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Journal of ISAKOS : Joint Disorders &... Mar 2024Peri-operative blood loss during joint replacement procedures is a modifiable risk factor that impacts wound complications, hospital stay and total costs. Tranexamic... (Review)
Review
Tranexamic acid reduces perioperative blood loss and postoperative hemoglobin loss during total ankle arthroplasty: A systematic review and meta-analysis of clinical comparative studies.
IMPORTANCE
Peri-operative blood loss during joint replacement procedures is a modifiable risk factor that impacts wound complications, hospital stay and total costs. Tranexamic acid (TXA) is an anti-fibrinolytic that has been widely used in orthopedic surgery, but its efficacy in the setting of total ankle arthroplasty (TAA) has not been quantified to date.
AIM
The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of administering TXA in patients undergoing TAA.
EVIDENCE REVIEW
The Medline, Embase and Cochrane library databases were systematically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five comparative studies examining blood loss following administration of TXA for patients undergoing TAA were included. The outcome measures of interest were blood loss, reduction in hemoglobin concentration, transfusion requirements, total complications and wound complications.
FINDINGS
In total, 194 patients received TXA and 187 patients did not receive TXA while undergoing TAA. Based on the common-effects model for total blood loss for the TXA group versus control, the standardized mean difference (SMD) was -0.7832 (95% CI, -1.1544, -0.4120; P < 0.0001), in favor of lower total blood loss for TXA. Based on the random-effects model for reduction in hemoglobin for the TXA group versus control, the SMD was -0.9548 (95% CI, -1.7850, -0.1246; P = 0.0242) in favor of lower hemoglobin loss for TXA. Based on the random-effects model for total complications for the TXA group versus control, the risk ratio was 0.512 (95% CI, 0.1588, 1.6512; P = 0.1876), in favor of lower total complications for TXA but this was not statistically significant.
CONCLUSIONS
This current review demonstrated that administration of TXA led to a reduction in blood loss and hemoglobin loss without an increased risk of the development of venous thromboembolism in patients undergoing TAA. No difference was observed with respect to total complication rates between the TXA cohort and the control group. TXA appears to be an effective hemostatic agent in the setting of TAA, but further studies are necessary to identify the optimal timing, dosage and route of TXA during TAA.
LEVEL OF EVIDENCE
III.
PubMed: 38521460
DOI: 10.1016/j.jisako.2024.03.009 -
The British Journal of Oral &... May 2024Cleft palate repair is a common reconstructive procedure that can involve significant blood loss. Tranexamic acid (TXA) has been proposed to minimise blood loss during... (Meta-Analysis)
Meta-Analysis Review
Cleft palate repair is a common reconstructive procedure that can involve significant blood loss. Tranexamic acid (TXA) has been proposed to minimise blood loss during various surgical procedures, but its effectiveness in cleft palate repair remains unclear. This systematic review and meta-analysis aimed to assess the effectiveness of TXA to reduce postoperative blood loss. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive search across multiple databases, including PubMed, Cochrane, and Web of Science, to identify relevant studies published up to September 2023. Only randomised controlled trials (RCTs) were included. Primary outcomes measured were total blood loss, transfusion rates, and postoperative complications. We identified four relevant RCTs, which included 275 cleft palate patients with a mean (range) age of 28.7 (6-65) months. The pooled analysis found no significant difference in duration of surgery (MD -18.40 minutes, p = 0.09), preoperative haemoglobin (MD 0.46 g/dl, p = 0.27), or postoperative haemoglobin (MD 0.07 g/dl, p = 0.86) between TXA and control groups. Intraoperative blood loss was lower with TXA, but with TXA, the difference was not statistically significant (MD -16.63 ml, p = 0.15). TXA significantly improved surgical field visibility (p = 0.004). No adverse events occurred with its use. While no significant differences were found in surgical outcomes with TXA, surgical field visibility significantly improved, and TXA showed a promising safety profile. Larger and higher-quality RCTs are still needed to validate these preliminary findings before TXA can be considered as a standard treatment.
Topics: Tranexamic Acid; Humans; Cleft Palate; Blood Loss, Surgical; Antifibrinolytic Agents; Postoperative Hemorrhage; Blood Transfusion
PubMed: 38508902
DOI: 10.1016/j.bjoms.2023.12.019 -
The American Journal of Emergency... Jun 2024Tranexamic acid (TXA) holds a pivotal role in the therapeutic approach to traumatic conditions. Nevertheless, its precise influence on diminishing mortality and limiting... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Tranexamic acid (TXA) holds a pivotal role in the therapeutic approach to traumatic conditions. Nevertheless, its precise influence on diminishing mortality and limiting the progression of intracranial hemorrhage (ICH) during the treatment of traumatic brain injury (TBI) remains indeterminate.
METHODS
PubMed, EMBASE, Cochrane Library, and Web of Science were searched for randomized controlled trials that compared TXA and a placebo in adults with TBI up to September 31, 2023. Two authors independently abstracted the data and assessed the quality of evidence. Additionally, subgroup analyses were performed to assess outcomes with low heterogenety.
RESULTS
Our search strategy yielded 11,299 patients from 11 studies. The result showed that TXA had no effect on mortality (RR 0.93 [0.86, 1.00], p = 0.06; I: 0%, p = 0.79), poor clinical outcomes (RR 0.92 [0.78, 1.09], p = 0.34; I: 0%, p = 0.40), adverse events (RR 0.94 [0.83, 1.07], p = 0.34; I: 48%, p = 0.10), vascular occlusive events (RR 0.85 [0.68, 1.06], p = 0.16; I: 32%, p = 0.22), pulmonary embolism (RR 0.76 [0.47, 1.22], p = 0.26; I: 0%, p = 0.83), seizure (RR 1.11 [0.92, 1.35], p = 0.27; I: 0%, p = 0.49) and hemorrhagic complications (RR 0.78 [0.55, 1.09], p = 0.14; I: 0%, p = 0.42). TXA might reduce the rate of hemorrhagic expansion (RR 0.83 [0.70, 0.99], p = 0.03; I: 18%, p = 0.29) and mean hemorrhage volume (SMD -0.39 [-0.60, -0.18], p <0.001; I: 44%, p = 0.13).When the time interval from symptom onset to treatment was <3 h, TXA reduced mean hemorrhage volume (SMD -0.51 [-0.81, -0.20], p = 0.001; I: 0%, p = 0.94).
CONCLUSIONS
TXA did not elevate the risk of adverse event, however, the lack of reduction in mortality and the poor clinical outcomes constrain the value of clinical application. Early administration of TXA (within 3 h) may significantly decrease the likelihood of ICH growth in patients with TBI.
Topics: Tranexamic Acid; Humans; Antifibrinolytic Agents; Randomized Controlled Trials as Topic; Brain Injuries, Traumatic; Treatment Outcome
PubMed: 38502985
DOI: 10.1016/j.ajem.2024.03.005 -
The Australian Journal of Rural Health Apr 2024Primary postpartum haemorrhage causes approximately 25% of global maternal deaths and accounts for significant maternal morbidity. While high certainty evidence... (Review)
Review
INTRODUCTION
Primary postpartum haemorrhage causes approximately 25% of global maternal deaths and accounts for significant maternal morbidity. While high certainty evidence demonstrates that tranexamic acid reduces comparative blood loss in postpartum haemorrhage in hospital settings, limited data exist on the specific pharmacological management of this condition in out-of-hospital settings, and the implications for rural communities.
OBJECTIVE
To determine the efficacy of oxytocin compared to tranexamic acid in women suffering postpartum haemorrhage in the out-of-hospital environment.
DESIGN
A systematic review comparing evidence containing patients with postpartum haemorrhage in the out-of-hospital and/or rural setting, in which oxytocin/tranexamic acid were used. Outcome measures were comparative blood loss/haemorrhagic shock, the need for further interventions and maternal/neonatal morbidity/mortality.
FINDINGS
No randomised control trials have been conducted in an out-of-hospital environment in relation to oxytocin/tranexamic acid. In this setting, there is no difference in outcome measures when using oxytocin compared to no intervention, or oxytocin compared to standard care. Data are lacking on the effect of tranexamic acid on the same outcome measures.
DISCUSSION
Rural and out-of-hospital management of postpartum haemorrhage is limited by resource availability and practitioner availability, capacity and experience. In-hospital evidence may lack transferability, therefore direct evidence on the efficacy of pharmacological management in these contexts is scant and requires redress.
CONCLUSION
There is no difference in blood loss, neonatal or maternal mortality or morbidity, or need for further interventions, when using oxytocin or TXA compared to no intervention, or compared to standard care, for PPH. Further studies are needed on the efficacy of these drugs, and alternate or co-drug therapies, for PPH in the out-of-hospital environment and rural clinical practice.
Topics: Humans; Postpartum Hemorrhage; Tranexamic Acid; Female; Oxytocin; Antifibrinolytic Agents; Pregnancy; Rural Health Services; Oxytocics; Adult
PubMed: 38491718
DOI: 10.1111/ajr.13103 -
The American Journal of Cardiology May 2024Left atrial or left atrial appendage thrombosis (LAT) is contraindicated for cardiac ablation (CA) or cardioversion (CV) of atrial fibrillation (AF). This study was... (Meta-Analysis)
Meta-Analysis
Atrial Thrombosis Prevalence Before Cardioversion or Catheter Ablation of Atrial Fibrillation: An Updated Systematic Review and Meta-Analysis of Direct Oral Anticoagulants Versus Vitamin K Antagonists.
Left atrial or left atrial appendage thrombosis (LAT) is contraindicated for cardiac ablation (CA) or cardioversion (CV) of atrial fibrillation (AF). This study was aimed to compare the frequency of LAT detected by transesophageal echocardiography (TEE) before CA or CV in patients with AF treated with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). We searched PubMed, Scopus, Web of Science, and Cochran Library databases from inception through July 13, 2023 to select studies reporting data on LAT identification before CA or CV using TEE in patients with AF treated with DOACs or VKAs. Pooled odds ratios (ORs) with 95% confidence interval were calculated with a random-effects model. Studies retrieved were 50 (38 observational), 29 on CA, 15 on CV, and 6 on both procedures (17,096 patients on DOACs and 13,666 on VKAs). The overall prevalence of LAT was smaller in DOACs than in VKAs, with an OR of 0.66 (0.52 to 0.84), confirmed at sensitivity analysis and in most subgroups. This finding was consistent for the 3 most reported DOACs: the pooled OR for LAT was 0.68 (0.50 to 0.90) in apixaban, 0.67 (0.51 to 0.88) in dabigatran, 0.61 (0.43 to 0.89) in rivaroxaban, and 1.10 (0.74 to 1.64) in edoxaban (not significant). In conclusion, in this large meta-analysis in patients with AF, the prevalence of LAT by TEE evaluation performed before CV or CA appears lower in those treated with DOACs than in those on VKAs. Additional research may help in better understanding differences between these classes of anticoagulant drugs in the setting of protection against AF-related left atrial thrombotic formation.
Topics: Humans; Atrial Fibrillation; Electric Countershock; Prevalence; Anticoagulants; Thrombosis; Heart Diseases; Catheter Ablation; Vitamin K; Administration, Oral; Stroke
PubMed: 38458580
DOI: 10.1016/j.amjcard.2024.02.042 -
Scandinavian Journal of Trauma,... Mar 2024Tranexamic acid (TXA) demonstrates therapeutic efficacy in the management of traumatic brain injury (TBI). The objective of this systematic review and meta-analysis was... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Tranexamic acid (TXA) demonstrates therapeutic efficacy in the management of traumatic brain injury (TBI). The objective of this systematic review and meta-analysis was to evaluate the safety and effectiveness of TXA in patients with TBI.
METHODS
The databases, namely PubMed, Embase, Web of Science, and Cochrane Library databases, were systematically searched to retrieve randomized controlled trials (RCTs) investigating the efficacy of TXA for TBI from January 2000 to November 2023.
RESULTS
The present meta-analysis incorporates ten RCTs. Compared to the placebo group, administration of TXA in patients with TBI resulted in a significant reduction in mortality (P = 0.05), hemorrhage growth (P = 0.03), and volume of hemorrhage growth (P = 0.003). However, no significant impact was observed on neurosurgery outcomes (P = 0.25), seizure occurrence (P = 0.78), or pulmonary embolism incidence (P = 0.52).
CONCLUSION
The administration of TXA is significantly associated with reduced mortality and hemorrhage growth in patients suffering from TBI, while the need of neurosurgery, seizures, and incidence of pulmonary embolism remains comparable to that observed with placebo.
Topics: Humans; Tranexamic Acid; Antifibrinolytic Agents; Hemorrhage; Brain Injuries, Traumatic; Pulmonary Embolism
PubMed: 38454455
DOI: 10.1186/s13049-024-01188-z -
BMC Anesthesiology Mar 2024Reducing blood loss during excisional surgery in burn patients remains a challenge. Tranexamic acid during surgery can potentially reduce blood loss. The use of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Reducing blood loss during excisional surgery in burn patients remains a challenge. Tranexamic acid during surgery can potentially reduce blood loss. The use of tranexamic acid during excisional surgery in burn patients has recently been described in a review and meta-analysis. However, quality assessment on studies included was not performed and this review did not apply independent reviewers. Quality assessment of studies investigating the effectiveness of tranexamic acid in burn patients is crucial before concusions can be drawn. Therefore, we conducted a systematic review and meta-analysis of the literature investigating the effectiveness of tranexamic acid in burn patients undergoing surgery.
METHODS
A systematic review and meta-analysis of the literature was conducted. The study was pre-registered in PROSPERO database (CRD42023396183).
RESULTS
Five studies including two randomised controlled trials (RCTs) with a total of 303 patients were included. Risk of bias of the included studies was moderate to high. Individual results of the studies were heterogeneous. In three studies of moderate quality the administration of tranexamic acid resulted in a reduction of blood loss per unit excised area, accounting as moderate level of evidence. In two low-quality studies and one moderate quality study the administration of tranexamic acid resulted in a reduction of transfused packed Red Blood Cells (pRBC's), accounting for moderate level of evidence. Postoperative haemoglobin levels were higher after tranexamic acid administration in one study, accounting for insufficient evidence. Meta-analysis pooling overall blood loss from two separate RCTs failed to detect a statistically significant reduction. Substantial heterogeneity was observed.
CONCLUSIONS
Moderate level of evidence indicates that tranexamic acid reduces blood loss per unit of excised area and transfusion of packed Red Blood Cells. Results indicate that tranexamic acid can be beneficial in burn patients undergoing surgery. More high-quality research is needed to confirm these results. Future studies should focus on the dosing of tranexamic acid, the administration approaches, and even consider combining these approaches.
TRIAL REGISTRATION
PROSPERO: CRD42023396183.
Topics: Humans; Tranexamic Acid; Burns; Databases, Factual; Postoperative Period; Qualitative Research; Randomized Controlled Trials as Topic
PubMed: 38438978
DOI: 10.1186/s12871-024-02471-3 -
Revista Espanola de Anestesiologia Y... May 2024We performed a meta-analysis to assess the effectiveness and safety of tranexamic acid in patients with traumatic brain injury (TBI). (Meta-Analysis)
Meta-Analysis
BACKGROUND
We performed a meta-analysis to assess the effectiveness and safety of tranexamic acid in patients with traumatic brain injury (TBI).
METHODS
We searched the literature for articles evaluating the effectiveness and safety of tranexamic acid (TXA) in TBI published between January 2012 and January 2021, and identified 8 studies with a total of 10860 patients: 5660 received TXA and 5200 served as controls. We used a dichotomous or continuous approach with a random or fixed-effect model to assess the efficacy and safety of TXA in TBI, and calculated the mean difference (MD) and odds ratio (OR) with the corresponding 95% confidence interval.
RESULTS
In patients with TBI, early administration of TXA was associated with a greater relative benefit (MD -2.45; 95% CI = -4.78 to -0.12; p=0.04) and less total haematoma expansion (MD - 2.52; 95% CI = -4.85 to -0.19; p=0.03) compared to controls. There were no statistically significant differences in mortality (OR 0.94; 95% CI=0.85-1.03; p=0.18), presence of progressive haemorrhage (OR 0.75; 95% CI=0.56-1.01; p=0.06), need for neurosurgery (OR 1.15; 95% CI=0.66-1.98; p=0.63), high Disability Rating Scale score (OR 0.90; 95% CI=0.56-1.45; p=0.68), and incidence of ischaemic or thromboembolic complications (OR 1.34; 95% CI=0.33-5.46; p=0.68) between TBI patients treated with TXA and controls.
CONCLUSIONS
Early administration of TXA in TBI patients may have a greater relative benefit and may inhibit haematoma expansion. There were no significant differences in mortality, presence of progressive haemorrhage, need for neurosurgery, high Disability Rating Scale score, and incidence of ischaemic or thromboembolic complications between TBI patients treated with TXA and controls. Further studies are needed to validate these results.
Topics: Tranexamic Acid; Brain Injuries, Traumatic; Humans; Antifibrinolytic Agents; Treatment Outcome
PubMed: 38387502
DOI: 10.1016/j.redare.2024.02.013 -
Journal of Clinical Anesthesia Jun 2024To assess how kidney disease is handled in randomized trials evaluating the safety and efficacy of perioperative tranexamic acid, and to evaluate its effects across... (Meta-Analysis)
Meta-Analysis
STUDY OBJECTIVE
To assess how kidney disease is handled in randomized trials evaluating the safety and efficacy of perioperative tranexamic acid, and to evaluate its effects across levels of kidney function.
DESIGN
Systematic review and meta-analysis of randomized controlled trials.
SETTING
We screened studies from a previous comprehensive systematic review, and updated its search of PubMed, Embase, and Cochrane CENTRAL to July 31, 2023.
PATIENTS
Patients undergoing non-obstetric surgery.
INTERVENTIONS
Intravenous tranexamic acid compared to placebo or usual care without tranexamic acid.
MEASUREMENT
We summarized the handling of kidney disease in eligibility criteria, dose adjustments for kidney function, and effects of tranexamic acid on thrombotic events, seizures, and bleeding by subgroups of kidney function.
MAIN RESULTS
We evaluated 300 trials with 53,085 participants; 45,958 participants (86.6%) were enrolled in 228 trials (76.0%) that explicitly excluded patients with kidney disease. Definitions of kidney diseased used for exclusion varied widely. Most were non-specific and some corresponded to mild disease. Only 5 trials adjusted dosing for kidney function. Meta-analysis of two large trials found tranexamic acid unlikely to substantially increase or decrease the occurrence of thrombotic events in patients with eGFR <60 mL/min/1.73m (RR, 0.95; 95% CI: 0.83 to 1.07) or ≥ 60 mL/min/1.73m (RR, 1.00; 95% CI, 0.91 to 1.11; P for subgroup difference = 0.47), but both trials excluded patients with severe kidney disease. No analysis could be performed regarding seizure risk. One large trial in noncardiac surgery reported similar reduction in bleeding across subgroups of kidney function but excluded patients with creatinine clearance <30 mL/min.
CONCLUSIONS
The large evidence base supporting perioperative tranexamic acid suffers from broad and unjustified exclusion of patients with kidney disease. Typical perioperative dosing of tranexamic acid is likely safe and effective in patients with creatinine clearance >30 mL/min, but effects in more severe kidney disease are unknown.
Topics: Humans; Antifibrinolytic Agents; Creatinine; Hemorrhage; Kidney Diseases; Tranexamic Acid
PubMed: 38387241
DOI: 10.1016/j.jclinane.2024.111417 -
Critical Care Medicine May 2024Four-factor prothrombin complex concentrate (4-PCC) is recommended for rapid reversal of vitamin K antagonists (VKAs) such as warfarin, yet optimal dosing remains... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Four-factor prothrombin complex concentrate (4-PCC) is recommended for rapid reversal of vitamin K antagonists (VKAs) such as warfarin, yet optimal dosing remains uncertain.
DATA SOURCES
A systematic review was conducted of PubMed, Embase, and Ovid MEDLINE (Wolters Kluwer) databases from January 2000 to August 2023 for clinical studies comparing fixed- vs. variable-dose 4-PCC for emergent VKA reversal with at least one reported clinical outcome.
STUDY SELECTION
Abstracts and full texts were assessed independently and in duplicate by two reviewers.
DATA EXTRACTION
Data were extracted independently and in duplicate by two reviewers using predefined extraction forms.
DATA SYNTHESIS
The analysis comprised three randomized trials and 16 cohort studies comprising a total of 323 participants in randomized trials (161 in fixed dosage and 162 in variable dosage) and 1912 patients in cohort studies (858 in fixed-dose and 1054 in variable dose). Extracranial bleeding was the predominant indication, while intracranial hemorrhage varied. Overall, a fixed-dose regimen may be associated with a lower dose of 4-PCC and results in a reduction in 4-PCC administration time compared with a variable-dose regimen. A fixed-dose regimen also likely results in increased clinical hemostasis. While there is no clear difference between the two regimens in terms of achieving a goal international normalized ratio (INR) less than 2, a fixed-dose regimen is less likely to achieve a goal INR less than 1.5. High certainty evidence indicates that the fixed-dose regimen reduces both mortality and the occurrence of thromboembolic events. Additional subgroup analyses provides exploratory data to guide future studies.
CONCLUSIONS
A fixed-dose regimen for 4-PCC administration provides benefits over a variable-dose regimen in terms of dose reduction, faster administration time, improved clinical hemostasis, and reduced mortality and thromboembolic events. Further studies are warranted to better refine the optimal fixed-dose regimen.
Topics: Humans; Blood Coagulation Factors; Anticoagulants; Hemorrhage; Thromboembolism; International Normalized Ratio; Fibrinolytic Agents; Vitamin K; Retrospective Studies
PubMed: 38353592
DOI: 10.1097/CCM.0000000000006212