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Innovative Surgical Sciences Dec 2023Proximal femur fractures (PFF) are common injuries in elderly patients and can have considerable effects on their quality of life, morbidity, and mortality. Due to... (Review)
Review
OBJECTIVES
Proximal femur fractures (PFF) are common injuries in elderly patients and can have considerable effects on their quality of life, morbidity, and mortality. Due to pre-existing comorbidities, the prevalence of anticoagulated patients is increasing. The right timing for surgery and perioperative anticoagulation treatment remains controversial.
CONTENT
This overview aims to summarize current practices in the pre- and postoperative anticoagulation management and the recommended time to surgery in elderly patients with PFF.
SUMMARY AND OUTLOOK
Time to surgery for anticoagulated patients is often prolonged due to worries about serious perioperative bleeding and higher transfusion demands. But the delay of surgical PFF treatment increases the risk for perioperative complications like pulmonary embolism, pneumonia, deep vein thrombosis and urinary tract infections. Early surgery can be achieved with a consistent and interdisciplinary perioperative anticoagulation management. Antiplatelets do not have to be discontinued and surgery should be performed early without delay. For patients taking vitamin K antagonists (VKA) an INR less than 1.5 is recommended prior to surgery, which can be achieved by pausing VKA intake or by administering vitamin K, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). For the treatment with direct oral anticoagulants (DOAC) a plasma drug level of under 50 pg/mL is considered safe for surgery. If the plasma level can not be determined, a gap of 24 h between the last DOAC dose and surgery is recommended. The systemic administration of tranexamic acid can reduce overall blood loss and transfusion rates in anticoagulated patients with PFF. Surgical treatment of PFF should be performed within 24 h, as delayed surgery increases the risk for perioperative complications. This also applies to anticoagulated patients, when clinically appropriate. International and interdisciplinary guidelines are necessary to ensure early and appropriate treatment of anticoagulated elderly patients with PFF.
PubMed: 38510368
DOI: 10.1515/iss-2023-0030 -
SAGE Open Medical Case Reports 2024Factor XI (FXI) deficiency is one of the rarest coagulation disorders with a frequency of 1:1,000,000. A 30-year-old woman, diagnosed with FXI deficiency at the age of...
Factor XI (FXI) deficiency is one of the rarest coagulation disorders with a frequency of 1:1,000,000. A 30-year-old woman, diagnosed with FXI deficiency at the age of 4, was admitted to our maternity service at 25 weeks of gestation. The patient had no history of hemorrhage or abnormal bleeding, and the clinical examination was unremarkable. Antenatal care was also normal. The parturient was admitted in early labor at 38 weeks of gestation. Despite the absence of clinical hemorrhagic syndrome, a transfusion of fresh frozen plasma combined with tranexamic acid was initiated once the active stage of labor was started. Management of FXI deficiency in pregnant women is a challenge due to its unpredictable bleeding tendency, and careful planning and knowledge of appropriate hemostatic management is pivotal for their care.
PubMed: 38505580
DOI: 10.1177/2050313X241241196 -
Critical Care (London, England) Mar 2024In trauma systems, criteria for individualised and optimised administration of tranexamic acid (TXA), an antifibrinolytic, are yet to be established. This study used...
BACKGROUND
In trauma systems, criteria for individualised and optimised administration of tranexamic acid (TXA), an antifibrinolytic, are yet to be established. This study used nationwide cohort data from Japan to evaluate the association between TXA and in-hospital mortality among all patients with blunt trauma based on clinical phenotypes (trauma phenotypes).
METHODS
A retrospective analysis was conducted using data from the Japan Trauma Data Bank (JTDB) spanning 2019 to 2021.
RESULTS
Of 80,463 patients with trauma registered in the JTDB, 53,703 met the inclusion criteria, and 8046 (15.0%) received TXA treatment. The patients were categorised into eight trauma phenotypes. After adjusting with inverse probability treatment weighting, in-hospital mortality of the following trauma phenotypes significantly reduced with TXA administration: trauma phenotype 1 (odds ratio [OR] 0.68 [95% confidence interval [CI] 0.57-0.81]), trauma phenotype 2 (OR 0.73 [0.66-0.81]), trauma phenotype 6 (OR 0.52 [0.39-0.70]), and trauma phenotype 8 (OR 0.67 [0.60-0.75]). Conversely, trauma phenotypes 3 (OR 2.62 [1.98-3.47]) and 4 (OR 1.39 [1.11-1.74]) exhibited a significant increase in in-hospital mortality.
CONCLUSIONS
This is the first study to evaluate the association between TXA administration and survival outcomes based on clinical phenotypes. We found an association between trauma phenotypes and in-hospital mortality, indicating that treatment with TXA could potentially influence this relationship. Further studies are needed to assess the usefulness of these phenotypes.
Topics: Humans; Tranexamic Acid; Retrospective Studies; Japan; Antifibrinolytic Agents; Registries; Wounds and Injuries
PubMed: 38504320
DOI: 10.1186/s13054-024-04871-w -
Cureus Feb 2024Tranexamic acid (TXA) is an essential procoagulant drug used in various intra- and postoperative situations. Its efficacy and safety profile in obese cases undergoing... (Review)
Review
Tranexamic acid (TXA) is an essential procoagulant drug used in various intra- and postoperative situations. Its efficacy and safety profile in obese cases undergoing laparoscopic sleeve gastrectomy (LSG) is still unresolved. Therefore, this meta-analysis evaluated and investigated the current intra- and postoperative effects and hazards of TXA on patients undergoing LSG. As for methodology, Web of Science, Cochrane Library, Scopus, and PubMed were thoroughly searched for relevant studies. Retrieved results were prepared for screening through Endnote, helping to identify eligible studies. Relevant patient characteristics and outcomes were extracted. The methodological quality of the relevant studies was appraised using the respected appraisal tool. Six studies of different designs were enrolled, comprising 753 cases that underwent LSG and administered TXA. Their mean BMI and age went from 37.3 to 56.25 kg/m and 33.5 to 43.25 years, respectively. Tranexamic acid significantly linked to reduction in intraoperative bleeding instances, operative blood loss, and operative duration, compared to placebo ((RR = 0.66, 95% CI [0.44, 0.98], P=0.04, I = 81%); (MD = -39.64, 95%CI [-75.49, -3.78], P=0.03, I=94%); (MD=-5.84, 95%CI [-9.62, -2.05], P=0.003, I=73%)). Tranexamic acid also significantly showed superiority regarding postoperative bleeding events and duration of hospitalization compared to the control group ((RR= 0.45, 95%CI [0.29, 0.69], P=0.0002, I =0%); (MD=-0.24, 95%CI [-0.32, -0.17], P< 0.0000, I =0%)). Moreover, follow-up of the enrolled patients for a minimum of three to six months resulted in no reported thromboembolic instances, suggesting a negligible risk for thromboembolism among patients undergoing LSG and receiving TXA. In conclusion, tranexamic acid demonstrates a robust safety and efficacy profile for its use in patients undergoing LSG, with no reported instances of thromboembolism. Variations in TXA administration regimens, bleeding definitions, procedural techniques, and potential confounding medications could not be accounted for, necessitating additional large-scale RCTs to address and bridge knowledge gaps.
PubMed: 38496064
DOI: 10.7759/cureus.54269 -
Perioperative Medicine (London, England) Mar 2024Our aim was to analyze factors that influence transfusion requirements in surgical patients in order to achieve a transfusion-saving strategy.
BACKGROUND AND PURPOSE
Our aim was to analyze factors that influence transfusion requirements in surgical patients in order to achieve a transfusion-saving strategy.
METHODS
Data was collected from patient's files at the Notre Dame de Secours-Jbeil University Hospital Center between January 2017 and June 2019. Selection was made for 400 patients who had undergone surgery and required transfusion. The studied variables were age, sex, and type of surgery whether planned or urgent with its expected level of bleeding. The presence of chronic anemia, coronary artery disease, values of hemoglobin and hematocrit before and after transfusion, iron status preoperatively, and post-operation complications were also noted.
RESULTS
The analysis of 400 transfused surgical patients showed that the mean age was 62 ± 18 years with 52.5% women and 47.5% men. In 82.3% of patients, surgical bleeding was expected, 77.8% of surgeries were scheduled, and 22.3% were urgent. Fifty-two percent of patients were known to have coronary artery disease. Orthopedic (35%) and cardiothoracic (29.5%) surgeries had the highest transfusion rate. Among all patients, only 106 patients (26.5%) underwent a preoperative iron workup. The pre-transfusion levels of hemoglobin were 9.9 ± 0.6 and hematocrit of 29.7 ± 1.9. 26.3% of patients had a post-transfusion complication. On the other hand, 19.5% of women and 20% of men were already anemic when admitted to the hospital. Anemic women required 7.6 times more transfusions than non-anemic, while anemic men required 12.38 times more transfusions than non-anemic men. Age, presence of coronary artery disease, and chronic anemia have been found to be factors increasing the risk of post-transfusion complications. Finally, urgent and unplanned surgeries are 2.9 times more likely to cause post-transfusion complications.
CONCLUSION
This study therefore confirms that anemic patients are more likely to receive perioperative blood transfusions. Consequently, in order to reduce blood transfusion and its complications, it would be beneficial primarily to diagnose and treat anemia preoperatively. Other transfusion-saving strategies could also be useful in the setting of surgical bleeding, such as the use of tranexamic acid and different autologous transfusion methods like the cell saver.
PubMed: 38491398
DOI: 10.1186/s13741-024-00374-y -
The Disease Burden of Hereditary Angioedema: Insights from a Survey in French-Canadians from Quebec.Journal of Immunology Research 2024Limited data are available on the clinical profile and disease burden of hereditary angioedema (HAE) in Canadians.
BACKGROUND
Limited data are available on the clinical profile and disease burden of hereditary angioedema (HAE) in Canadians.
OBJECTIVE
This study aimed to assess HAE disease characteristics and the burden of disease in Canadians with HAE types I, II, and normal levels of C1 inhibitor (nC1-INH).
MATERIALS AND METHODS
A 46-item patient survey evaluating clinical characteristics and burden of disease was developed and disseminated by the HAE patient organization in Quebec, Canada, from May 2019 to February 2020. The survey received Research Review Board ethics approval.
RESULTS
In the 35 respondents, HAE type I was the most common (46%), followed by nC1-INH (43%). Female participants were significantly younger at first symptom presentation than males (=0.04). Prior to diagnosis, 69% of participants underwent unnecessary treatments and procedures, with a 10-year delay between first symptoms and diagnosis. Before starting the current treatment, 42% of participants experienced weekly HAE attacks. Most participants identified experiencing attacks in the abdomen (89%), followed by the larynx (66%), feet (66%), hands (63%), and face (63%). Most attacks were severe or moderate, yet almost half of patients waited >1 hr before getting medical attention at their last emergency department (ED) visit. HAE was associated with decreased health-related quality of life, leading to significant functional impairment in personal and professional life. As compared to HAE type I/II, patients with HAE nC1-INH were treated more often with tranexamic acid for long-term prophylaxis, and their condition was less controlled, resulting in more attacks and ED visits.
CONCLUSION
HAE manifests in this patient population as frequent moderate-to-severe attacks and a high disease burden; the HAE subtype may differentially affect care requirements. There is an urgent need for increased awareness and education on HAE among treating physicians.
Topics: Female; Humans; Male; Angioedemas, Hereditary; Canada; Cost of Illness; North American People; Quality of Life; Quebec; Surveys and Questionnaires
PubMed: 38487730
DOI: 10.1155/2024/3028617 -
Critical Care Explorations Mar 2024To determine the risk difference of arterial and venous thromboembolic events between patients with upper gastrointestinal bleeding (UGIB) who received and did not...
OBJECTIVES
To determine the risk difference of arterial and venous thromboembolic events between patients with upper gastrointestinal bleeding (UGIB) who received and did not receive tranexamic acid.
DESIGN
Retrospective cohort study.
SETTING
The TriNetX Analytics (Cambridge, MA) Research Network, a deidentified mixed electronic health record and claims-derived database with over 110 million patients, primarily located in the United States.
PATIENTS
A total of 2,016,763 patients diagnosed with hematemesis or melena between October 31, 2003, and October 31, 2023.
INTERVENTIONS
Receipt of tranexamic acid within 7 days of a UGIB diagnosis.
MEASUREMENTS AND MAIN RESULTS
We measured the incidence of thromboembolic events, both venous (deep venous thrombosis [DVT] and pulmonary embolism [PE]) and arterial (cerebrovascular accident [CVA] and myocardial infarction [MI]), within either 7 days of tranexamic acid (for recipients) or 7 days of UGIB diagnosis (for nonrecipients). Subsequently, we developed similar subcohorts using propensity score matching (PSM) for demographic and comorbidity data and reexamined the incidence of thromboembolic events, both before and after excluding any patients with any prior episodes of the outcomes. In all analyses, tranexamic acid recipients experienced significantly more adverse thromboembolic outcomes, with the post-PSM cohorts' risk difference generating an odds ratio of 1.4 for MI (95% CI, 1.2-1.7), 1.6 in CVA (95% CI, 1.3-1.9), 1.8 in PE (95% CI, 1.5-2.3), and 2.1 in DVT (95% CI, 1.8-2.5); all values of less than 0.001.
CONCLUSIONS
Leveraging data from a large, multi-institutional database, we identified a correlation between tranexamic acid use in patients with UGIB and the occurrence of both venous and arterial thromboembolic events. Although the former is well-attested in the literature, the latter finding is more novel, underscoring the need for further prospective research to better characterize the risk-benefit profile of tranexamic acid in the management of gastrointestinal bleeding.
PubMed: 38481541
DOI: 10.1097/CCE.0000000000001060 -
Trauma Surgery & Acute Care Open 2024
PubMed: 38464550
DOI: 10.1136/tsaco-2024-001429 -
Plastic and Reconstructive Surgery.... Mar 2024Tranexamic acid (TXA) has demonstrated promising outcomes in plastic surgery. Our aim was to assess the effect of TXA in intraoperative bleeding, operative time, and...
BACKGROUND
Tranexamic acid (TXA) has demonstrated promising outcomes in plastic surgery. Our aim was to assess the effect of TXA in intraoperative bleeding, operative time, and complications among patients undergoing facial surgical procedures.
METHODS
A retrospective cohort study of patients who underwent multiplane facial rhytidectomy from January 2018 to September 2022 at the Clinica Ziegler, Lima, Peru. Patients were divided into two groups according to the use of intravenous plus local infiltration of TXA. We performed the chi square test to assess associations among categorical variables, the Student test and Mann-Whitney U test for categorical with continuous variables, and Pearson correlation for quantitative variables.
RESULTS
A total of 100 patients were included with 50 patients in each group. The median age was 59.5 years and the majority were women (88%). The median operative time was 288.5 minutes. The TXA group presented less intraoperative bleeding (40 versus 90 mL, < 0.05) and shorter operative time (237 versus 353 minutes, < 0.05); no differences in the development of hematoma (2% versus 12%, = 0.11), less ecchymosis (2% versus 36%, < 0.05), edema (2% versus 100%, < 0.05), and time to drain removal (3 versus 6 days, < 0.05).
CONCLUSIONS
TXA improves the short- and long-term outcomes of patients who undergo multiplane facial rhytidectomy. It also decreases intraoperative bleeding by more than half and reduces the operative time by one third. Moreover, patients receiving TXA presented significantly less ecchymosis, edema, and time to drain removal.
PubMed: 38463701
DOI: 10.1097/GOX.0000000000005653 -
Journal of Thrombosis and Haemostasis :... Jun 2024The widespread use of the antifibrinolytic agent, tranexamic acid (TXA), interferes with the quantification of fibrinolysis by dynamic laboratory assays such as clot...
BACKGROUND
The widespread use of the antifibrinolytic agent, tranexamic acid (TXA), interferes with the quantification of fibrinolysis by dynamic laboratory assays such as clot lysis, making it difficult to measure fibrinolysis in many trauma patients. At the final stage of coagulation, factor (F)XIIIa catalyzes the formation of fibrin-fibrin and fibrin-α-antiplasmin (αAP) cross-links, which increases clot mechanical strength and resistance to fibrinolysis.
OBJECTIVES
Here, we developed a method to quantify fibrin-fibrin and fibrin-αAP cross-links that avoids the challenges posed by TXA in determining fibrinolytic resistance in conventional assays.
METHODS
Fibrinogen alpha (FGA) chain (FGA-FGA), fibrinogen gamma (FGG) chain (FGG-FGG), and FGA-αAP cross-links were quantified using liquid chromatography-mass spectrometry (LC-MS) and parallel reaction monitoring in paired plasma samples from trauma patients prefibrinogen and postfibrinogen replacement. Differences in the abundance of cross-links in trauma patients receiving cryoprecipitate (cryo) or fibrinogen concentrate (Fg-C) were analyzed.
RESULTS
The abundance of cross-links was significantly increased in trauma patients postcryo, but not Fg-C transfusion (P < .0001). The abundance of cross-links was positively correlated with the toughness of individual fibrin fibers, the peak thrombin concentration, and FXIII antigen (P < .05).
CONCLUSION
We have developed a novel method that allows us to quantify fibrin cross-links in trauma patients who have received TXA, providing an indirect measure of fibrinolytic resistance. Using this novel approach, we have avoided the effect of TXA and shown that cryo increases fibrin-fibrin and fibrin-αAP cross-linking when compared with Fg-C, highlighting the importance of FXIII in clot formation and stability in trauma patients.
Topics: Humans; Fibrin; alpha-2-Antiplasmin; Fibrinogen; Fibrinolysis; Wounds and Injuries; Antifibrinolytic Agents; Tranexamic Acid; Thrombosis; Blood Coagulation; Chromatography, Liquid; Male; Adult; Female; Mass Spectrometry; Middle Aged
PubMed: 38462220
DOI: 10.1016/j.jtha.2024.03.001