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The New England Journal of Medicine Jul 2023Whether prehospital administration of tranexamic acid increases the likelihood of survival with a favorable functional outcome among patients with major trauma and... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Whether prehospital administration of tranexamic acid increases the likelihood of survival with a favorable functional outcome among patients with major trauma and suspected trauma-induced coagulopathy who are being treated in advanced trauma systems is uncertain.
METHODS
We randomly assigned adults with major trauma who were at risk for trauma-induced coagulopathy to receive tranexamic acid (administered intravenously as a bolus dose of 1 g before hospital admission, followed by a 1-g infusion over a period of 8 hours after arrival at the hospital) or matched placebo. The primary outcome was survival with a favorable functional outcome at 6 months after injury, as assessed with the use of the Glasgow Outcome Scale-Extended (GOS-E). Levels on the GOS-E range from 1 (death) to 8 ("upper good recovery" [no injury-related problems]). We defined survival with a favorable functional outcome as a GOS-E level of 5 ("lower moderate disability") or higher. Secondary outcomes included death from any cause within 28 days and within 6 months after injury.
RESULTS
A total of 1310 patients were recruited by 15 emergency medical services in Australia, New Zealand, and Germany. Of these patients, 661 were assigned to receive tranexamic acid, and 646 were assigned to receive placebo; the trial-group assignment was unknown for 3 patients. Survival with a favorable functional outcome at 6 months occurred in 307 of 572 patients (53.7%) in the tranexamic acid group and in 299 of 559 (53.5%) in the placebo group (risk ratio, 1.00; 95% confidence interval [CI], 0.90 to 1.12; P = 0.95). At 28 days after injury, 113 of 653 patients (17.3%) in the tranexamic acid group and 139 of 637 (21.8%) in the placebo group had died (risk ratio, 0.79; 95% CI, 0.63 to 0.99). By 6 months, 123 of 648 patients (19.0%) in the tranexamic acid group and 144 of 629 (22.9%) in the placebo group had died (risk ratio, 0.83; 95% CI, 0.67 to 1.03). The number of serious adverse events, including vascular occlusive events, did not differ meaningfully between the groups.
CONCLUSIONS
Among adults with major trauma and suspected trauma-induced coagulopathy who were being treated in advanced trauma systems, prehospital administration of tranexamic acid followed by an infusion over 8 hours did not result in a greater number of patients surviving with a favorable functional outcome at 6 months than placebo. (Funded by the Australian National Health and Medical Research Council and others; PATCH-Trauma ClinicalTrials.gov number, NCT02187120.).
Topics: Adult; Humans; Antifibrinolytic Agents; Australia; Emergency Medical Services; Tranexamic Acid; Vascular Diseases; Wounds and Injuries; Blood Coagulation Disorders
PubMed: 37314244
DOI: 10.1056/NEJMoa2215457 -
Brazilian Journal of Anesthesiology... 2022Tranexamic acid (TXA) significantly reduces blood loss in a wide range of surgical procedures and improves survival rates in obstetric and trauma patients with severe... (Review)
Review
Tranexamic acid (TXA) significantly reduces blood loss in a wide range of surgical procedures and improves survival rates in obstetric and trauma patients with severe bleeding. Although it mainly acts as a fibrinolysis inhibitor, it also has an anti-inflammatory effect, and may help attenuate the systemic inflammatory response syndrome found in some cardiac surgery patients. However, the administration of high doses of TXA has been associated with seizures and other adverse effects that increase the cost of care, and the administration of TXA to reduce perioperative bleeding needs to be standardized. Tranexamic acid is generally well tolerated, and most adverse reactions are considered mild or moderate. Severe events are rare in clinical trials, and literature reviews have shown tranexamic acid to be safe in several different surgical procedures. However, after many years of experience with TXA in various fields, such as orthopedic surgery, clinicians are now querying whether the dosage, route and interval of administration currently used and the methods used to control and analyze the antifibrinolytic mechanism of TXA are really optimal. These issues need to be evaluated and reviewed using the latest evidence to improve the safety and effectiveness of TXA in treating intracranial hemorrhage and bleeding in procedures such as liver transplantation, and cardiac, trauma and obstetric surgery.
Topics: Pregnancy; Female; Humans; Tranexamic Acid; Antifibrinolytic Agents; Hemorrhage; Orthopedic Procedures; Blood Loss, Surgical
PubMed: 34626756
DOI: 10.1016/j.bjane.2021.08.022 -
Anaesthesiology Intensive Therapy 2015Blood loss and subsequent transfusions are associated with major morbidity and mortality. The use of antifibrinolytics can reduce blood loss in cardiac surgery, trauma,... (Review)
Review
Blood loss and subsequent transfusions are associated with major morbidity and mortality. The use of antifibrinolytics can reduce blood loss in cardiac surgery, trauma, orthopedic surgery, liver surgery and solid organ transplantation, obstetrics and gynecology, neurosurgery and non-surgical diseases. The evidence of their efficacy has been mounting for years. Tranexamic acid (TXA), a synthetic lysine-analogue antifibrinolytic, was first patented in 1957 and its use has been increasing in contrast to aprotinin, a serine protease inhibitor antifibrinolytic. This review aims to help acute care physicians navigate through the clinical evidence available for TXA therapy, develop appropriate dose regimens whilst minimizing harm, as well as understand its broadening scope of applications. Many questions remain unanswered regarding other clinical effects of TXA such as anti-inflammatory response to cardiopulmonary bypass, the risk of thromboembolic events, adverse neurological effects such as seizures, and its morbidity and mortality, all of which necessitate further clinical trials on its usage and safety in various clinical settings.
Topics: Antifibrinolytic Agents; Blood Loss, Surgical; General Surgery; Humans; Tranexamic Acid
PubMed: 25797505
DOI: 10.5603/AIT.a2015.0011 -
Transfusion Aug 2022Tranexamic acid (TXA) is a popular antifibrinolytic drug widely used in hemorrhagic trauma patients and cardiovascular, orthopedic, and gynecological surgical patients.... (Review)
Review
Tranexamic acid (TXA) is a popular antifibrinolytic drug widely used in hemorrhagic trauma patients and cardiovascular, orthopedic, and gynecological surgical patients. TXA binds plasminogen and prevents its maturation to the fibrinolytic enzyme plasmin. A number of studies have demonstrated the broad life-saving effects of TXA in trauma, superior to those of other antifibrinolytic agents. Besides preventing fibrinolysis and blood loss, TXA has been reported to suppress posttraumatic inflammation and edema. Although the efficiency of TXA transcends simple inhibition of fibrinolysis, little is known about its mechanisms of action besides the suppression of plasmin maturation. Understanding the broader effects of TXA at the cell, organ, and organism levels are required to elucidate its potential mechanisms of action transcending antifibrinolytic activity. In this article, we provide a brief review of the current clinical use of TXA and then focus on the effects of TXA beyond antifibrinolytics such as its anti-inflammatory activity, protection of the endothelial and epithelial monolayers, stimulation of mitochondrial respiration, and suppression of melanogenesis.
Topics: Antifibrinolytic Agents; Blood Coagulation Disorders; Fibrinolysin; Fibrinolysis; Hemorrhage; Humans; Tranexamic Acid
PubMed: 35834488
DOI: 10.1111/trf.16976 -
The American Journal of Emergency... Jun 2022Over the last decade, tranexamic acid (TXA) has been incorporated into treatment algorithms for a multitude of emergent conditions and the evidence surrounding its role... (Review)
Review
INTRODUCTION
Over the last decade, tranexamic acid (TXA) has been incorporated into treatment algorithms for a multitude of emergent conditions and the evidence surrounding its role in emergency medicine continues to evolve.
OBJECTIVE
The objective of this literature review is to provide an evidence-based approach to the utilization of TXA in the emergency department.
DISCUSSION
The most robust trials suggest TXA may offer a modest improvement in mortality in patients at risk of significant bleeding from trauma, but is not beneficial in spontaneous intracranial hemorrhage or gastrointestinal bleeding. The role of TXA in other clinical scenarios is less clear and requires clinical judgment.
CONCLUSION
Tranexamic acid appears to be a reasonable adjunct for the emergency medicine clinician to consider in the management of many hemorrhagic conditions and angiotensin converting enzyme inhibitor-induced angioedema. Additional high-quality research in these areas is needed to further identity patients who may benefit most from TXA.
Topics: Angioedema; Antifibrinolytic Agents; Emergency Medicine; Gastrointestinal Hemorrhage; Humans; Tranexamic Acid
PubMed: 35364476
DOI: 10.1016/j.ajem.2022.03.027 -
The Journal of Trauma and Acute Care... Jan 2023There 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... (Randomized Controlled Trial)
Randomized Controlled Trial Observational Study
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.
Topics: Humans; Tranexamic Acid; Antifibrinolytic Agents; Retrospective Studies; Prospective Studies; Hemorrhage; Blood Coagulation Disorders; Wounds and Injuries
PubMed: 36044459
DOI: 10.1097/TA.0000000000003775 -
Expert Review of Hematology Sep 2019: Postpartum hemorrhage (PPH) is a major cause of maternal death and severe maternal morbidity after childbirth. : Tranexamic acid, an antifibrinolytic agent, reduces... (Review)
Review
: Postpartum hemorrhage (PPH) is a major cause of maternal death and severe maternal morbidity after childbirth. : Tranexamic acid, an antifibrinolytic agent, reduces bleeding-related mortality in women with PPH, especially when administered shortly after delivery, and is consequently recommended in this situation (1g intravenously with a second dose of 1 g if bleeding continues), even in high income countries where the magnitude of the effect of tranexamic is uncertain. : Pharmacovigilance surveys are warranted in high income areas to ensure that this new policy for the treatment of PPH is not associated to rare but severe adverse events such as renal failure. The evidence remains insufficient to recommend the universal use of tranexamic acid for prevention of postpartum hemorrhage after both vaginal and cesarean deliveries.
Topics: Antifibrinolytic Agents; Female; Humans; Parturition; Postpartum Hemorrhage; Pregnancy; Tranexamic Acid; Treatment Outcome
PubMed: 31295414
DOI: 10.1080/17474086.2019.1642744 -
British Journal of Anaesthesia Oct 2022Tranexamic acid reduces surgical bleeding. Consistent with previous research, the POISE-3 (Peri-Operative Ischemic Evaluation-3) trial found that tranexamic acid reduces...
Tranexamic acid reduces surgical bleeding. Consistent with previous research, the POISE-3 (Peri-Operative Ischemic Evaluation-3) trial found that tranexamic acid reduces major bleeding by 25% and with a low probability of any increase in thromboembolic events. Wider tranexamic acid use will improve surgical safety, avoid unnecessary blood use, reduce the risk of transfusion transmitted infections, and save healthcare funds. 'Consideration of tranexamic acid use' should be included in the safe surgery checklist. We have the evidence, and we need to act on it.
Topics: Blood Loss, Surgical; Clinical Trials as Topic; Humans; Tranexamic Acid
PubMed: 36070986
DOI: 10.1016/j.bja.2022.06.024 -
Blood Sep 2022
Topics: Antifibrinolytic Agents; Blood Platelets; Hematologic Neoplasms; Humans; Tranexamic Acid
PubMed: 36107459
DOI: 10.1182/blood.2022017207 -
The Orthopedic Clinics of North America Jan 2020Surgical techniques used to decrease the amount of blood lost during the procedure range from tourniquets to electrocautery and, more recently, the use of... (Comparative Study)
Comparative Study Review
Surgical techniques used to decrease the amount of blood lost during the procedure range from tourniquets to electrocautery and, more recently, the use of antifibrinolytics. Currently, tranexamic acid is the most commonly used antifibrinolytic in arthroplasty procedures. It was previously thought that intravenous tranexamic acid was more effective than topical tranexamic acid, but had an increased risk of thrombosis and cardiac events; however, this study showed that topical tranexamic acid is as effective in decreasing blood loss and the need for a blood transfusion after hybrid fixation total knee arthroplasty as with cemented total knee arthroplasty.
Topics: Administration, Topical; Antifibrinolytic Agents; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Blood Transfusion; Cementation; Humans; Postoperative Period; Retrospective Studies; Tourniquets; Tranexamic Acid
PubMed: 31739881
DOI: 10.1016/j.ocl.2019.08.002