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Takahashi Y, Hayakawa M, Itagaki Y, Ono K, Kudo D, Kushimoto S. Coagulopathy as a predictor of the effectiveness of tranexamic acid in severe blunt trauma: a multicenter retrospective study. Thromb J 2025; 23:37. [PMID: 40264127 PMCID: PMC12013063 DOI: 10.1186/s12959-025-00723-x] [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: 01/29/2025] [Accepted: 04/07/2025] [Indexed: 04/24/2025] Open
Abstract
BACKGROUND Tranexamic acid (TXA) reduces mortality in severe trauma cases. However, the relationships between TXA administration and coagulation/fibrinolysis abnormalities are unclear. We performed a retrospective observational study to investigate relationships between mortality and coagulation/fibrinolysis abnormalities of patients on arrival at the emergency department and whether TXA is more effective in patients with severe trauma who have coagulation/fibrinolysis abnormalities than in those who do not. METHODS Data was collected from 15 tertiary emergency and critical care centers in Japan. Adult patients with blunt trauma and an Injury Severity Score of ≥ 16 were included in the study. Patients were categorized into two groups: the TXA group received TXA within 3 h of arrival, and the non-TXA group did not. RESULTS Overall, 790 patients were included (TXA group, 276; non-TXA group, 514). In cubic spline curves for relationships between mortality and coagulation/fibrinolysis variables on arrival, odds for mortality increased and plateaued with a prothrombin time-international normalized ratio ≥ 1.2; the disseminated intravascular coagulation (DIC) score showed a marked odds increase when > 4 points. Odds increased and plateaued from an activated partial thromboplastin time (APTT) of ≥ 35 s and gradually increased as fibrinogen decreased from 250 mg/dL. Fibrinogen and fibrin degradation products (FDP) and D-dimer exhibited upward-sloping curves. In cubic spline curves for relationships between the effectiveness of TXA administration and coagulation/fibrinolysis variables on arrival, a favorable effect on mortality was observed with TXA administration when fibrinogen was ≤ 200 mg/dL or when the DIC score was ≥ 4 points; FDP, ≥ 50 µg/mL; D-dimer, ≥ 30 µg/mL; or APTT, ≥ 35 s. In each threshold subgroup, interactions between TXA administration and in-hospital mortality were observed. CONCLUSIONS TXA demonstrates increased effectiveness in patients with traumatic coagulation/fibrinolysis abnormalities.
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Affiliation(s)
- Yuki Takahashi
- Emergency and Critical Care Center, Hokkaido University Hospital, North 14-West5, Kita- ku, Sapporo, 060-8648, Japan
| | - Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, North 14-West5, Kita- ku, Sapporo, 060-8648, Japan.
- Department Emergency and General Medicine, Sapporo City General Hospital, Chuo-Ku, N11W13, 060-8604, Sapporo, Japan.
| | - Yuki Itagaki
- Emergency and Critical Care Center, Hokkaido University Hospital, North 14-West5, Kita- ku, Sapporo, 060-8648, Japan
| | - Kota Ono
- Ono Biostat Consulting, Narita-Higashi, Suginami-ku, Tokyo, 166-0015, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- Kawasaki Saiwai Hospital, Kawasaki, Japan
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Althobaiti MA, Maniya MT, Alelyani RH, Farooqui SK, Aljuaid AS, Alfarej ZM, Almenhali AA, Aljindan FK. Tranexamic Acid for Postoperative Outcomes in Breast Plastic Surgery: A Systematic Review and Meta-analysis. Aesthetic Plast Surg 2025:10.1007/s00266-025-04772-5. [PMID: 40097792 DOI: 10.1007/s00266-025-04772-5] [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: 11/19/2024] [Accepted: 02/10/2025] [Indexed: 03/19/2025]
Abstract
BACKGROUND AND OBJECTIVES Tranexamic acid (TXA), a synthetic antifibrinolytic agent, offers considerable promise as a potential therapy to improve postoperative outcomes for patients undergoing breast surgery. However, its specific role in plastic breast surgery remains understudied. Hence, we aimed to evaluate its efficacy in cosmetic plastic breast surgery. METHODS An extensive literature search of electronic databases such as PubMed, Embase, and Cochrane CENTRAL was conducted from inception to October 2023. Quality assessment of the included studies was done using the Newcastle-Ottawa scale (NOS). The results of our analyses were presented as odds ratios (ORs) with 95% confidence intervals (CIs) and pooled using a random effects model. A p-value < 0.05 was considered significant in all cases. RESULTS A total of 8 studies, encompassing 2311 participants were included in our analysis. The pooled analysis demonstrates that TXA is associated with a significant improvement in hematoma formation (OR 0.37, 95% CI: 0.24-0.58; p < 0.0001). There was no significant improvement in seroma formation (OR 0.65, 95% CI: 0.33-1.27; p = 0.21), infection rate (OR 1.84, 95% CI: 0.49-6.94; p = 0.37) or partial loss of the nipple-areolar complex (OR 0.47, 95% CI: 0.12-1.82; p = 0.28). CONCLUSION Tranexamic acid demonstrated considerable efficacy in improving postoperative outcomes for patients undergoing cosmetic and reconstructive breast surgeries. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Mohammed A Althobaiti
- Division of Plastic Surgery and Burn, Department of Surgery, King Faisal Medical Complex, Taif, Saudi Arabia
| | | | - Rakan H Alelyani
- Department of Plastic and Reconstructive Surgery, Ministry of National Guards, Health Affairs, Riyadh, Saudi Arabia
| | | | - Abdulaziz Saud Aljuaid
- Division of Plastic Surgery and Burn, Department of Surgery, King Faisal Medical Complex, Taif, Saudi Arabia
| | | | | | - Fahad K Aljindan
- Plastic and Reconstructive Microsurgery, King Abdulah Medical City, Makkah, Saudi Arabia
- Makkah Health Cluster, Makkah, Saudi Arabia
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Vallejo MC, Zukowski AL, Long JM, Lilly CL, Nield LS, Zakowski MI. Efficacy of Prophylactic Policy-Driven Tranexamic Acid Administration during Cesarean Delivery in a Rural Healthcare Setting. South Med J 2025; 118:196-200. [PMID: 40031771 DOI: 10.14423/smj.0000000000001796] [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: 03/05/2025]
Abstract
OBJECTIVES Postpartum hemorrhage (PPH) is a major contributor to maternal mortality worldwide and is a leading cause of pregnancy-related mortality in the United States. The American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynecologists, and the World Health Organization advocate for the early use of tranexamic acid (TXA) in the prevention of PPH. The purpose of this study was to determine the efficacy and patient characteristics of the use of prophylactic TXA administration during cesarean delivery (CD) as part of a newly instituted policy to reduce blood loss and PPH rates in a tertiary care regional rural and underserved maternal care center. METHODS An electronic quality assurance chart review from February 2020 through October 2021 of more than 2705 patients was conducted, comparing two groups after implementation of a TXA protocol for all CDs. In total, four CD groups were analyzed (control group without TXA before policy, PPH group without TXA before policy, TXA control group after policy, and PPH group with TXA after policy). RESULTS PPH rates decreased with TXA use (9.7% vs 1.5%). TXA use was more likely to be given to patients with one or more of the following characteristics: commercial insurance, self-identified Asian race, admission from a doctor's office, urgent CD delivery, fetal distress, abruptio placenta/placenta previa, and extended hospital length of stay with increased hospitalization cost. Subset analysis of 720 patients revealed decreased blood loss (896.4 ± 521.0 mL vs 771.1 ± 405.6 mL, P = 0.0004) and fewer blood transfusions with TXA use (6.7% vs 1.1%, P = 0.0001). CONCLUSIONS Prophylactic policy-driven TXA administration during CD protocol-driven TXA administration decreases PPH.
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Affiliation(s)
| | - Anna L Zukowski
- From the Department of Medical Education, School of Medicine
| | | | - Christa L Lilly
- the School of Public Health, West Virginia University, Morgantown
| | - Linda S Nield
- From the Department of Medical Education, School of Medicine
| | - Mark I Zakowski
- the Department of Anesthesiology, Cedars Sinai Medical Center, Los Angeles, California
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Magni S, Guggenheim L, Fournier G, Parodi C, Pagnamenta A, Schmauss D, Harder Y. The Effects of Systemic Tranexamic Acid Administration on Drainage Volume, Length of Hospital Stay, and Postoperative Complications in Reduction Mammaplasty. J Clin Med 2024; 14:151. [PMID: 39797232 PMCID: PMC11720834 DOI: 10.3390/jcm14010151] [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: 11/13/2024] [Revised: 12/12/2024] [Accepted: 12/25/2024] [Indexed: 01/13/2025] Open
Abstract
Background: Reduction mammaplasty is a common, elective, and safe operation, usually executed in healthy patients. Nonetheless, postoperative complications like bleeding and seroma formation can occur and significantly complicate the postoperative course. Tranexamic acid (TXA), a commonly used antifibrinolytic drug, offers a novel approach to reduce these complications. This study aims to evaluate its effect on the rate of postoperative bleeding, drainage volume, length of hospital stay, and other postoperative complications in patients undergoing reduction mammaplasty. Method: A retrospective study on all patients undergoing reduction mammaplasty at the Department of Plastic, Reconstructive, and Aesthetic Surgery EOC between 2015 and 2022 was conducted. Patients were divided into the TXA group receiving systemic TXA for 48 h and the control group not receiving any TXA. All data were analyzed using nonparametric formulas. Results: A total of 209 breasts were included in the study, with 138 cases in the control group and 71 in the TXA group. Three cases requiring revision surgery due to bleeding were observed in the control group, whereas none were observed in the TXA group. Total drainage volume was significantly reduced in the TXA group compared to the control group (TXA: 41.6 mL vs. control: 53.8 mL; p = 0.012), resulting in a significant reduction in length of hospital stay (TXA: 1.6 days vs. control: 2.2 days; p = 0.0001). Conclusions: TXA is a well-tolerated drug that significantly reduces postoperative bleeding and drainage volume, resulting in earlier drain removal and reduced length of hospital stay. TXA should, therefore, be widely used in plastic surgery, especially as trends in healthcare systems necessitate more outpatient procedures and quicker postoperative recovery.
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Affiliation(s)
- Sara Magni
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (S.M.); (C.P.); (D.S.)
| | - Leon Guggenheim
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland; (L.G.); (A.P.)
| | - Geraldine Fournier
- Department of General Surgery, Spital Maennedorf, 8708 Maennedorf, Switzerland;
| | - Corrado Parodi
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (S.M.); (C.P.); (D.S.)
| | - Alberto Pagnamenta
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland; (L.G.); (A.P.)
- Clinical Trial Unit (CTU), Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland
| | - Daniel Schmauss
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (S.M.); (C.P.); (D.S.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland; (L.G.); (A.P.)
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), 1015 Lausanne, Switzerland
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Nam JS, Oh CS, Kim JY, Choi DK, Oh AR, Park J, Lee JH, Yun SC, Kim KW, Jang MU, Kim TY, Choi IC. A multi-center, double-blind, placebo-controlled, randomized, parallel-group, non-inferiority study to compare the efficacy of goal-directed tranexamic acid administration based on viscoelastic test versus preemptive tranexamic acid administration on postoperative bleeding in cardiovascular surgery (GDT trial). Trials 2024; 25:623. [PMID: 39334224 PMCID: PMC11429631 DOI: 10.1186/s13063-024-08467-1] [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: 04/10/2024] [Accepted: 09/16/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Tranexamic acid (TXA) effectively attenuates hyperfibrinolysis and preemptive administration has been employed to reduce bleeding and blood transfusions in various surgical settings. However, TXA administration could be associated with adverse effects, such as seizures and thromboembolic risks. While patients with fibrinolysis shutdown showed greater thromboembolic complications and mortality, TXA administration may aggravate the degree of shutdown in these patients. Selective TXA administration based on the results of rotational thromboelastometry (ROTEM) would be non-inferior to preemptive TXA administration in reducing postoperative bleeding and beneficial in reducing its risks in patients undergoing cardiovascular surgery. METHODS This non-inferiority, randomized, double-blind, placebo-controlled, multicenter trial will be performed in 3 tertiary university hospitals from August 2023 to March 2025. Seven hundred sixty-four patients undergoing cardiovascular surgery will be randomly allocated to get TXA as a preemptive (Group-P) or goal-directed strategy (Group-GDT) in each institution (with a 1:1 allocation ratio). After anesthesia induction, TXA (10 mg/kg and 2 mg/kg/h) and a placebo are administered after anesthesia induction in Group-P and Group-GDT, respectively. ROTEM tests are performed immediately before weaning from CPB and at the considerable bleeding post-CPB period. After getting the test results, a placebo is administered in Group-P (regardless of the test results). In Group-GDT, placebo or TXA is administered according to the results: placebo is administered if the amplitude at 10 min (A10-EXTEM) is ≥ 40 mm and lysis within 60 min (LI60-EXTEM) of EXTEM assay is ≥ 85%, or TXA (20 mg/kg) is administered if A10-EXTEM is < 40 mm or LI60-EXTEM is < 85%. The primary outcome is inter-group comparisons of postoperative bleeding (for 24 h). The secondary measures include comparisons of perioperative blood transfusion, coagulation profiles, reoperation, thromboembolic complications, seizures, in-hospital mortality, fibrinolysis phenotypes, and hospital costs. DISCUSSION The absence of inter-group differences in postoperative bleeding would support the selective strategy's non-inferiority in reducing postoperative bleeding in these patients. The possible reduction in thromboembolic risks, seizures, and fibrinolysis shutdown in Group-GDT would support its superiority in reducing TXA-induced adverse events and the cost of their management. TRIAL REGISTRATION This trial was registered at ClinicalTrials.gov with the registration number NCT05806346 on March 28, 2023. TRIAL STATUS recruiting. Issue date: 2023 March 28 (by Tae-Yop Kim, MD, PhD). The trial was registered in the clinical registration on March 28, 2023 (ClinicalTrials.gov, NCT05806346) and revised to the latest version of its protocol (version no. 8, August 26, 2024) approved by the institutional review boards (IRBs) of all 3 university hospitals (Konkuk University Medical Center, 2023-07-005-001, Asan Medical Center, 2023-0248, and Samsung Medical Center, SMC 2023-06-048-002). Its recruitment was started on August 1, 2023, and will be completed on December 31, 2024. Protocol amendment number: 08 (protocol version 08, August 26, 2024). Revision chronology: 2023 March 28:Original. 2023 April 10:Amendment No 01. The primary reason for the amendment is the modification of Arms (adding one arm for sub-group analyses) and Interventions, Outcome Measures, Study Design, Study Description, Study Status, Eligibility, and Study Identification. 2023 May 03:Amendment No 02. The primary reason for the amendment is to modify the Outcome Measures and update the study status. 2023 July 06:Amendment No 03. The primary reason for amendment is to update the chronological study status. 2023 July 07:Amendment No 04. The primary reason for the amendment is the modification of study information (the treatment category was changed to diagnostic, and Phase 4 was changed to not applicable) and a chronological update on the study status. 2023 September 12:Amendment No 06. The primary reason for the amendment is a chronological update in the study status and the inclusion of additional information regarding contacts/locations and oversight. 2023 December 29:Amendment No 07. The primary reason for the amendment is to modify the outcome measures (including detailed information on outcome measures, addition of extra secondary measures, and chronological updates in study status). 2024 August 26:Amendment No 08. The primary reason for the amendment is to add detailed descriptions regarding data handling and the names and roles of the participating institutions and to update the chronological process of the trial.
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Affiliation(s)
- Jae-Sik Nam
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chung-Sik Oh
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, and Institution for Patient-Centered Goal-Directed Strategy, Chungju, Republic of Korea
- Institution for Patient-Centered Goal-Directed Strategy, Konkuk University, Chungju, Republic of Korea
| | - Ji-Yoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dae-Kee Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung-Cheol Yun
- Department of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyeng Whan Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Min Uk Jang
- Cheorwon Public Health Center, Cheorwon-Gun, Gangwon-Do, Republic of Korea
| | - Tae-Yop Kim
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, and Institution for Patient-Centered Goal-Directed Strategy, Chungju, Republic of Korea.
- Institution for Patient-Centered Goal-Directed Strategy, Konkuk University, Chungju, Republic of Korea.
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Gulickx M, Lokerman RD, Waalwijk JF, Dercksen B, van Wessem KJP, Tuinema RM, Leenen LPH, van Heijl M. Pre-hospital tranexamic acid administration in patients with a severe hemorrhage: an evaluation after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol. Eur J Trauma Emerg Surg 2024; 50:139-147. [PMID: 37067552 PMCID: PMC10923991 DOI: 10.1007/s00068-023-02262-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/16/2023] [Indexed: 04/18/2023]
Abstract
PURPOSE To evaluate the pre-hospital administration of tranexamic acid in ambulance-treated trauma patients with a severe hemorrhage after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol. METHODS All patients with a severe hemorrhage who were treated and conveyed by EMS professionals between January 2015, and December 2017, to any trauma-receiving emergency department in the eight participating trauma regions in the Netherlands, were included. A severe hemorrhage was defined as extracranial injury with > 20% body volume blood loss, an extremity amputation above the wrist or ankle, or a grade ≥ 4 visceral organ injury. The main outcome was to determine the proportion of patients with a severe hemorrhage who received pre-hospital treatment with tranexamic acid. A Generalized Linear Model (GLM) was performed to investigate the relationship between pre-hospital tranexamic acid treatment and 24 h mortality. RESULTS A total of 477 patients had a severe hemorrhage, of whom 124 patients (26.0%) received tranexamic acid before arriving at the hospital. More than half (58.4%) of the untreated patients were suspected of a severe hemorrhage by EMS professionals. Patients treated with tranexamic acid had a significantly lower risk on 24 h mortality than untreated patients (OR 0.43 [95% CI 0.19-0.97]). CONCLUSION Approximately a quarter of the patients with a severe hemorrhage received tranexamic acid before arriving at the hospital, while a severe hemorrhage was suspected in more than half of the non-treated patients. Severely hemorrhaging patients treated with tranexamic acid before arrival at the hospital had a lower risk to die within 24 h after injury.
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Affiliation(s)
- Max Gulickx
- Department of Surgery, University Medical Center Utrecht, C04.332, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Robin D Lokerman
- Department of Surgery, University Medical Center Utrecht, C04.332, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Job F Waalwijk
- Department of Surgery, University Medical Center Utrecht, C04.332, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bert Dercksen
- Department of Anesthesiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Karlijn J P van Wessem
- Department of Surgery, University Medical Center Utrecht, C04.332, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rinske M Tuinema
- Regional Ambulance Facilities Utrecht, Bilthoven, The Netherlands
- Department of Emergency Medicine, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, C04.332, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Trauma Center Utrecht, Utrecht, The Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Center Utrecht, C04.332, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Trauma Center Utrecht, Utrecht, The Netherlands
- Department of Surgery, DiakonessenhuisUtrecht/Zeist/Doorn, Utrecht, The Netherlands
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Iba T, Helms J, Neal MD, Levy JH. Mechanisms and management of the coagulopathy of trauma and sepsis: trauma-induced coagulopathy, sepsis-induced coagulopathy, and disseminated intravascular coagulation. J Thromb Haemost 2023; 21:3360-3370. [PMID: 37722532 PMCID: PMC10873124 DOI: 10.1016/j.jtha.2023.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/18/2023] [Accepted: 05/12/2023] [Indexed: 09/20/2023]
Abstract
Disseminated intravascular coagulation can occur due to different causes but commonly following sepsis. Trauma-induced coagulopathy (TIC) occurs on hospital arrival in approximately 25% of seriously injured patients who initially presents with impaired hemostasis and a bleeding phenotype that can later progress to a prothrombotic phase. Following traumatic injury, ineffective hemostasis is driven by massive blood loss, tissue damage, and hyperfibrinolysis. This initial impaired hemostasis continues until surgical or other management strategies not only to stop the causes of hemorrhage but also progresses to a prothrombotic and hypofibrinolytic state, also termed fibrinolytic shutdown. Prothrombotic progression is also promoted by inflammatory mediator release, endothelial injury, and platelet dysregulation, which is commonly seen in sepsis with increased mortality. Unlike TIC, the early phase of sepsis is frequently complicated by multiorgan dysfunction described as sepsis-induced coagulopathy (SIC) that lacks a hemorrhagic phase. The phenotypes of SIC and TIC are different, especially in their initial presentations; however, patients who survive TIC may also develop subsequent infections and potentially sepsis and SIC. Although the pathophysiology of SIC and TIC are different, endothelial injury, dysregulated fibrinolysis, and coagulation abnormalities are common. Management includes treatment of the underlying cause, tissue injury vs infection is critical, and supportive therapies, such as hemostatic resuscitation and circulatory support are essential, and adjunct therapies are recommended in guidelines. Based on clinical studies and certain guidelines, additional therapies include tranexamic acid in the limited timing of initial traumatic injury and anticoagulants, such as antithrombin and recombinant thrombomodulin in disseminated intravascular coagulation.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Julie Helms
- Strasbourg University (UNISTRA); Strasbourg University Hospital, Medical Intensive Care Unit - NHC; INSERM (French National Institute of Health and Medical Research), Strasbourg, France
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA. https://twitter.com/JerroldLevy
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Safran T, Vorstenbosch J, Viezel-Mathieu A, Davison P, Dionisopoulos T. Topical Tranexamic Acid in Breast Reconstruction: A Double-Blind Randomized Controlled Trial. Plast Reconstr Surg 2023; 152:699-706. [PMID: 36827482 DOI: 10.1097/prs.0000000000010322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND Excess fluid accumulation (seroma/hematoma) around the breast implant after reconstruction can lead to significant complications. Topical administration of tranexamic acid (TXA) may reduce fluid accumulation and reduce postoperative complications. This trial aims to investigate whether TXA-treated mastectomy pockets will exhibit less postoperative fluid production and complications. METHODS This paired, double-blind, randomized, controlled trial enrolled patients undergoing bilateral mastectomies with immediate direct-to-implant reconstruction. In each patient, one breast was randomized to receive 3 g of TXA (100 cc), and the other received 100 cc of normal saline. The blinded solutions were soaked in the mastectomy pocket for 5 minutes before implant placement. Postoperatively, daily drain outputs, complications, and baseline demographics were recorded. RESULTS Fifty-three eligible patients, representing 106 breasts, were enrolled. All patients underwent bilateral nipple-sparing mastectomies. After randomization, TXA was placed in the right breast in 30 patients (56.6%). The use of topical TXA resulted in a mean drain output reduction of 30.5% (range, -83.6% to 26.6%). Drains on the TXA-treated breast were eligible for removal 1.4 days (range, 0 to 4 days) sooner than the control side. The TXA-treated group had three complications (5.67%) versus 15 (28.3%) in the control group (OR, 0.1920; P = 0.0129). Specifically, for operative hematomas, the TXA group had none (0%), versus three in the control group (5.7%) (OR, 0.1348; P = 0.18). CONCLUSIONS Soaking the mastectomy bed with 3% topical TXA before implant insertion leads to a decrease in drain output and a decrease in complications. Topical administration of TXA represents an option to decrease complications in alloplastic breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, I.
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Affiliation(s)
- Tyler Safran
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Center
| | - Joshua Vorstenbosch
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Center
| | | | - Peter Davison
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Center
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Nicholson H, Scotney N, Briscoe S, Kirby K, Bedson A, Goodwin L, Robinson M, Taylor H, Thompson Coon J, Voss S, Benger JR. Factors that influence the administration of tranexamic acid (TXA) to trauma patients in prehospital settings: a systematic review. BMJ Open 2023; 13:e073075. [PMID: 37258083 PMCID: PMC10255319 DOI: 10.1136/bmjopen-2023-073075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVE In the UK there are around 5400 deaths annually from injury. Tranexamic acid (TXA) prevents bleeding and has been shown to reduce trauma mortality. However, only 5% of UK major trauma patients who are at risk of haemorrhage receive prehospital TXA. This review aims to examine the evidence regarding factors influencing the prehospital administration of TXA to trauma patients. DESIGN Systematic literature review. DATA SOURCES AMED, CENTRAL, CINAHL, Cochrane Database of Systematic Reviews, Conference Proceedings Citation Index-Science, Embase and MEDLINE were searched from January 2010 to 2020; searches were updated in June 2022. CLINICALTRIALS gov and OpenGrey were also searched and forward and backwards citation chasing performed. ELIGIBILITY CRITERIA All primary research reporting factors influencing TXA administration to trauma patients in the prehospital setting was included. DATA EXTRACTION AND SYNTHESIS Two independent reviewers performed the selection process, quality assessment and data extraction. Data were tabulated, grouped by setting and influencing factor and synthesised narratively. RESULTS Twenty papers (278 249 participants in total) were included in the final synthesis; 13 papers from civilian and 7 from military settings. Thirteen studies were rated as 'moderate' using the Effective Public Health Practice Project Quality Assessment Tool. Several common factors were identified: knowledge and skills; consequences and social influences; injury type (severity, injury site and mechanism); protocols; resources; priorities; patient age; patient sex. CONCLUSIONS This review highlights an absence of high-quality research. Preliminary evidence suggests a host of system and individual-level factors that may be important in determining whether TXA is administered to trauma patients in the prehospital setting. FUNDING AND REGISTRATION This review was supported by Research Capability Funding from the South Western Ambulance Service NHS Foundation Trust and the National Institute for Health Research Applied Research Collaboration South West Peninsula. PROSPERO REGISTRATION NUMBER CRD42020162943.
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Affiliation(s)
- Helen Nicholson
- College of Health, Science and Society, University of the West of England, Bristol, UK
| | - Natalie Scotney
- Research, Audit and Quality Improvement Department, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Simon Briscoe
- Exeter HS&DR Evidence Synthesis Centre, University of Exeter Medical School, Exeter, UK
| | - Kim Kirby
- Research, Audit and Quality Improvement Department, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
- Department of Health and Social Sciences, University of the West of England, Bristol, UK
| | - Adam Bedson
- Research, Audit and Quality Improvement Department, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Laura Goodwin
- College of Health, Science and Society, University of the West of England, Bristol, UK
| | - Maria Robinson
- Research, Audit and Quality Improvement Department, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Hazel Taylor
- Research Design Service, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Jo Thompson Coon
- NIHR CLAHRC South West Peninsula, University of Exeter, Exeter, UK
| | - Sarah Voss
- College of Health, Science and Society, University of the West of England, Bristol, UK
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10
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Bunch CM, Chang E, Moore EE, Moore HB, Kwaan HC, Miller JB, Al-Fadhl MD, Thomas AV, Zackariya N, Patel SS, Zackariya S, Haidar S, Patel B, McCurdy MT, Thomas SG, Zimmer D, Fulkerson D, Kim PY, Walsh MR, Hake D, Kedar A, Aboukhaled M, Walsh MM. SHock-INduced Endotheliopathy (SHINE): A mechanistic justification for viscoelastography-guided resuscitation of traumatic and non-traumatic shock. Front Physiol 2023; 14:1094845. [PMID: 36923287 PMCID: PMC10009294 DOI: 10.3389/fphys.2023.1094845] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/07/2023] [Indexed: 03/03/2023] Open
Abstract
Irrespective of the reason for hypoperfusion, hypocoagulable and/or hyperfibrinolytic hemostatic aberrancies afflict up to one-quarter of critically ill patients in shock. Intensivists and traumatologists have embraced the concept of SHock-INduced Endotheliopathy (SHINE) as a foundational derangement in progressive shock wherein sympatho-adrenal activation may cause systemic endothelial injury. The pro-thrombotic endothelium lends to micro-thrombosis, enacting a cycle of worsening perfusion and increasing catecholamines, endothelial injury, de-endothelialization, and multiple organ failure. The hypocoagulable/hyperfibrinolytic hemostatic phenotype is thought to be driven by endothelial release of anti-thrombogenic mediators to the bloodstream and perivascular sympathetic nerve release of tissue plasminogen activator directly into the microvasculature. In the shock state, this hemostatic phenotype may be a counterbalancing, yet maladaptive, attempt to restore blood flow against a systemically pro-thrombotic endothelium and increased blood viscosity. We therefore review endothelial physiology with emphasis on glycocalyx function, unique biomarkers, and coagulofibrinolytic mediators, setting the stage for understanding the pathophysiology and hemostatic phenotypes of SHINE in various etiologies of shock. We propose that the hyperfibrinolytic phenotype is exemplified in progressive shock whether related to trauma-induced coagulopathy, sepsis-induced coagulopathy, or post-cardiac arrest syndrome-associated coagulopathy. Regardless of the initial insult, SHINE appears to be a catecholamine-driven entity which early in the disease course may manifest as hyper- or hypocoagulopathic and hyper- or hypofibrinolytic hemostatic imbalance. Moreover, these hemostatic derangements may rapidly evolve along the thrombohemorrhagic spectrum depending on the etiology, timing, and methods of resuscitation. Given the intricate hemochemical makeup and changes during these shock states, macroscopic whole blood tests of coagulative kinetics and clot strength serve as clinically useful and simple means for hemostasis phenotyping. We suggest that viscoelastic hemostatic assays such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are currently the most applicable clinical tools for assaying global hemostatic function-including fibrinolysis-to enable dynamic resuscitation with blood products and hemostatic adjuncts for those patients with thrombotic and/or hemorrhagic complications in shock states.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Eric Chang
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, United States
| | - Hunter B Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, United States.,Department of Transplant Surgery, Denver Health and University of Colorado Health Sciences Center, Denver, CO, United States
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Mahmoud D Al-Fadhl
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Anthony V Thomas
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Nuha Zackariya
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Shivani S Patel
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Sufyan Zackariya
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Saadeddine Haidar
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Bhavesh Patel
- Division of Critical Care, Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Scott G Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Donald Zimmer
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Daniel Fulkerson
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | - Daniel Hake
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Archana Kedar
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Michael Aboukhaled
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Mark M Walsh
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States.,Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
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11
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Gkiatas I, Kontokostopoulos AP, Tsirigkakis SE, Kostas-Agnantis I, Gelalis I, Korompilias A, Pakos E. Topical use of tranexamic acid: Are there concerns for cytotoxicity? World J Orthop 2022; 13:555-563. [PMID: 35949709 PMCID: PMC9244960 DOI: 10.5312/wjo.v13.i6.555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/23/2022] [Accepted: 06/14/2022] [Indexed: 02/06/2023] Open
Abstract
Tranexamic acid (TXA) has revolutionized modern blood management in orthopaedic surgery, especially in total joint arthroplasty, by significantly reducing blood loss and transfusion rates. It is an antifibrinolytic agent and a synthetic derivative of the amino acid lysine, which can inhibit the activation of plasminogen and the fibrin breakdown process. The administration of TXA can be intravenous (IV), topical, and oral. In patients where the IV administration is contraindicated, topical use is preferred. Topical administration of the drug theoretically increases concentration at the operative site with reduced systemic exposure, reduces cost, and gives the surgeon the control of the administration. According to recent studies, topical administration of TXA is not inferior compared to IV administration, in terms of safety and efficacy. However, there are concerns regarding the possible toxicity in the cartilage tissue with the topical use of TXA mainly in hemiarthroplasty operations of the hip, unilateral knee arthroplasties, total knee arthroplasties where the patella is not resurfaced, and other intraarticular procedures, like anterior cruciate ligament reconstruction. The purpose of the present review is to present all the recent updates on the use of TXA focusing on the toxicity on chondrocytes and the articular cartilage that may or may not be provoked by the topical use of TXA.
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Affiliation(s)
- Ioannis Gkiatas
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
| | | | - Spyridon E Tsirigkakis
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
| | | | - Ioannis Gelalis
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
| | - Anastasios Korompilias
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
| | - Emilios Pakos
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
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12
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Oguayo C, Helal A, Dawkins J, Bhimani A, Nimmons SJB, Jones AL, Rizkalla JM. Relation of tranexamic acid therapy to length of stay in the hip fracture population. Proc AMIA Symp 2022; 35:301-304. [DOI: 10.1080/08998280.2022.2028347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Chris Oguayo
- Department of Orthopedics, Baylor University Medical Center, Dallas, Texas
| | - Asad Helal
- Department of Orthopedics, Baylor University Medical Center, Dallas, Texas
| | - Jonathan Dawkins
- Department of Orthopedics, Baylor University Medical Center, Dallas, Texas
| | - Aamir Bhimani
- Department of Orthopedics, Baylor University Medical Center, Dallas, Texas
| | | | - Alan L. Jones
- Department of Orthopedics, Baylor University Medical Center, Dallas, Texas
| | - James M. Rizkalla
- Department of Orthopedics, Baylor University Medical Center, Dallas, Texas
- Coptic Medical Association of North America (CMANA) Research Institute, Dallas, Texas
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13
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Tumber S, Bacon A, Stondell C, Tafoya S, Taylor SL, Javidan Y, Klineberg E, Roberto R. High- versus low-dose tranexamic acid as part of a Patient Blood Management strategy for reducing blood loss in patients undergoing surgery for adolescent idiopathic scoliosis. Spine Deform 2022; 10:107-113. [PMID: 34272686 PMCID: PMC8742801 DOI: 10.1007/s43390-021-00387-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/10/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE The administration of tranexamic acid (TXA) has been shown to be beneficial in reducing blood loss during surgery for adolescent idiopathic scoliosis (AIS), but optimal dosing has yet to be defined. This retrospective study compared high- versus low-dose TXA as part of a Patient Blood Management strategy for reducing blood loss in patients undergoing posterior spine fusion surgery. METHODS Clinical records were reviewed for 223 patients with AIS who underwent posterior spinal fusion of five or more levels during a 6-year time period. We compared normalized blood loss, total estimated blood loss (EBL), and the need for transfusion between patients receiving high-dose TXA (loading dose of ≥ 30 mg/kg) versus low-dose TXA (loading dose < 30 mg/kg). Both groups received maintenance TXA infusions of 10 mg/kg/h until skin closure. RESULTS Patient demographics, curves, and surgical characteristics were similar in both groups. The high-dose TXA group had a 36% reduction in normalized blood loss (1.8 cc/kg/level fused versus 2.8 cc/kg/level fused, p < 0.001) and a 37.5% reduction in total EBL (1000 cc versus 1600 cc, p < 0.001). Patients in the high-dose group had a 48% reduction in PRBC transfusion, with only 19% receiving a transfusion of PRBC compared to 67% in the low-dose group (p < 0.001). CONCLUSION When combined with other proven Patient Blood Management strategies, the use of high-dose TXA compared to low-dose TXA may be beneficial in reducing blood loss for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion surgery. LEVEL OF EVIDENCE Level III, retrospective cohort.
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Affiliation(s)
- Sundeep Tumber
- Department of Anesthesiology, Shriners Hospitals for Children, Northern California, 2425 Stockton Blvd., Sacramento, CA, USA.
| | - Adam Bacon
- University of California, Davis, Sacramento, CA, USA
| | - Casey Stondell
- Department of Anesthesiology, Shriners Hospitals for Children, Northern California, 2425 Stockton Blvd., Sacramento, CA, USA
| | - Sampaguita Tafoya
- Department of Anesthesiology, Shriners Hospitals for Children, Northern California, 2425 Stockton Blvd., Sacramento, CA, USA
| | - Sandra L Taylor
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Yashar Javidan
- Department of Anesthesiology, Shriners Hospitals for Children, Northern California, 2425 Stockton Blvd., Sacramento, CA, USA
| | - Eric Klineberg
- Department of Anesthesiology, Shriners Hospitals for Children, Northern California, 2425 Stockton Blvd., Sacramento, CA, USA
| | - Rolando Roberto
- Department of Anesthesiology, Shriners Hospitals for Children, Northern California, 2425 Stockton Blvd., Sacramento, CA, USA
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14
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Efficacy of topical tranexamic acid in epistaxis: A systematic review and meta-analysis. Am J Emerg Med 2021; 51:169-175. [PMID: 34763235 DOI: 10.1016/j.ajem.2021.10.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/17/2021] [Accepted: 10/24/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Epistaxis is a very common presentation in the emergency department (ED), accounting for approximately 1 in 200 ED visits in the United States. Currently, standard practice includes the initial use of topical anesthetics and vasoconstrictors, followed by more invasive treatments such as nasal packing, cauterization or surgical ligation for refractory cases. Over the years several studies have investigated the potential use of topical Tranexamic Acid (TXA) in the management of epistaxis. We have conducted a meta-analysis to assess the efficacy of topical TXA versus other standard practices or placebo in the management of epistaxis. METHODS PubMed and Scopus databases were searched from inception to April 2021. We included randomized controlled trials and observational studies investigating the efficacy of TXA in bleeding cessation in epistaxis in adults. The primary outcome measured was the prevalence of bleeding cessation after treatment at first assessment. Other outcomes were bleeding reoccurrence between 24 and 72 h and at 7-8 days. A random-effects model was used to estimate odds ratio (OR) for outcomes. RESULTS A total of eight studies were included in the analysis, including seven randomized trials and one retrospective study. We included a total of 1299 patients, 596 (46%) received TXA while 703 (54%) received control treatment (placebo, lidocaine plus vasoconstrictors or local anesthetics). Patients who were treated with TXA were 3.5 times (OR 3.5, 95% CI 1.3-9.7) more likely to achieve bleeding cessation at the first assessment. Patients treated with TXA had 63% (OR 0.37, 95% CI 0.20-0.66) less likelihood of returning due to rebleeding at 24-72 h. CONCLUSION Topical TXA is associated with better bleeding cessation rates after treatment compared to the standard practices.
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15
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Jamal L, Saini A, Quencer K, Altun I, Albadawi H, Khurana A, Naidu S, Patel I, Alzubaidi S, Oklu R. Emerging approaches to pre-hospital hemorrhage control: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1192. [PMID: 34430633 PMCID: PMC8350651 DOI: 10.21037/atm-20-5452] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/18/2021] [Indexed: 12/18/2022]
Abstract
In the United States, trauma claims the lives of over 150,000 civilians each year. In military settings, trauma and exsanguination result in 50% of combat related deaths. The majority of these deaths result from uncontrolled non-compressible hemorrhage. Non-compressible hemorrhage often results from deep vascular injuries within the torso, however can also occur secondary to penetrating injuries that involve the extremities. Given the high mortality rates for non-compressible hemorrhage, rapid and effective management of patients suffering from hemorrhage is essential to good patient outcomes. Consequently, there has been increasing interest in solutions for point-of-injury hemorrhage control in trauma and military medicine. Undoubtedly there is a great need for prehospital hemostatic interventions that can be deployed by trained and untrained personnel. Since 2001, various hemostatic agents have been developed, each with its advantages based upon the type and severity of injury, wound size, wound location, accessibility to injury site, and the coagulation status of the patient. These agents are often used in the military setting as a temporizing measure prior to definitive therapy and include techniques such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and bioengineered agents including ResQFoam, RevMedx’s XSTAT, Tranexamic acid (TXA), and QuikClot Combat Gauze (QCG). Here, we review the indications, composition, technique, efficacy, and outcomes of these hemostatic agents.
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Affiliation(s)
- Leila Jamal
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Aman Saini
- Department of Radiology, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Keith Quencer
- Department of Radiology, University of Utah, Salt Lake City, Utah, USA
| | - Izzet Altun
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Hassan Albadawi
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Aditya Khurana
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Sailendra Naidu
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Indravadan Patel
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Sadeer Alzubaidi
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Laboratory for Patient Inspired Engineering, Mayo Clinic, Phoenix, AZ, USA
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16
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Exploration of Active Site-Directed Plasmin Inhibitors: Beyond Tranexamic Acid. Processes (Basel) 2021. [DOI: 10.3390/pr9020329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Plasmin (Plm), a trypsin-like serine protease, is responsible for fibrinolysis pathway and pathologic events, such as angiogenesis, tumor invasion, and metastasis, and alters the expression of cytokines. A growing body of data indicates that a Plm inhibitor is a potential candidate as an anti-inflammatory and anti-cancer agent. A class of active site-directed plasmin inhibitors containing tranexamic acid residue has been designed. As evidenced by docking studies, the inhibitor binds to the active site not to the lysine binding site (LBS) in plasmin, thus preventing plasmin from digesting the substrate. Further optimization of the series, concerning both activity and selectivity, led to the second generation of inhibitors. This review focuses on the Plm inhibitory activity-structure relationship of Plm inhibitors with the goal of realizing their design and clinical application.
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17
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Webster S, Barnard EBG, Smith JE, Marsden MER, Wright C. Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004-2014). BMJ Mil Health 2020; 167:84-88. [PMID: 32487673 DOI: 10.1136/bmjmilitary-2020-001490] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The majority of combat deaths occur before arrival at a medical treatment facility but no previous studies have comprehensively examined this phase of care. METHODS The UK Joint Theatre Trauma Registry was used to identify all UK military personnel who died in Afghanistan (2004-2014). These data were linked to non-medical tactical and operational records to provide an accurate timeline of events. Cause of death was determined from records taken at postmortem review. The primary objective was to report time between injury and death in those killed in action (KIA); secondary objectives included: reporting mortality at key North Atlantic Treaty Organisation timelines (0, 10, 60, 120 min), comparison of temporal lethality for different anatomical injuries and analysing trends in the case fatality rate (CFR). RESULTS 2413 UK personnel were injured in Afghanistan from 2004 to 2014; 448 died, with a CFR of 18.6%. 390 (87.1%) of these died prehospital (n=348 KIA, n=42 killed non-enemy action). Complete data were available for n=303 (87.1%) KIA: median Injury Severity Score 75.0 (IQR 55.5-75.0). The predominant mechanisms were improvised explosive device (n=166, 54.8%) and gunshot wound (n=96, 31.7%).In the KIA cohort, the median time to death was 0.0 (IQR 0.0-21.8) min; 173 (57.1%) died immediately (0 min). At 10, 60 and 120 min post injury, 205 (67.7%), 277 (91.4%) and 300 (99.0%) casualties were dead, respectively. Whole body primary injury had the fastest mortality. Overall prehospital CFR improved throughout the period while in-hospital CFR remained constant. CONCLUSION Over two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase.
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Affiliation(s)
- Stacey Webster
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK .,The 2nd Battalion Parachute Regiment, Colchester, UK
| | - E B G Barnard
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK.,Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK
| | - M E R Marsden
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK.,Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - C Wright
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK
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18
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Boccio E, Hultz K, Wong AH. Topical Tranexamic Acid for Hemostasis of an Oral Bleed in a Patient on a Direct Oral Anticoagulant. Clin Pract Cases Emerg Med 2020; 4:146-149. [PMID: 32426657 PMCID: PMC7219988 DOI: 10.5811/cpcem.2020.1.45326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/22/2020] [Accepted: 01/28/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Tranexamic acid (TXA) is an antifibrinolytic agent currently approved and utilized in the treatment of dysfunctional uterine bleeding, traumatic extracranial hemorrhage, anterior epistaxis, and dental procedures on patients with hemophilia. There is a paucity of literature evaluating the use of TXA for hemostasis in patients on direct oral anticoagulants (DOACs). Case Report Our patient, a 72 year-old male on rivaroxaban, presented with persistent bleeding following a punch biopsy of the buccal mucosa. Given the site of bleeding, inability to effectively tamponade, patient's anticoagulated state, and risk of impending airway compromise, a dressing was soaked with 500 milligram (mg) of TXA and was held in place with pressure using a makeshift clamp until a thrombus formed. Hemostasis was achieved preventing the need for acute ENTotolaryngologic intervention and/or intubation. The patient was observed in the medical setting overnight and discharged home without any recurrence of bleeding or adverse events. Discussion This case report describes our experience achieving hemostasis for an otherwise uncontrollable oral bleed in an anticoagulated patient on a DOAC who could not be reversed. Intervention is simple to perform, cost-effective, and requires few resources which are readily available in most emergency departments. Conclusion We report a novel application of TXA to control an oral mucosal bleed in an anticoagulated patient which was on a DOAC refractory to traditional measures.
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Affiliation(s)
- Eric Boccio
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut.,Yale-New Haven Hospital, Department of Emergency Medicine, New Haven, Connecticut
| | - Kyle Hultz
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Ambrose H Wong
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut.,Yale-New Haven Hospital, Department of Emergency Medicine, New Haven, Connecticut
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19
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Franchini M, Mannucci PM. The never ending success story of tranexamic acid in acquired bleeding. Haematologica 2020; 105:1201-1205. [PMID: 32336684 PMCID: PMC7193503 DOI: 10.3324/haematol.2020.250720] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/16/2020] [Indexed: 12/13/2022] Open
Abstract
Tranexamic acid (TXA) is an anti-fibrinolytic agent that acts by inhibiting plasminogen activation and fibrinolysis. Although its first clinical use dates back more than 50 years, this hemostatic agent is still the object of intense clinical and developmental research. In particular, renewed interest in TXA has arisen following evidence that it has a beneficial effect in reducing blood loss in a variety of medical and surgical conditions at increased risk of bleeding. Given this characteristic, TXA is currently considered a mainstay of Patient Blood Management programs aimed at reducing patients’ exposure to allogeneic blood transfusion. Importantly, recent large randomized controlled trials have consistently documented that the use of TXA confers a survival advantage in a number of globally critical clinical conditions associated with acute bleeding, including traumatic injury and post-partum hemorrhage, without increasing the thromboembolic risk.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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The Use of Tranexamic Acid (TXA) for the Management of Hemorrhage in Trauma Patients in the Prehospital Environment: Literature Review and Descriptive Analysis of Principal Themes. Shock 2020; 53:277-283. [DOI: 10.1097/shk.0000000000001389] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Coats TJ, Morsy M. Biological mechanisms and individual variation in fibrinolysis after major trauma. Emerg Med J 2020; 37:135-140. [DOI: 10.1136/emermed-2019-209181] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 01/03/2020] [Accepted: 01/12/2020] [Indexed: 01/12/2023]
Abstract
ObjectiveTo understand more about the individual variation in the time course of fibrinolysis following major injury and to assess the potential for stratification of trauma patients for tranexamic acid (TXA) therapy.MethodsA historical dataset (from 2004) was used, consisting of samples from 52 injured patients attended by a medical prehospital system. Blood samples were taken at the incident scene, on arrival in the emergency department, 2.5 hours after hospital arrival and 5 hours after hospital arrival. From the study database, we extracted values for tissue-type plasminogen activator (tPA; an activator of fibrinolysis), one of the plasminogen activator inhibitors (PAI-1; as a natural inhibitor of fibrinolysis) and D-dimer (as a marker of the extent of fibrinolysis).ResultsThe changes over time in median tPA and PAI-1 were mirror images, with initial high tPA levels which then rapidly decreased and low initial PAI-1 levels which slowly increased. There were high levels of fibrinolytic activity (D-dimer) throughout. This pattern was present in patients across a broad range of injury severities.ConclusionsAfter major trauma, there seems to be an early ‘antifibrinolytic gap’ with the natural antifibrinolytic system lagging several hours behind the natural profibrinolytics. An early dose of exogenous antifibrinolytic (TXA) might have its effect by filling this gap. The finding that tPA and subsequent clot breakdown (illustrated by D-dimer formation) are raised in a broad range of patients, with little correlation between the initial fibrinolytic response and markers of injury severity, may be the reason that TXA is effective across a broad range of injured patients.
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Huang J, Gao C, Dong J, Zhang J, Jiang R. Drug treatment of chronic subdural hematoma. Expert Opin Pharmacother 2020; 21:435-444. [PMID: 31957506 DOI: 10.1080/14656566.2020.1713095] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Jingfei Dong
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
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Luo X, Huang H, Tang X. Efficacy and safety of tranexamic acid for reducing blood loss in elderly patients with intertrochanteric fracture treated with intramedullary fixation surgery: A meta-analysis of randomized controlled trials. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:4-14. [PMID: 32175891 DOI: 10.5152/j.aott.2020.01.88] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy and safety of tranexamic acid (TXA) in elderly patients with intertrochanteric fracture undergoing intramedullary fixation surgery. METHODS We searched MEDLINE, the Cochrane Library and EMBASE for published randomized clinical trials relevant to use of TXA in elderly patients with intertrochanteric fracture treated with intramedullary fixation surgery. Meta-analysis was performed according to the guidelines of the Cochrane Reviewer's Hand book. RESULTS Five trials assessing 540 patients were included for meta-analysis. The pooled results showed that the mean total blood loss in TXA group was significant lower than that in the control group (mean difference - 172.83, 95% CI -241.43 to -104.23; p<0.00001, fixed-effect model). The intra- and postoperative transfusion rate for the TXA group was 34.4% (91/264) and for the control group was 49.27% (136/276), and the relative risk was 0.71 (95% CI 0.52 to 0.97; p<0.03, random-effect model) with substantial heterogeneity (I2=63%, p=0.03). The overall incidence of thrombotic events was 6.43% (17/264) in the intravenous TXA group, 7.63% (21/275) in the control group, with no significant difference (relative risk 0.84, 95% CI 0.46 to 1.54; p=0.57, fixed-effect model). CONCLUSION The present evidence shows that TXA can significantly reduce total and hidden blood loss, transfusion rate, and do not increase the risk of thrombotic events in elderly patients with intertrochanteric fracture undergoing intramedullary fixation surgery. However, the impact of TXA on thrombotic events needs to be researched in more high-quality, large-sample randomized clinical trials. LEVEL OF EVIDENCE Level I Therapeutic Study.
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Affiliation(s)
- Xiangping Luo
- Department of Orthopaedics, Hengyang Central Hospital, Hunan, China
| | - Hangqing Huang
- Department of Orthopaedics, Hengyang Central Hospital, Hunan, China
| | - Xiong Tang
- Department of Orthopaedics, Hengyang Central Hospital, Hunan, China
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Does tranexamic acid increase the risk of thromboembolic events in immediate or delayed breast reconstruction? A review of the literature. EUROPEAN JOURNAL OF PLASTIC SURGERY 2019. [DOI: 10.1007/s00238-019-01527-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Walsh K, O'Keeffe F, Mitra B. Geographical Variance in the Use of Tranexamic Acid for Major Trauma Patients. ACTA ACUST UNITED AC 2019; 55:medicina55090561. [PMID: 31480783 PMCID: PMC6780548 DOI: 10.3390/medicina55090561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/20/2019] [Accepted: 08/26/2019] [Indexed: 11/16/2022]
Abstract
Background and Objectives: The CRASH-2 trial is the largest randomised control trial examining tranexamic acid (TXA) for injured patients. Since its publication, debate has arisen around whether results could be applied to mature trauma systems in developed nations, with global opinion divided. The aim of this study was to determine if, among trauma patients in or at significant risk of major haemorrhages, there is an association of geographic region with the proportion of patients that received tranexamic acid. Materials and Methods: We conducted a systematic review of the literature. Potentially eligible papers were first screened via title and abstract screening. A full copy of the remaining papers was then obtained and screened for final inclusion. The Newcastle-Ottawa Scale for non-randomised control trials was used for quality assessment of the final studies included. A meta-analysis was conducted using a random-effects model, reporting variation in use sub-grouped by geographical location. Results: There were 727 papers identified through database searching and 23 manuscripts met the criteria for final inclusion in this review. There was a statistically significant variation in the use of TXA for included patients. Europe and Oceania had higher usage rates of TXA compared to other continents. Use of TXA in Asia and Africa was significantly less than other continents and varied use was observed in North America. Conclusions: A large geographical variance in the use of TXA for trauma patients in or at significant risk of major haemorrhage currently exists. The populations in Asia and Africa, where the results of CRASH-2 could be most readily generalised to, reported low rates of use. The reason why remains unclear and further research is required to standardise the use of TXA for trauma resuscitation.
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Affiliation(s)
- Kieran Walsh
- National Trauma Research Institute, The Alfred Hospital, Melbourne 3004, Australia.
- Critical Care Research, School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia.
- Emergency & Trauma Centre, Alfred Health, Melbourne 3004, Australia.
| | - Francis O'Keeffe
- National Trauma Research Institute, The Alfred Hospital, Melbourne 3004, Australia
- Emergency Department, Mater Misericordiae University Hospital, Dublin D7, Ireland
| | - Biswadev Mitra
- National Trauma Research Institute, The Alfred Hospital, Melbourne 3004, Australia
- Critical Care Research, School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia
- Emergency & Trauma Centre, Alfred Health, Melbourne 3004, Australia
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Derzon JH, Clarke N, Alford A, Gross I, Shander A, Thurer R. Reducing red blood cell transfusion in orthopedic and cardiac surgeries with Antifibrinolytics: A laboratory medicine best practice systematic review and meta-analysis. Clin Biochem 2019; 71:1-13. [DOI: 10.1016/j.clinbiochem.2019.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/02/2019] [Accepted: 06/28/2019] [Indexed: 12/15/2022]
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Guo J, Gao X, Ma Y, Lv H, Hu W, Zhang S, Ji H, Wang G, Shi J. Different dose regimes and administration methods of tranexamic acid in cardiac surgery: a meta-analysis of randomized trials. BMC Anesthesiol 2019; 19:129. [PMID: 31307381 PMCID: PMC6631782 DOI: 10.1186/s12871-019-0772-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 05/28/2019] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The efficacy of tranexamic acid (TXA) to reduce perioperative blood loss and allogeneic blood transfusion in cardiac surgeries has been proved in previous studies, but its adverse effects especially seizure has always been a problem of concern. This meta-analysis aims to provide information on the optimal dosage and delivery method which is effective with the least adverse outcomes. METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE for all relevant articles published before 2018/12/31. Inclusion criteria were adult patients undergoing elective heart surgeries, and only randomized control trials comparing TXA with placebo were considered. Two authors independently assessed trial quality and extracted relevant data. RESULTS We included 49 studies with 10,591 patients into analysis. TXA significantly reduced transfusion rate (RR 0.71, 95% CI 0.65 to 0.78, P<0.00001). The overall transfusion rate was 35%(1573/4477) for patients using TXA and 49%(2190/4408) for patients in the control group. Peri-operative blood loss (MD - 246.98 ml, 95% CI - 287.89 to - 206.06 ml, P<0.00001) and re-operation rate (RR 0.62, 95% CI 0.49 to 0.79, P<0.0001) were also reduced significantly. TXA usage did not increase risk of mortality, myocardial infarction, stroke, pulmonary embolism and renal dysfunction, but was associated with a significantly increase in seizure attack (RR 3.21, 95% CI 1.04 to 9.90, P = 0.04).The overall rate of seizure attack was 0.62%(21/3378) for patients using TXA and 0.15%(5/3406) for patients in the control group. In subgroup analysis, TXA was effective for both on-pump and off-pump surgeries. Topical application didn't reduce the need for transfusion requirement, while intravenous delivery no matter as bolus injection alone or bolus plus continuous infusion were effective. Intravenous high-dose TXA didn't further decrease transfusion rate compared with low-dose regimen, and increased the risk of seizure by 4.83 times. No patients in the low-dose group had seizure attack. CONCLUSIONS TXA was effective in reducing transfusion requirement in all kinds of cardiac surgeries. Low-dose intravenous infusion was the most preferable delivery method which was as effective as high-dose regimen in reducing transfusion rate without increasing the risk of seizure.
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Affiliation(s)
- Jingfei Guo
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Xurong Gao
- Department of Blood Transfusion, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Yan Ma
- Operating room, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Huran Lv
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Wenjun Hu
- Department of Anesthesiology, The 305th Hospital of the Chinese People’s Liberation Army, No.13 Wenjin Road, Xicheng district, Beijing, China
| | - Shijie Zhang
- Department of Anesthesiology, Wu’an First People’s Hospital, Kuangjian Road, Handan, Hebei Province China
| | - Hongwen Ji
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Guyan Wang
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Jia Shi
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
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Alone and Sometimes Unafraid: Military Perspective on Forward Damage Control Resuscitation on the Modern Battlefield. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-00173-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Murphy B, Winter DC, Kavanagh DO. Small Bowel Gastrointestinal Bleeding Diagnosis and Management-A Narrative Review. Front Surg 2019; 6:25. [PMID: 31157232 PMCID: PMC6532547 DOI: 10.3389/fsurg.2019.00025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/24/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Small bowel bleeding accounts for 5-10% of all gastrointestinal bleeding. Despite advances in imaging, endoscopy and minimally invasive therapeutic techniques, its diagnosis and treatment remains a challenge and a standardized algorithm for approaching suspected small bowel bleeding remains elusive. Furthermore, the choice of investigation is subject to timing of presentation and accessibility to investigations. The aim of this study was to construct a narrative review of recent literature surrounding the diagnosis and management of small bowel bleeding. Methods: A literature review was conducted examining the database pubmed with the following key words and Boolean operators: occult GI bleed OR mesenteric bleed OR gastrointestinal hemorrhage OR GI hemorrhage AND management. Articles were selected and reviewed based on relevance to the research topic. Where necessary, the full text was sought to further assess relevance. Results: In overt GI bleeding, CT angiography and red cell scintigraphy are both feasible and reliable diagnostic imaging modalities if standard endoscopy is negative. Red cell scintigraphy may be advantageous through detection of lower bleeding rates but it is subject to availability. Overt bleeding and a positive CT angiogram or red cell scan improves the diagnostic yield of formal angiography ± embolization. Video capsule endoscopy or double balloon endoscopy can be considered in occult GI bleeding following normal upper and lower endoscopy. Conclusions: Small bowel bleeding remains a rare but significant diagnostic and therapeutic challenge. Technological advances in diagnostics have aided evaluation but have not broadened the range of therapeutic interventions.
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Affiliation(s)
- B. Murphy
- Department of Colorectal Surgery, University Hospital Tallaght, Dublin, Ireland
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - D. C. Winter
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - D. O. Kavanagh
- Department of Colorectal Surgery, University Hospital Tallaght, Dublin, Ireland
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 748] [Impact Index Per Article: 124.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Miyata S, Itakura A, Ueda Y, Usui A, Okita Y, Ohnishi Y, Katori N, Kushimoto S, Sasaki H, Shimizu H, Nishimura K, Nishiwaki K, Matsushita T, Ogawa S, Kino S, Kubo T, Saito N, Tanaka H, Tamura T, Nakai M, Fujii S, Maeda T, Maeda H, Makino S, Matsunaga S. TRANSFUSION GUIDELINES FOR PATIENTS WITH MASSIVE BLEEDING. ACTA ACUST UNITED AC 2019. [DOI: 10.3925/jjtc.65.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Shigeki Miyata
- Department of Clinical Laboratory Medicine, National Cerebral and Cardiovascular Center
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Yuichi Ueda
- Nara Prefectural Hospital Organization, Nara Prefecture General Medical Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University
| | - Yoshihiko Ohnishi
- Operation Room, Anesthesiology, National Cerebral and Cardiovascular Center
| | - Nobuyuki Katori
- Department of Anesthesiology, Keio University School of Medicine
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | | | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | | | | | - Satoru Ogawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine
| | | | | | - Nobuyuki Saito
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital
| | - Hiroshi Tanaka
- Department of Surgery, Division of Minimum Invasive Surgery, Kobe University
| | | | - Michikazu Nakai
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | - Satoshi Fujii
- Department of Laboratory Medicine, Asahikawa Medical University
| | - Takuma Maeda
- Division of Transfusion Medicine, National Cerebral and Cardiovascular Center
| | - Hiroo Maeda
- Transfusion Medicine and Cell Therapy, Saitama Medical Center/Saitama Medical University
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Shigetaka Matsunaga
- Department of Obstetrics and Gynecology, Saitama Medical Center/Saitama Medical University
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Wearmouth C, Smith J. Development of a nurse-led tranexamic acid administration protocol for trauma patients in rural South Africa. Afr J Emerg Med 2019; 9:S52-S55. [PMID: 30976502 PMCID: PMC6440919 DOI: 10.1016/j.afjem.2018.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 10/03/2018] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Administration of tranexamic acid (TXA) has been shown to effectively reduce all-cause mortality in trauma patients when given within three hours of injury. We found that many trauma patients in our hospital were not receiving TXA. This was due to a variety of factors, including late presentation to hospital, lack of staff awareness, short staffing, and unavailable drugs or equipment. Our aim was to develop a protocol for safe, nurse-led administration of TXA in the emergency centre in order to increase the number of eligible patients treated. METHODS We developed a protocol based on the inclusion criteria of the CRASH-2 study, opting to use physiological observations along with criteria from the South African Triage Scale to allow nursing staff to identify patients with, or at risk of, significant haemorrhage. We tailored the protocol to the equipment and training available in our poorly resourced rural healthcare setting. RESULTS In a two-month period, 14 patients were given TXA by nurses before the arrival of a doctor. 13/14 (92.9%) were deemed appropriate, with 1/14 (7.1%) deemed inappropriate due to the time since injury. 12/13 (92.3%) patients received the correct infusion dose, with 1/13 (7.7%) only receiving the infusion once the doctor arrived. No adverse events were reported. CONCLUSIONS Nursing staff in resource poor rural settings can use a protocol based on the South African Triage Scale and the CRASH-2 study to safely administer TXA to trauma patients. We believe this to be the first published literature on nurse-led administration of TXA. Mortality from trauma may be reduced in rural settings by the timely administration of TXA in the prehospital and rural primary healthcare settings.
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Affiliation(s)
- Christopher Wearmouth
- Emergency Department, James Cook University Hospital, Middlesbrough, TS4 3BW, United Kingdom
| | - Jacob Smith
- Benedictine Hospital, Nongoma, KwaZulu-Natal, South Africa
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Luo X, He S, Lin Z, Li Z, Huang C, Li Q. Efficacy and Safety of Tranexamic Acid for Controlling Bleeding During Surgical Treatment of Intertrochanteric Fragility Fracture with Proximal Femoral Nail Anti-rotation: A Randomized Controlled Trial. Indian J Orthop 2019; 53:263-269. [PMID: 30967695 PMCID: PMC6415572 DOI: 10.4103/ortho.ijortho_401_17] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Intertrochanteric fragility fracture (IFF) treated with proximal femoral nail anti-rotation (PFNA) is associated with significant hidden blood loss and high blood transfusion rate. The purpose of the present study was to evaluate the efficacy and safety of tranexamic acid (TXA) in reducing blood loss in these patients. MATERIALS AND METHODS Consecutive eligible patients were recruited and randomly assigned to a TXA group or a control group. The TXA group received 15 mg/kg body weight of TXA intravenously 15 min before incision and the same dose 3 h later. The control group received 100 mL of saline intravenously 15 min before incision. The efficacy outcomes included the total perioperative blood loss, postoperative transfusion rate, postoperative hemoglobin level, and length of the hospital stay. The safety outcomes were the incidence of thrombotic events and the mortality rate within 6 weeks after surgery. RESULTS We had 44 patients in the TXA group and 46 patients in the control group for the final analysis. The TXA group had significantly lower total perioperative blood loss than the control group (384.5 ± 366.3 mL vs. 566.2 ± 361.5 mL; P < 0.020). Postoperative transfusion rate was 15.9% in the TXA group versus 36.9% in the control group (P = 0.024). Each group had one patient with postoperative deep venous thrombosis. In the control group, three patients had cerebral infarction, and one patient died within 6 weeks after the operation. CONCLUSION Intravenous TXA is effective in reducing total perioperative blood loss and transfusion rate in IFF treated with PFNA. No increased risk of thrombotic events was observed with the use of TXA; however, this study was underpowered for detecting this outcome. Further research is necessary before TXA can be recommended for high-risk patients.
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Affiliation(s)
- Xiangping Luo
- Department of Orthopaedic, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shunqing He
- Department of Orthopaedic, People's Hospital of Leiyang, Hunan, China
| | - Zhaowei Lin
- Department of Orthopaedic, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Zhian Li
- Department of Orthopaedic, People's Hospital of Leiyang, Hunan, China
| | - Chao Huang
- Department of Orthopaedic, People's Hospital of Leiyang, Hunan, China
| | - Qi Li
- Department of Orthopaedic, Zhujiang Hospital, Southern Medical University, Guangzhou, China,Address for correspondence: Dr. Qi Li, Department of Orthopaedic, Zhujiang Hospital, Southern Medical University, Guangzhou, China. E-mail:
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Neoh K, Gray R, Grant-Casey J, Estcourt L, Malia C, Boland JW, Bennett MI. National comparative audit of red blood cell transfusion practice in hospices: Recommendations for palliative care practice. Palliat Med 2019; 33:102-108. [PMID: 30260291 PMCID: PMC6291900 DOI: 10.1177/0269216318801755] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Red blood cell transfusions are commonly used in palliative care to treat anaemia or symptoms caused by anaemia. In patients with advanced disease, there is little evidence of benefit to guide treatment decisions in the face of increased risk of harms. Aim: To determine national transfusion practice in hospices and compare this against National Institute for Health and Care Excellence and British Society of Haematology guidelines to develop recommendations to improve practice. Design and Setting: Prospective data collection on red blood cell transfusion practice in UK adult hospices over a 3-month census period. Results: A total of 121/210 (58%) hospices participated. A total of 465 transfusion episodes occurred in 83 hospices. Patients had a mean age of 71 years, and 96% had cancer. Mean pre-transfusion haemoglobin was 75 g/L (standard deviation = 11.15). Anaemia of chronic disease was the largest cause of anaemia (176; 38%); potentially amenable to alternative treatments. Haematinics were not checked in 70% of patients. Alternative treatments such as B12, folate and iron were rarely used. Despite transfusion-associated circulatory overload risk, 85% of patients were not weighed, and 84% had two or more units transfused. Only 83 (18%) patients had an improvement maintained at 30 days; 142 (31%) had <14 day improvement, and 50 (11%) had no improvement. A total of 150 patients (32%) were dead at 30 days. Conclusion: More rigorous investigation of anaemia, increased use of alternative therapies and more restrictive approach to red cell transfusions are recommended. Clinicians should discuss the limited benefit versus potentially higher risks with patients in hospice services to inform treatment decisions.
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Affiliation(s)
- Karen Neoh
- St Gemma’s Academic Unit of Palliative
Care, University of Leeds, Leeds, UK
| | - Ross Gray
- National Comparative Audit of Blood
Transfusion, NHS Blood and Transplant, Oxford, UK
| | - John Grant-Casey
- National Comparative Audit of Blood
Transfusion, NHS Blood and Transplant, Oxford, UK
| | - Lise Estcourt
- NHS Blood and Transplant, Oxford,
UK
- University of Oxford, Oxford, UK
| | | | - Jason W Boland
- Wolfson Centre for Palliative Care
Research, Hull York Medical School, University of Hull, Hull, UK
| | - Michael I Bennett
- St Gemma’s Academic Unit of Palliative
Care, University of Leeds, Leeds, UK
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Zhang Y, Gao X, Yuan S, Guo J, Lv H, Zhou Y, Wang Y, Ji H, Wang G, Li L, Shi J. Effects of tranexamic acid on short‐term and long‐term outcomes of on‐pump coronary artery bypass grafting: Randomized trial and 7‐year follow‐up. Cardiovasc Ther 2018; 36:e12472. [PMID: 30372588 DOI: 10.1111/1755-5922.12472] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 09/30/2018] [Accepted: 10/22/2018] [Indexed: 11/26/2022] Open
Affiliation(s)
- Yu Zhang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Xurong Gao
- Department of Transfusion, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Jingfei Guo
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Huanran Lv
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Yong Zhou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Yuefu Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Hongwen Ji
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Guyan Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Lihuan Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Jia Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
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Nishijima DK, VanBuren J, Hewes HA, Myers SR, Stanley RM, Adelson PD, Barnhard SE, Bobinski M, Ghetti S, Holmes JF, Roberts I, Schalick WO, Tran NK, Tzimenatos LS, Michael Dean J, Kuppermann N. Traumatic injury clinical trial evaluating tranexamic acid in children (TIC-TOC): study protocol for a pilot randomized controlled trial. Trials 2018; 19:593. [PMID: 30376893 PMCID: PMC6208101 DOI: 10.1186/s13063-018-2974-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 10/10/2018] [Indexed: 01/29/2023] Open
Abstract
Background Trauma is the leading cause of morbidity and mortality in children in the United States. The antifibrinolytic drug tranexamic acid (TXA) improves survival in adults with traumatic hemorrhage, however, the drug has not been evaluated in a clinical trial in severely injured children. We designed the Traumatic Injury Clinical Trial Evaluating Tranexamic Acid in Children (TIC-TOC) trial to evaluate the feasibility of conducting a confirmatory clinical trial that evaluates the effects of TXA in children with severe trauma and hemorrhagic injuries. Methods Children with severe trauma and evidence of hemorrhagic torso or brain injuries will be randomized to one of three arms: (1) TXA dose A (15 mg/kg bolus dose over 20 min, followed by 2 mg/kg/hr infusion over 8 h), (2) TXA dose B (30 mg/kg bolus dose over 20 min, followed by 4 mg/kg/hr infusion over 8 h), or (3) placebo. We will use permuted-block randomization by injury type: hemorrhagic brain injury, hemorrhagic torso injury, and combined hemorrhagic brain and torso injury. The trial will be conducted at four pediatric Level I trauma centers. We will collect the following outcome measures: global functioning as measured by the Pediatric Quality of Life (PedsQL) and Pediatric Glasgow Outcome Scale Extended (GOS-E Peds), working memory (digit span test), total amount of blood products transfused in the initial 48 h, intracranial hemorrhage progression at 24 h, coagulation biomarkers, and adverse events (specifically thromboembolic events and seizures). Discussion This multicenter trial will provide important preliminary data and assess the feasibility of conducting a confirmatory clinical trial that evaluates the benefits of TXA in children with severe trauma and hemorrhagic injuries to the torso and/or brain. Trial registration ClinicalTrials.gov registration number: NCT02840097. Registered on 14 July 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2974-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, UC Davis School of Medicine, 4150 V. Street, PSSB 2100, Sacramento, CA, 95817, USA.
| | - John VanBuren
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Hilary A Hewes
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah School of Medicine, Primary Children's Hospital, 100 N. Mario Capecchi Dr., Salt Lake City, UT, 84113, USA
| | - Sage R Myers
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Rachel M Stanley
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Ohio State University School of Medicine, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205, USA
| | - P David Adelson
- Department of Pediatric Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Rd, Phoenix, AZ, 85016, USA
| | - Sarah E Barnhard
- Department of Pathology and Laboratory Medicine, UC Davis School of Medicine, 2315 Stockton Blvd., Sacramento, CA, 95817, USA
| | - Matthew Bobinski
- Department of Radiology, UC Davis School of Medicine, 2315 Stockton Blvd., Sacramento, CA, 95817, USA
| | - Simona Ghetti
- Department of Psychology, University of California, Davis, 102K Young Hall, 1 Shields Ave., Davis, CA, 95616, USA
| | - James F Holmes
- Department of Emergency Medicine, UC Davis School of Medicine, 4150 V. Street, PSSB 2100, Sacramento, CA, 95817, USA
| | - Ian Roberts
- Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Walton O Schalick
- Department of Orthopedics and Rehabilitation, University of Wisconsin, 317 Knutson Drive, Madison, WI, 53704, USA
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California, Davis, 3422 Tupper Hall, Davis, CA, 95616, USA
| | - Leah S Tzimenatos
- Department of Emergency Medicine, UC Davis School of Medicine, 4150 V. Street, PSSB 2100, Sacramento, CA, 95817, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, UC Davis School of Medicine, 4150 V. Street, PSSB 2100, Sacramento, CA, 95817, USA
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Phillips JB, Mohorn PL, Bookstaver RE, Ezekiel TO, Watson CM. Hemostatic Management of Trauma-Induced Coagulopathy. Crit Care Nurse 2018; 37:37-47. [PMID: 28765353 DOI: 10.4037/ccn2017476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Trauma-induced coagulopathy is a primary factor in many trauma-related fatalities. Management hinges upon rapid diagnosis of coagulation abnormalities and immediate administration of appropriate hemostatic agents. Use of crystalloids and packed red blood cells has traditionally been the core of trauma resuscitation, but current massive transfusion protocols include combination therapy with fresh frozen plasma and predefined ratios of platelets to packed red blood cells, limiting crystalloid administration. Hemostatic agents such as tranexamic acid, prothrombin complex concentrate, fibrinogen concentrate, and, in cases of refractory bleeding, recombinant activated factor VIIa may also be warranted. Goal-directed resuscitation using viscoelastic tools allows specific component-centered therapy based on individual clotting abnormalities that may limit blood product use and thromboembolic risks and may lead to reduced mortality. Because of the complex management of patients with trauma-induced coagulopathy, critical care nurses must be familiar with the pathophysiology, acute diagnostics, and pharmacotherapeutic options used to treat these patients.
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Affiliation(s)
- Janise B Phillips
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina.,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina.,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina
| | - Phillip L Mohorn
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates. .,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina. .,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina. .,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina. .,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina.
| | - Rebecca E Bookstaver
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina.,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina.,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina
| | - Tanya O Ezekiel
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina.,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina.,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina
| | - Christopher M Watson
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina.,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina.,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina
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Huang B, Xu Q, Ye R, Xu J. Influence of tranexamic acid on cerebral hemorrhage: A meta-analysis of randomized controlled trials. Clin Neurol Neurosurg 2018; 171:174-178. [PMID: 29929173 DOI: 10.1016/j.clineuro.2018.06.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 05/07/2018] [Accepted: 06/11/2018] [Indexed: 11/28/2022]
Abstract
Tranexamic acid might be beneficial for cerebral hemorrhage. However, the results remained controversial. We conducted a systematic review and meta-analysis to explore the influence of tranexamic acid on cerebral hemorrhage. PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of tranexamic acid on cerebral hemorrhage were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. This meta-analysis was performed using the random-effect model. Seven RCTs involving 1702 patients were included in the meta-analysis. Overall, compared with control intervention in cerebral hemorrhage, tranexamic acid could significantly reduce growth of hemorrhagic mass (RR = 0.78; 95% CI = 0.61-0.99; P = 0.04) and unfavorable outcome (RR = 0.75; 95% CI = 0.61-0.93; P = 0.008), but demonstrated no substantial influence on volume of hemorrhagic lesion (Std. MD = -0.10; 95% CI = -0.27 to 0.08; P = 0.28), neurologic deterioration (RR = 1.25; 95% CI = 0.60-2.60; P = 0.56), rebleeding (RR = 0.62; 95% CI = 0.35-1.09; P = 0.10), surgery requirement (RR = 0.78; 95% CI = 0.40-1.51; P = 0.46), and mortality (RR = 0.86; 95% CI = 0.69-1.05; P = 0.14). Compared to control intervention in cerebral hemorrhage, tranexamic acid was found to significantly decrease growth of hemorrhagic mass and unfavorable outcome, but showed no notable impact on volume of hemorrhagic lesion, neurologic deterioration, rebleeding, surgery requirement and mortality.
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Affiliation(s)
- Beilei Huang
- Emergency Department, Wenzhou People's Hospital, Wenzhou Maternal and Child Health Care Hospital, The Third Clinical Institute Affiliated To Wenzhou Medical University, Wenzhou, Zhejiang Province, 400700, PR China.
| | - Qiusheng Xu
- Emergency Department, Wenzhou People's Hospital, Wenzhou Maternal and Child Health Care Hospital, The Third Clinical Institute Affiliated To Wenzhou Medical University, Wenzhou, Zhejiang Province, 400700, PR China.
| | - Ru Ye
- Emergency Department, Wenzhou People's Hospital, Wenzhou Maternal and Child Health Care Hospital, The Third Clinical Institute Affiliated To Wenzhou Medical University, Wenzhou, Zhejiang Province, 400700, PR China.
| | - Jun Xu
- Emergency Department, Wenzhou People's Hospital, Wenzhou Maternal and Child Health Care Hospital, The Third Clinical Institute Affiliated To Wenzhou Medical University, Wenzhou, Zhejiang Province, 400700, PR China.
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Sridharan K, Sivaramakrishnan G. Tranexamic acid in total hip arthroplasty: Mixed treatment comparisons of randomized controlled trials and cohort studies. J Orthop 2018; 15:81-88. [PMID: 29657445 DOI: 10.1016/j.jor.2018.01.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 01/14/2018] [Indexed: 01/08/2023] Open
Abstract
Background The present study is a network meta-analysis of various routes of tranexamic acid (TXA) in patients with total hip arthroplasty (THA). Methods Randomized controlled trials and cohort studies evaluating TXA in patients with THA were included. Number of patients requiring blood transfusion was the primary outcome. Results Pooled estimate for TXA use against placebo for blood transfusion rate was 0.30 [0.23, 0.39] favoring TXA. Maximum reduction in the risk of blood transfusion was observed with topical plus intra-operative intravenous TXA. Conclusion Combined topical and intravenous TXA during surgery may perform better than other modes in patients undergoing THA.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Gowri Sivaramakrishnan
- School of Oral Health, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
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Hibbs SP, Roberts I, Shakur-Still H, Hunt BJ. Post-partum haemorrhage and tranexamic acid: a global issue. Br J Haematol 2018; 180:799-807. [DOI: 10.1111/bjh.15073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Ian Roberts
- Clinical Trials Unit; London School of Hygiene and Tropical Medicine; London UK
| | | | - Beverley J. Hunt
- Thrombosis & Haemophilia; Guy's & St Thomas' NHS Foundation Trust & King's College; London UK
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Luehr E, Grone G, Pathak M, Austin C, Thompson S. Administration of tranexamic acid in trauma patients under stricter inclusion criteria increases the treatment window for stabilization from 24 to 48 hours-a retrospective review. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2017; 7:115-119. [PMID: 29119064 PMCID: PMC5665843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 10/20/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Since 2010, the use of Tranexamic Acid (TXA) in trauma has been brought to the forefront of severe hemorrhage treatment. However, the mixed literature illustrates the need for additional proof of efficacy and determining which patients may benefit from TXA. The purpose of this retrospective study was to evaluate a more stringent TXA inclusion criterion (heart rate ≥ 120 beats per minute (BPM) with a systolic blood pressure (SBP) ≤ 90 mmHg) as compared to the standard CRASH-2 inclusion criteria. METHODS From 2013-2016 a total of 115 patients (control, n = 62; TXA, n = 53) were included in the analysis. These patients adhered to the standard CRASH-2 and more stringent inclusion criteria; they also survived at least 8.5 hrs (minimum amount of time required for full TXA dose) from the initiation. Basic characteristics of the patients were summarized. The mortality rates between TXA and control groups were compared using two proportion z-tests. All p values <0.05 were considered statistically significant. RESULTS There was no statistical significant difference in patient characteristics between the two treatment groups, making them more comparable (p value >0.05). This study found a significant reduction of percent mortality at the 24 hr time point against the control (p = 0.007). Additionally, utilizing the more strict inclusion criteria (BPM ≥ 120 and SBP ≤ 90) substantially extended time to stabilize patients to 48 hrs (p = 0.029). CONCLUSION By imposing the more strict criteria, TXA appears to be a better treatment option in reducing mortality rates and potentially extends the treatment time-frame for stabilizing the patient up to 48 hours.
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Affiliation(s)
- Eric Luehr
- Mercy Hospital-Springfield, Department of Trauma ServicesSpringfield, MO, USA
| | - Gary Grone
- Mercy Hospital-Springfield, Department of Trauma ServicesSpringfield, MO, USA
| | - Manoj Pathak
- Murray State University, Department of Mathematics & StatisticsMurray, KY, USA
| | - Cindy Austin
- Mercy Hospital-Springfield, Trauma & Burn ResearchSpringfield, MO, USA
| | - Simon Thompson
- Mercy Hospital-Springfield, Trauma & Burn ResearchSpringfield, MO, USA
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Fakharian E, Abedzadeh-Kalahroudi M, Atoof F. Effect of Tranexamic Acid on Prevention of Hemorrhagic Mass Growth in Patients with Traumatic Brain Injury. World Neurosurg 2017; 109:e748-e753. [PMID: 29074420 DOI: 10.1016/j.wneu.2017.10.075] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Intracranial hemorrhage is a common complication of traumatic brain injury (TBI). The purpose of this study is evaluation of the effect of tranexamic acid (TXA) on hemorrhagic mass growth in TBI patients. PATIENTS AND METHODS In this randomized, double-blind clinical trial, 149 patients with TBI and any kind of blood on their computed tomography scan enrolled in the study and were randomly allocated to receive TXA or placebo. After 24 hours, computed tomography scan was repeated for assessing the changes in hemorrhage, new bleeding, and mass effects of blood on brain tissue. The primary outcome was growth of the hemorrhagic lesion. Data were analyzed by SPSS software using Fisher exact, chi-square, and Mann-Whitney U tests, as well as linear and logistic regression models. FINDINGS The incidence of hemorrhagic lesion growth was 20.5% in the TXA group and 22.7% in the placebo group. The difference was not significant (P = 0.87, RR = 0.89). The mean (standard deviation) of hemorrhagic lesion growth was 9.4 (15.3) in the TXA group and 10.2 (10.1) in the placebo group without significant difference (P = 0.27). The frequency of deaths (2.7% vs. 4%), adverse outcome at discharge (10.8% vs. 17.3%), and 3 months later (6.8% vs. 14.7%) in the TXA group were lower than the placebo, but the difference was not statistically significant. No side effect was observed with the administration of TXA. CONCLUSION Administration of a short dose of TXA does not lead to significant prevention of growth of posttraumatic hemorrhagic lesion or improvement of clinical outcomes.
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Affiliation(s)
- Esmaeil Fakharian
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | | | - Fatemeh Atoof
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
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Abstract
Fibrinolytic dysregulation is an important mechanism in traumatic coagulopathy. It is an incompletely understood process that consists of a spectrum ranging from excessive breakdown (hyperfibrinolysis) and the shutdown of fibrinolysis. Both hyperfibrinolysis and shutdown are associated with excess mortality and post-traumatic organ failure. The pathophysiology appears to relate to endothelial injury and hypoperfusion, with several molecular markers identified in playing a role. Although there are no universally accepted diagnostic tests, viscoelastic studies appear to offer the greatest potential for timely identification of patients presenting with fibrinolytic dysregulation. Treatment is multimodal, involving prompt hemorrhage control and resuscitation, with controversy surrounding the use of antifibrinolytic drug therapy. This review presents the current evidence on the pathophysiology, diagnostic challenges, as well as the management of this hemostatic dysfunction. LEVEL OF EVIDENCE Level III.
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Zekcer A, Del Priori R, Tieppo C, Silva RSD, Severino NR. Estudo comparativo com uso do ácido tranexâmico tópico e intravenoso em relação à perda sanguínea na artroplastia total do joelho. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Comparative study of topical vs. intravenous tranexamic acid regarding blood loss in total knee arthroplasty. Rev Bras Ortop 2017; 52:589-595. [PMID: 29062824 PMCID: PMC5643894 DOI: 10.1016/j.rboe.2017.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 09/20/2016] [Indexed: 12/02/2022] Open
Abstract
Objective To compare topical vs. intravenous tranexamic acid (TA) in total knee arthroplasty regarding blood loss and transfusion. Methods Ninety patients were randomized to receive TA intravenously (20 mg/kg in 100 mL of saline; group IV), topically (1.5 g in 50 mL of saline, sprayed over the operated site, before release of the tourniquet; topical group), or intravenous saline (100 mL with anesthesia; control group). The volume of drained blood in 48 h, the amount of transfused blood, and the serum levels of hemoglobin and hematocrit before and after surgery were evaluated. Results The groups were similar for gender, age, weight, laterality, and preoperative hemoglobin and hematocrit levels (p > 0.2). The hemoglobin level dropped in all groups when comparing the preoperative and the 48-h evaluations: the control group decreased 3.8 mg/dL on average, while the IV group had a decrease of 3.0, and the topical group, of 3.2 (p = 0.019). The difference between the control and IV groups was confirmed by Bonferroni test (p = 0.020). The difference between the control group and the topical group was not significant (p = 0.130), although there was less reduction in hemoglobin in the topical group; the comparison between the IV group and the topical group was also not significant (p = 1.000). Conclusion Using topic and IV tranexamic acid decreased blood loss and the need for transfusion in total knee arthroplasty. Topical application showed results similar to IV use regarding the need for blood transfusion, but without the possible side effects of IV administration.
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Sridharan K, Sivaramakrishnan G. Tranexamic Acid in Total Knee Arthroplasty: Mixed Treatment Comparisons and Recursive Cumulative Meta-Analysis of Randomized, Controlled Trials and Cohort Studies. Basic Clin Pharmacol Toxicol 2017; 122:111-119. [DOI: 10.1111/bcpt.12847] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/04/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Kannan Sridharan
- Pharmacology; School of Health Sciences; College of Medicine, Nursing and Health Sciences; Fiji National University; Suva Fiji Islands
| | - Gowri Sivaramakrishnan
- Prosthodontics; School of Oral Health; College of Medicine, Nursing and Health Sciences; Fiji National University; Suva Fiji Islands
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Xi C, Zhu L, Zhuang Y, Wang S, Sun G, Liu Y, Wang D. Experimental Evaluation of Tranexamic Acid-Loaded Porous Starch as a Hemostatic Powder. Clin Appl Thromb Hemost 2017; 24:279-286. [PMID: 28731369 DOI: 10.1177/1076029617716770] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
We evaluated the effectiveness of a novel hemostatic powder called Tranexamic Acid-loaded Porous Starch (TAPS) developed recently on blood clotting activity and hemostasis. The effectiveness of TAPS was evaluated by comparing hemostatic properties with those of Quick-acting Styptic Powder (QSP) and Compound Microporous Polysaccharide Haemostatic powder (CMPHP). The blood clotting activities of human blood were analyzed by thromboela-stogram (TEG) assays in vitro. The hemostatic effectiveness in vivo was evaluated using a rat model with hepatic traumatic hemorrhage. The blood loss and standardized bleeding score, which reflects the degree of bleeding after treatment with styptic powder, were used to evaluate hemostatic efficacy. In vitro, the values of TEG parameters in TAPS group were significantly different, compared with untreated controls or CMPHP group (p < 0.05). In vivo, the application of QSP, CMPHP and TAPS led to significantly decreased post-treatment blood loss than in the control group (p < 0.01). The scores of the groups treated with QSP, CMPHP and TAPS (0, 0.2±0.422, 0.3±0.483, respectively) were significant lower than with gauze control (1.6±0.516) which success hemostatic was achieved at 5 minutes (p < 0.01). Hemostasis was achieved successfully within approximately 4 minutes after the application of TAPS. TAPS could help blood to form an artificial scab on a wound and to seal injuries for hemostasis to reduce blood loss in rats with hepatic trauma and hemorrhage. It was safe to use with no impact on blood clotting function or other apparent side effects.
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Affiliation(s)
- Chaoyun Xi
- 1 Department of Blood Transfusion, Chinese PLA General Hospital, Beijing, China.,Chaoyun Xi and Liguo Zhu are both first co authors and contributed equally to this paper
| | - Liguo Zhu
- 1 Department of Blood Transfusion, Chinese PLA General Hospital, Beijing, China.,Chaoyun Xi and Liguo Zhu are both first co authors and contributed equally to this paper
| | - Yuan Zhuang
- 1 Department of Blood Transfusion, Chinese PLA General Hospital, Beijing, China
| | - Shufang Wang
- 1 Department of Blood Transfusion, Chinese PLA General Hospital, Beijing, China
| | - Guixiang Sun
- 1 Department of Blood Transfusion, Chinese PLA General Hospital, Beijing, China
| | - Yaqian Liu
- 2 Laboratory Animal Center, Chinese PLA General Hospital, Bejing, China
| | - Deqing Wang
- 1 Department of Blood Transfusion, Chinese PLA General Hospital, Beijing, China
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Peters J, Pendry K. Patient blood management: an update of current guidance in clinical practice. Br J Hosp Med (Lond) 2017; 78:88-95. [PMID: 28165794 DOI: 10.12968/hmed.2017.78.2.88] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Patient blood management is a global, evidence-based, multidisciplinary initiative to reduce unnecessary blood transfusion while optimizing other available techniques. This article summarizes current patient blood management strategies and highlights future developments in UK practice.
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Affiliation(s)
- Jayne Peters
- Specialty Trainee Registrar Year 6 in Haematology, Department of Clinical Haematology, Manchester Royal Infirmary, Manchester M13 9WL
| | - Kate Pendry
- Consultant Haematologist and Clinical Director for Patient Blood Management, NHSBT, Manchester Blood Centre, Manchester
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Yao Q, Wu M, Zhou J, Zhou M, Chen D, Fu L, Bian R, Xing X, Sun L, Hu X, Li L, Dai B, Wüthrich RP, Ma Y, Mei CL. Treatment of Persistent Gross Hematuria with Tranexamic Acid in Autosomal Dominant Polycystic Kidney Disease. Kidney Blood Press Res 2017; 42:156-164. [PMID: 28395294 DOI: 10.1159/000474961] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/17/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS In this retrospective study we aimed to compare the effect of tranexamic acid (TXA) vs etamsylate, two hemostatic agents, on hematuria duration in autosomal dominant polycystic kidney disease (ADPKD) patients with persistent gross hematuria. METHODS This is a retrospective study of 40 patients with ADPKD and macroscopic hematuria. 20 patients receiving TXA and snake venom blood clotting enzyme injection were compared with 20 matched patients receiving etamsylate and snake venom blood clotting enzyme injection. The primary outcome was hematuria duration and the secondary outcomes were blood transfusion requirements and adverse events. RESULTS The hematuria duration was shorter in the TXA group compared with the etamsylate group (4[3-5] d vs 7[6-10] d, P<0.001). The volume of blood transfusion tended to be less in the TXA group than in the etamsylate group (300±115 ml vs 486±195 ml, P=0.12), and the number of patients needing a blood transfusion also tended to be lower [20% (4/20) vs 35% (7/20), P=0.29]. TXA and etamsylate were equally well tolerated and no serious adverse events were observed in both groups. CONCLUSIONS Our study indicates that TXA treatment was more effective than etamsylate in stopping bleeding in ADPKD patients with persistent gross hematuria.
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Affiliation(s)
- Qing Yao
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Ming Wu
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jie Zhou
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Meiyang Zhou
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Present address: Department of Nephrology, Yinzhou People's Hospital, Ningbo, China
| | - Dongping Chen
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Lili Fu
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Rongrong Bian
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xiaohong Xing
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Lijun Sun
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xiaohong Hu
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Lin Li
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Bing Dai
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | | | - Yiyi Ma
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Chang-Lin Mei
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
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50
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Jokar A, Ahmadi K, Salehi T, Sharif-Alhoseini M, Rahimi-Movaghar V. The effect of tranexamic acid in traumatic brain injury: A randomized controlled trial. Chin J Traumatol 2017; 20:49-51. [PMID: 28209450 PMCID: PMC5343096 DOI: 10.1016/j.cjtee.2016.02.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 01/27/2016] [Accepted: 02/01/2016] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Traumatic brain injury (TBI) is a leading cause of death and disability. Intracranial hemorrhage (ICH) secondary to TBI is associated with a high risk of coagulopathy which leads to increasing risk of hemorrhage growth and higher mortality rate. Therefore, antifibrinolytic agents such as tranexamic acid (TA) might reduce traumatic ICH. The aim of the present study was to investigate the extent of ICH growth after TA administration in TBI patients. METHODS This single-blind randomized controlled trial was conducted on patients with traumatic ICH (with less than 30 ml) referring to the emergency department of Vali-Asr Hospital, Arak, Iran in 2014. Patients, based on the inclusion and exclusion criteria, were divided into intervention and control groups (40 patients each). All patients received a conservative treatment for ICH, as well as either intravenous TA or placebo. The extent of ICH growth as the primary outcome was measured by brain CT scan after 48 h. RESULTS Although brain CT scan showed a significant increase in hemorrhage volume in both groups after 48 h, it was significantly less in the TA group than in the control group (p = 0.04). The mean total hemorrhage expansion was (1.7 ± 9.7) ml and (4.3 ± 12.9) ml in TA and placebo groups, respectively (p < 0.001). CONCLUSION It has been established that TA, as an effective hospital-based treatment for acute TBI, could reduce ICH growth. Larger studies are needed to compare the effectiveness of different doses.
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Affiliation(s)
- Abolfazl Jokar
- Department of Emergency Medicine, Arak University of Medical Science, Arak, Iran
| | - Koorosh Ahmadi
- Department of Emergency Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Tayyebeh Salehi
- Department of Emergency Medicine, Arak University of Medical Science, Arak, Iran
| | - Mahdi Sharif-Alhoseini
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran,Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran,Corresponding author. Sina Trauma and Surgery Research Center, Sina Hospital, Hassan-Abad Square, Imam Khomeini Ave, Tehran, 11365-3876, Iran. Fax: +98 216 6757009.Sina Trauma and Surgery Research CenterSina HospitalHassan-Abad SquareImam Khomeini AveTehran11365-3876Iran
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