID: 38214552 DOI: 10.1097/eja.0000000000001950] [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: 01/13/2024]
Abstract
BACKGROUND Oral as compared to intravenous tranexamic acid (TXA) is an attractive option, in terms of cost and safety, to reduce blood loss and transfusion in total hip arthroplasty. Exclusion criteria applied in the most recent randomised trials may have limited the generalisability of oral tranexamic acid in this indication. Larger and more inclusive studies are needed to definitively establish oral administration as a credible alternative to intravenous administration. OBJECTIVES To assess the noninferiority of oral to intravenous TXA at reducing intra-operative and postoperative total blood loss (TBL) in primary posterolateral approached total hip arthroplasty (PLTHA). DESIGN Noninferiority, single centre, randomised, double-blind controlled study. SETTING Patients scheduled for primary PLTHA. Data acquisition occurred between May 2021 and November 2022 at the University Hospital of Liège, Belgium. PATIENTS Two hundred and twenty-eight patients, randomised in a 1 : 1 ratio from a computer-generated list, completed the trial. INTERVENTIONS Administration of 2 g of oral TXA 2 h before total hip arthroplasty and 4 h after incision (Group oral) was compared to the intravenous administration of 1 g of TXA 30 min before surgery and 4 h after incision (Group i.v.). MAIN OUTCOME MEASURES TBL (measured intra-operative and drainage blood loss up to 48 h after surgery, primary outcome), decrease in haemoglobin concentration, D-Dimer at day 1 and day 3, transfusion rate (secondary outcomes). RESULTS Analyses were performed on 108 out of 114 participants (Group i.v.) and 104 out of 114 participants (Group oral). Group oral was noninferior to Group i.v. with regard to TBL, with a difference between medians (95% CI) of 35 ml (-103.77 to 33.77) within the noninferiority margins. Median [IQR] of estimated TBL was 480 ml [350 to 565] and 445 ml [323 to 558], respectively. No significant interaction between group and time was observed regarding the evolution of TBL and haemoglobin over time. CONCLUSIONS TXA as an oral premedication before PLTHA is noninferior to its intravenous administration regarding peri-operative TBL. TRIAL REGISTRATION European Clinical Trial Register under EudraCT-number 2020-004167-29 ( https://www.clinicaltrialsregister.eu/ctr-search/trial/2020-004167-29/BE ).
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Affiliation(s)
- Nicolas Piette
- From the Department of Anaesthesia and Intensive Care Medicine (NP, FB, MC, GH, J-PL, VLB), Department of Clinical Pharmacy (DM), Department of Locomotor System Surgery, Liege University Hospital (WK), Inflammation and Enhanced Rehabilitation Laboratory (Regional Anaesthesia and Analgesia), GIGA-I3 Thematic Unit (NP, MC, J-PL), Anaesthesia and Perioperative Neuroscience Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium (FB, VLB)
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Moser MM, Schoergenhofer C, Jilma B. Progress in von Willebrand Disease Treatment: Evolution towards Newer Therapies. Semin Thromb Hemost 2024. [PMID: 38331000 DOI: 10.1055/s-0044-1779485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
von Willebrand disease (VWD) is a very heterogenous disease, resulting in different phenotypes and different degrees of bleeding severity. Established therapies (i.e., desmopressin, antifibrinolytic agents, hormone therapy for heavy menstrual bleeding, and von Willebrand factor [VWF] concentrates) may work in some subtypes, but not in all patients. In recent years, progress has been made in improving the diagnosis of VWD subtypes, allowing for more specific therapy. The impact of VWD on women's daily lives has also come to the fore in recent years, with hormone therapy, tranexamic acid, or recombinant VWF as treatment options. New treatment approaches, including the replacement of lacking factor VIII (FVIII) function, may work in those subgroups affected by severe FVIII deficiency. Reducing the clearance of VWF is an alternative treatment pathway; for example, rondaptivon pegol is a VWFA1 domain-binding aptamer which not only improves plasma VWF/FVIII levels, but also corrects platelet counts in thrombocytopenic type 2B VWD patients. These approaches are currently in clinical development, which will be the focus of this review. In addition, half-life extension methods are also important for the improvement of patients' quality of life. Targeting specific mutations may further lead to personalized treatments in the future. Finally, a few randomized controlled trials, although relatively small, have been published in recent years, aiming to achieve a higher level of evidence in future guidelines.
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Affiliation(s)
- Miriam M Moser
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Tan TK, Tan P, Wang K, Hau R. Effect of tranexamic acid on shoulder surgery: an updated meta-analysis of randomized studies. J Shoulder Elbow Surg 2024; 33:e97-e108. [PMID: 37890768 DOI: 10.1016/j.jse.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/05/2023] [Accepted: 09/10/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The effect of tranexamic acid (TXA) has been proven to be effective in reducing blood loss in lower limb arthroplasty. The aim of this study is to investigate the effect of TXA in shoulder surgery with the updated studies. MATERIALS AND METHODS A systematic review and meta-analysis of all the randomized controlled trials were conducted. We compared the outcomes of patients with and without TXA. The PubMed, MEDLINE, EMBASE, and CENTRAL databases were systematically searched for relevant studies. RESULTS A total of 14 studies, enrolling 1131 patients, were included for qualitative and quantitative analysis. Our results revealed that TXA was associated with a significant reduction in total volume blood loss (mean difference [MD]: -112.97, P = .0006), drain output (MD: -81.90, P < .00001), hemoglobin changes (MD: -0.55, P = .02), shorter operative time (MD: -6.19, P = .01), and lower risk of hematoma formation (odds ratio: -0.20, P = .01). The postoperative visual analog scale pain score was also significantly better in the TXA group (MD: -0.78, P < .00001). No significant difference was detected in length of hospital stay and incidence of thromboembolization. CONCLUSION The usage of TXA in shoulder surgery appeared to be safe and effective in reducing blood loss without any significant complication.
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Affiliation(s)
- Tze Khiang Tan
- Department of Orthopaedic Surgery, Monash Health Dandenong Hospital, Dandenong, VIC, Australia.
| | - Pham Tan
- Radiology Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Kemble Wang
- Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia; Department of Orthopaedic Surgery, Royal Children's Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | - Raphael Hau
- Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia; Department of Surgery, University of Melbourne, Carlton, VIC, Australia
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Wang S, Yang J, Lin L. Intravenous Application of Tranexamic Acid in Patients Undergoing Plastic Surgery: A Systematic Review and Meta-analysis with GRADE Quality Assessment. Aesthetic Plast Surg 2024; 48:543-558. [PMID: 37721624 DOI: 10.1007/s00266-023-03637-z] [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: 05/15/2023] [Accepted: 08/07/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is a versatile antifibrinolytic agent that is widely used in modern surgeries. This review assessed the safety and efficacy of intravenous (IV) TXA in plastic surgery versus controls. METHODS This review selected English-language Randomized controlled trials (RCTs) evaluating IV TXA effects in plastic surgery from four electronic databases, PubMed, Web of Science, Embase, and Cochrane Library up to April 9, 2023. Primary outcomes were blood loss volume (BLV) and transfusion occurrence, with operation time and surgical field assessment as secondary outcomes. IV TXA-related complications were also important indicators. Meta-analyses and qualitative analyses were conducted and the quality of the evidence was assessed. RESULTS Thirty RCTs with 2150 patients were included. The total standard mean difference (SMD) of BLV and pooled relative risk of transfusion occurrence between the IV TXA and the control groups were - 1.11 (95% CI, - 1.42 to - 0.80) and 0.36 (95% CI, 0.23 to 0.55) respectively, indicating a significant blood loss reduction with IV TXA treatment, while an ambiguous outcome of operation time was observed, with an SMD of - 0.22 (95% CI, - 0.42 to - 0.02). The quality of evidence for BLV and transfusion occurrence was low and medium, respectively. A quantitative analysis of surgical field assessment was not performed because of the substantial heterogeneity in scoring methods. No IV TXA-related complications were observed. CONCLUSIONS In plastic surgery, IV TXA administration results in less blood loss, reduced need for transfusion and better surgical fields but probably does not increase the risk of adverse events. LEVEL OF EVIDENCE I 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Senmao Wang
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 33 Badachu Road, Shijingshan District, Beijing, 100144, China
| | - Jingwen Yang
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 33 Badachu Road, Shijingshan District, Beijing, 100144, China
| | - Lin Lin
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 33 Badachu Road, Shijingshan District, Beijing, 100144, China.
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Rosebery L, Miller M, Loizou P, Ho SJ, Adkins KJ, Deshpande K. A retrospective validation of ROTEM algorithms for detecting hyperfibrinolysis demonstrates poor agreement for prediction of in-hospital mortality and transfusion requirement in a general, non-cardiac, surgical population. Thromb Res 2023; 229:170-177. [PMID: 37517207 DOI: 10.1016/j.thromres.2023.07.009] [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: 05/10/2023] [Revised: 07/02/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION Hyperfibrinolysis diagnosed on Rotational Thromboelastography (ROTEM) is associated with increased transfusion requirements and mortality in trauma. The diagnosis and significance of hyperfibrinolysis in a mixed, non-cardiac, general surgical population has not been investigated. We aimed to measure agreement between four ROTEM algorithms for diagnosing hyperfibrinolysis and transfusion requirements and mortality in general surgical patients. These algorithms mostly incorporate measures of early or late clot amplitude reduction on the Extrinsic Clotting Pathway Test with Tissue Factor (EXTEM) channel. METHOD Four hospital administrative data sets were linked from 2019 to 2022. Adults >18 years were included if a ROTEM was performed during their surgery (intraoperative period) or within 24-h of the surgery completion (postoperative period). The four hyperfibrinolysis criteria were applied to the ROTEM data and assessed for their agreement, intraoperative and postoperative transfusion requirements and in-patient mortality. RESULTS We linked 933 ROTEMs to 558 patient-procedures. One algorithm identified hyperfibrinolysis on only three patients so was excluded. Agreement between the remaining three was slight (Cohens Kappa 0.18 (p < 0.001)) with hyperfibrinolysis diagnosed between 22 and 69 % of the procedures. The association between hyperfibrinolysis diagnosis and intraoperative or postoperative transfusion requirement was inconsistent between the criteria. However, an algorithm put forward by Goerling et al. was more often associated with transfusion requirement and inpatient mortality. DISCUSSION The poor agreement between criteria suggests that some ROTEM criteria may not transfer directly to general surgical patients. Future research should focus on optimising hyperfibrinolysis cut-off values to update algorithms for bleeding general surgical patients.
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Affiliation(s)
- Leon Rosebery
- Intensive Care Unit, St George Hospital, Gray St, Kogarah 2217, Australia
| | - Matthew Miller
- Department of Anaesthesia, St George Hospital, Gray St, Kogarah 2217, Australia; Conjoint Lecturer St George and Sutherland Clinical Campus, UNSW, Sydney, Australia.
| | - Peter Loizou
- Blood Bank Department, StG Public Hospital, Kogarah, NSW 2217, Australia
| | - Shir Jing Ho
- Conjoint Lecturer St George and Sutherland Clinical Campus, UNSW, Sydney, Australia; Department of Haematology, St George Hospital, Kogarah, NSW 2217, Australia
| | - Keith J Adkins
- Department of Perfusion, St George Hospital, Gray St, Kogarah, NSW 2217, Australia
| | - Kush Deshpande
- Intensive Care Unit, St George Hospital, Gray St, Kogarah 2217, Australia; Conjoint Lecturer St George and Sutherland Clinical Campus, UNSW, Sydney, Australia
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Wang JT, Seshadri SC, Butler CG, Staffa SJ, Kordun AS, Lukovits KE, Goobie SM. Tranexamic Acid Use in Pediatric Craniotomies at a Large Tertiary Care Pediatric Hospital: A Five Year Retrospective Study. J Clin Med 2023; 12:4403. [PMID: 37445437 DOI: 10.3390/jcm12134403] [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: 03/20/2023] [Revised: 05/30/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Tranexamic acid (TXA), a synthetic antifibrinolytic drug, has proven efficacy and is recommended for major pediatric surgery to decrease perioperative blood loss. Accumulating evidence suggests that TXA reduces bleeding and transfusion in a variety of adult neurosurgical settings. However, there is a paucity of research regarding TXA indications for pediatric neurosurgery and thus, there are currently no recommendations for its use with this specific population. The objective of this study is to evaluate the existing practice of TXA administration for pediatric neurosurgery at a U.S. tertiary care pediatric hospital over a five-year period. The authors conclude that TXA administration is feasible and should be considered for pediatric neurosurgical cases where potential blood loss is a concern.
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Affiliation(s)
- Jue T Wang
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Samir C Seshadri
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Carolyn G Butler
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Anna S Kordun
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Karina E Lukovits
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
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Eid J, Stahl D. Blood Product Replacement for Postpartum Hemorrhage. Clin Obstet Gynecol 2023; 66:408-414. [PMID: 36730283 DOI: 10.1097/grf.0000000000000766] [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: 02/03/2023]
Abstract
Consideration for blood products replacement in postpartum hemorrhage should be given when blood loss exceeds 1.5 L or when an estimated 25% of blood has been lost. In cases of massive hemorrhage, standardized transfusion protocols have been shown to improve maternal morbidity and mortality. Most protocols recommend a balanced transfusion involving a 1:1:1 ratio of packed red blood cells, platelets, and fresh frozen plasma. Alternatives such as cryoprecipitate, fibrinogen concentrate, and prothrombin complex concentrates can be used in select clinical situations. Although transfusion of blood products can be lifesaving, it does have associated risks.
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Affiliation(s)
- Joe Eid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center
| | - David Stahl
- Division of Critical Care Medicine, Department of Anesthesiology, The Ohio State University, Columbus, Ohio
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Tan GM, Murto K, Downey LA, Wilder MS, Goobie SM. Error traps in Pediatric Patient Blood Management in the Perioperative Period. Paediatr Anaesth 2023. [PMID: 37144721 DOI: 10.1111/pan.14683] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/04/2023] [Accepted: 04/12/2023] [Indexed: 05/06/2023]
Abstract
Patient blood management is a patient-centered evidence-based approach to improve patient outcomes by harnessing the patient's own hematopoietic system to optimize blood health while promoting patient safety and empowerment. Perioperative patient blood management is a standard of care in adult medicine, yet it is not commonly accepted in pediatrics. Raising awareness may be the first step in improving perioperative care for the anemic and/or bleeding child. This article highlights five preventable perioperative blood conservation error traps for children. The goal is to provide practical clinical guidance to improve preoperative diagnosis and treatment of anemia, facilitate recognition and treatment of massive hemorrhage, reduce unnecessary allogeneic blood transfusions, and decrease associated complications of anemia and blood component transfusions utilizing a patient/family-centered informed consent and shared decision-making approach.
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Affiliation(s)
- Gee Mei Tan
- Pediatric Anesthesiology Division, Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Kimmo Murto
- Department of Anesthesiology & Pain Medicine, Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Laura A Downey
- Department of Anesthesiology, Emory University Medical School, Atlanta, Georgia, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Matthew S Wilder
- Pediatric Anesthesiology Division, Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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12
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Longacre MM, Seshadri SC, Adil E, Baird LC, Goobie SM. Perioperative management of pediatric patients undergoing juvenile angiofibroma resection. A case series and educational review highlighting patient blood management. Paediatr Anaesth 2023. [PMID: 36869694 DOI: 10.1111/pan.14655] [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: 11/24/2022] [Revised: 02/25/2023] [Accepted: 02/28/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Juvenile nasopharyngeal angiofibromas are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. Juvenile nasopharyngeal angiofibromas are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for Juvenile nasopharyngeal angiofibromas. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for patients with Juvenile nasopharyngeal angiofibromas. METHODS We describe a contemporary and comprehensive approach in the management of patients with high grade Juvenile nasopharyngeal angiofibromas. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension. AIMS Using a case series, the authors introduce a contemporary approach to multimodal, multidisciplinary blood conservation strategies for Juvenile nasopharyngeal angiofibromas surgery. RESULTS Here in the authors report on an updated contemporary perioperative clinical approach to patients with Juvenile nasopharyngeal angiofibromas. From an anesthetic perspective, we describe the successful use of normal hemodynamic goals, restrictive transfusion strategy, antifibrinolytic therapy, autologous normovolemic hemodilution, and early extubation in the care of three adolescent males with highly invasive tumors. We demonstrate that new surgical and anesthetic strategies have yielded a significant decrease in intraoperative blood loss and eliminated the need for transfusion of autologous red blood cells, which enable improved outcomes. CONCLUSIONS The perioperative approach to elective surgery for Juvenile nasopharyngeal angiofibromas management is presented from a multidisciplinary patient blood management perspective.
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Affiliation(s)
- M M Longacre
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - S C Seshadri
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - E Adil
- Department of Otolaryngology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - L C Baird
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - S M Goobie
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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13
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Sun Y, Xiao D, Fu W, Cai W, Huang X, Li Q, Li J. Efficacy and Safety of Tranexamic Acid in Shoulder Arthroscopic Surgery: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11236886. [PMID: 36498460 PMCID: PMC9738808 DOI: 10.3390/jcm11236886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/12/2022] [Accepted: 11/19/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Visual clarity during shoulder arthroscopy can ensure an efficient and effective performance of the procedure, and it is highly related to bleeding without a tourniquet. Tranexamic acid (TXA) is widely used in adult reconstruction procedures; however, its use in shoulder arthroscopic operations is a relatively novel topic. PURPOSE To analyze the available literature on visual clarity, blood loss, pain control, functional outcomes, and complications after the administration of tranexamic acid in shoulder arthroscopic surgery. METHODS A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of shoulder arthroscopic surgery. The literature search included the MEDLINE, Embase, Web of Science, and Cochrane Library databases. The primary outcomes included visual clarity, blood loss, and visual analog scale scores for pain. Secondary outcomes were operative time, irrigation amount used, postoperative shoulder swelling, the need for pressure increase, mean arterial pressure (MAP), functional outcomes, postoperative adverse effects such as deep venous thrombosis, and pulmonary embolism. The outcomes were pooled to perform a meta-analysis. RESULTS Seven prospective randomized controlled trials met the inclusion criteria for analysis. All of the included studies performed arthroscopic rotator cuff repair. No significant difference in visual clarity was observed (SMD (standardized mean difference), 0.45 [95% CI(confidence interval), -0.68, 1.59]; p = 0.44) nor in pain score (MD (mean difference), -0.46 [95% CI, -0.97, 0.05]; p = 0.08) between the TXA group and the control group. Two studies found no significant difference in blood loss between the TXA group and the control group. The meta-analysis from five studies demonstrated no significant difference between the TXA and control groups in operative time (MD, -3.51 [95% CI, -15.82, 8.80]; p = 0.58) or irrigation amount used (MD, -2.53 [95% CI, -5.93, 0.87]; p = 0.14). Two trials reported different statistical results in postoperative shoulder swelling. No significant differences regarding the need for pressure increase and MAP were reported between groups. No wound complications or infections or cardiac, thrombotic, or thromboembolic complications were recorded in either group. CONCLUSION The use of intravenous or local TXA in shoulder arthroscopic surgery did not increase complications or thromboembolic events, but TXA had no obviously effect of reducing bleeding to obtain a clear visual field or pain release in patients undergoing shoulder arthroscopic surgery.
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Affiliation(s)
- Yiyuan Sun
- Day Surgery Center, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Dan Xiao
- Yong Chuan Hospital of ChongQing Medical University, Chongqing 402160, China
| | - Weili Fu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
- Correspondence:
| | - Wufeng Cai
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Xihao Huang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Qi Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Jian Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
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Goobie SM. Patient Blood Management Is a New Standard of Care to Optimize Blood Health. Anesth Analg 2022; 135:443-446. [PMID: 35977353 DOI: 10.1213/ane.0000000000006168] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Susan M Goobie
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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15
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Nathan N. Tranexamic Acid: Current Knowns and Unknowns. Anesth Analg 2022; 135:459. [PMID: 35977356 DOI: 10.1213/ane.0000000000006181] [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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