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Shim SR, Han S, Jeong JH, Hwang I, Cha Y, Ihm C. Effect of tranexamic acid in spine surgeries: a systematic review and network meta-analysis. Front Surg 2025; 12:1550854. [PMID: 40292415 PMCID: PMC12021860 DOI: 10.3389/fsurg.2025.1550854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2024] [Accepted: 03/31/2025] [Indexed: 04/30/2025] Open
Abstract
Background Severe blood loss during spine surgery increases the need for blood transfusion. Transfusion carries the risks of infection, complications, and postoperative morbidity; therefore, minimizing these risks is crucial for all surgical patients. Methods A comprehensive literature search was conducted in PubMed, Cochrane, and EMBASE to find studies examining the effect of tranexamic acid (TXA) on spine surgeries in patients who received blood transfusion. We used the mean difference (MD) and 95% credible intervals (CrI) to analyze continuous outcomes, such as intraoperative blood loss, postoperative blood loss, hemoglobin drop, and length of hospital stay. To evaluate categorical outcomes, such as blood transfusion rate and complication rate, the odds ratios (OR) and 95% CrI were determined. Results A total of 38 randomized controlled trials were included, evaluating six outcomes across 10 treatment groups. Low-dose intravenous (IV) TXA combined with temperature intervention (15 mg/kg) significantly reduced intraoperative blood loss compared with placebo [MD: -112.0; 95% CrI: -211.0 to -14.9, surface under the cumulative ranking curve (SUCRA): 78.37%]. The administration of more than two doses of TXA significantly reduced intraoperative blood loss (MD: -101.0, 95% CrI: -161.0 to -44.1, SUCRA: 77.65%) and postoperative blood loss (MD: -177.0, 95% CrI: -275.0 to -92.4, SUCRA: 85.66%) compared with placebo. Both treatments significantly impacted the hemoglobin drop and blood transfusion rate. Conclusions Low-dose IV TXA with temperature intervention and the combined use of TXA significantly improved blood loss, hemoglobin drop, and blood transfusion rate during spine surgeries. Further studies involving larger populations are warranted and should be carefully designed to determine the potential risk of complications. Systematic Review Registration www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024531557, identifier: CRD42024531557.
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Affiliation(s)
- Sung Ryul Shim
- Department of Biomedical Informatics, College of Medicine, Konyang University, Daejeon, Republic of Korea
- Konyang Medical Data Research Group-KYMERA, Konyang University Hospital, Daejeon, Republic of Korea
| | - Sangah Han
- Department of Blood Management Services, Daejeon Eulji Medical Center, Eulji University, Daejeon, Republic of Korea
| | - Ji Hun Jeong
- Department of Blood Management Services, Daejeon Eulji Medical Center, Eulji University, Daejeon, Republic of Korea
- Department of Laboratory Medicine, Daejeon Eulji Medical Center, Eulji University, Daejeon, Republic of Korea
| | - Inhwan Hwang
- Department of Hematooncology, Daejeon Eulji Medical Center, Eulji University, Daejeon, Republic of Korea
| | - Yonghan Cha
- Department of Orthopaedic Surgery, Daejeon Eulji Medical Center, Eulji University, Daejeon, Republic of Korea
| | - Chunhwa Ihm
- Department of Blood Management Services, Daejeon Eulji Medical Center, Eulji University, Daejeon, Republic of Korea
- Department of Laboratory Medicine, Daejeon Eulji Medical Center, Eulji University, Daejeon, Republic of Korea
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Koehne NH, Locke AR, Song J, Gerber AR, Alasadi Y, Yendluri A, Corvi JJ, Namiri NK, Kim JS, Cho SK, Chaudhary SB, Hecht AC. The Statistical Fragility of Tranexamic Acid in Spinal Surgery: A Systematic Review of Randomized Controlled Trials. Clin Spine Surg 2025:01933606-990000000-00481. [PMID: 40207798 DOI: 10.1097/bsd.0000000000001765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2024] [Accepted: 01/20/2025] [Indexed: 04/11/2025]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To evaluate the statistical robustness of TXA use in spine surgery as a potential contributor to controversies in this field. SUMMARY OF BACKGROUND DATA Tranexamic acid (TXA) is an antifibrinolytic medication administered during spinal surgery to limit blood loss. Existing randomized controlled trials (RCTs) on the efficacy of TXA contain varied results, particularly when reporting outcomes related to blood transfusion rates and thromboembolic events. By calculating the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ), statistical robustness was quantified and compared across all included RCTs. METHODS PubMed, Embase, and MEDLINE were systematically searched for recent RCTs (January 1, 2000-August 1, 2023) assessing TXA use in patients undergoing spine surgery. The FI and rFI were calculated for each outcome, representing the number of event reversals required to alter statistical significance for significant and nonsignificant outcomes, respectively. The FQ was determined by dividing the FI/rFI by the study sample size. RESULTS Of the 297 RCTs screened, 31 studies were included for analysis, yielding 80 dichotomous outcomes. Across these outcomes, the median FI (mFI) was 5.0, with an associated median FQ (mFQ) of 0.060. Nine outcomes were statistically significant (mFQ=0.018), and 71 were nonsignificant (mFQ=0.064). The most common outcome categories included blood/platelet transfusions (38 outcomes), thromboembolic events (15 outcomes), and other adverse events (27 outcomes), resulting in mFQs of 0.056, 0.049, and 0.064, respectively. CONCLUSIONS Outcomes examining TXA in spinal surgery demonstrated statistical fragility, with significant and thromboembolic outcomes proving the most fragile. Among all outcomes, there was a lack of significant results. To better guide future research on TXA use in spine surgery, this study recommends RCTs report fragility statistics along with P values and include these metrics when proposing clinical implications. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Niklas H Koehne
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Auston R Locke
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Junho Song
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Yazan Alasadi
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Avanish Yendluri
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John J Corvi
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nikan K Namiri
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jun S Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Saad B Chaudhary
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrew C Hecht
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Shi B, Xie W, Kai J, Li L, Sun L. The optimal dose of intravenous tranexamic acid for reducing blood loss in spinal surgery: a network meta-analysis. BMC Musculoskelet Disord 2024; 25:1093. [PMID: 39736682 DOI: 10.1186/s12891-024-08233-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 12/20/2024] [Indexed: 01/01/2025] Open
Abstract
BACKGROUND This study aims to evaluate the optimal dose of intravenous tranexamic acid (TXA) for reducing blood loss in spinal surgery. METHODS A systematic search was conducted in the PubMed, Embase, Cochrane Library database from inception until November 2023. Randomized controlled trials (RCTs) incorporating diverse TXA dosing regimens for spinal surgery were included. The surface under the cumulative ranking curve (SUCRA) analysis was employed to determine ranking order. R software with gemtc package was used for all analyses, with a significance threshold set at P < 0.05. RESULTS Twenty-four RCTs were considered eligible and finally included. All TXA treatments demonstrated superior efficacy compared to the placebo, with statistically significant differences (P < 0.05). SUCRA values indicated that Treatment I (100 mg/kg + 10 mg.kg/h) claimed the top rank (SUCRA, 80.3%), followed by Treatment F (15 mg/kg + 2 mg.kg/h) in second place (SUCRA, 76.7%), and Treatment E (10 mg/kg + 2 mg.kg/h) in third place (SUCRA, 75.2%). Conversely, the placebo ranked the lowest (SUCRA, 0.3%). Additionally, Treatment I (100 mg/kg + 10 mg.kg/h) held the top rank (SUCRA, 95.6%), followed by Treatment N (30 mg/kg + 10 mg.kg/h) in second place (SUCRA, 81.0%), and Treatment K (15 mg/kg + 6 mg.kg/h) in third place (SUCRA, 74.8%). Importantly, no statistically significant differences were observed between any TXA treatments and the placebo concerning the occurrence of deep vein thrombosis (DVT) (P > 0.05). CONCLUSIONS This network meta-analysis underscores that intravenous TXA is associated with decreased overall blood loss in multilevel spine surgery. Notably, the highest dose in this network meta-analysis (100 mg/kg + 10 mg.kg/h) emerged as the only regimen demonstrating significant benefits in pairwise comparisons with other TXA doses. Although this regimen did not significantly increase DVT risk, careful consideration of safety data for higher doses remains essential.
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Affiliation(s)
- Bo Shi
- Department of Orthopaedics, Shanxi Provincial People's Hospital, Shani Medical University, No. 29, Double Tower Street, Taiyuan, Shanxi, 030012, China
- Shanxi Bethune Hospital, Third Hospital of Shanxi Medical University, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Wenjuan Xie
- Department of Clinical Nutrition, Bethune Hospital, Shanxi Medical University, No. 99, Longcheng Street, Taiyuan City, 030032, China
| | - Jia Kai
- Shanxi Medical University, 29 Shuangtasi Street, Yingze District, Taiyuan, Shanxi, China
| | - Lijun Li
- Department of Orthopaedics, Shanxi Provincial People's Hospital, Shani Medical University, No. 29, Double Tower Street, Taiyuan, Shanxi, 030012, China.
| | - Lin Sun
- Shanxi Bethune Hospital, Third Hospital of Shanxi Medical University, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China.
- Shanxi Medical University, 29 Shuangtasi Street, Yingze District, Taiyuan, Shanxi, China.
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Martinelli ES, McCluskey SA, Karkouti K, Luzzi CA, Bieze M, Malbouisson LMS, Schmidt AP. The debate on antifibrinolytics in liver transplantation: always, never, or sometimes? BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:844562. [PMID: 39332678 PMCID: PMC11474311 DOI: 10.1016/j.bjane.2024.844562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/29/2024]
Affiliation(s)
- Eduarda S Martinelli
- University Health Network, Toronto General Hospital, Department of Anesthesia and Pain Management, Toronto, Canada; University of Toronto, Temerty Faculty of Medicine, Department of Anesthesiology and Pain Medicine, Toronto, Canada; Santa Casa de Porto Alegre, Serviço de Anestesia, Porto Alegre, RS, Brazil; Faculdade de Medicina da Universidade de São Paulo (FMUSP), Programa de Pós-graduação em Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, São Paulo, SP, Brazil
| | - Stuart A McCluskey
- University Health Network, Toronto General Hospital, Department of Anesthesia and Pain Management, Toronto, Canada; University of Toronto, Temerty Faculty of Medicine, Department of Anesthesiology and Pain Medicine, Toronto, Canada
| | - Keyvan Karkouti
- University Health Network, Toronto General Hospital, Department of Anesthesia and Pain Management, Toronto, Canada; University of Toronto, Temerty Faculty of Medicine, Department of Anesthesiology and Pain Medicine, Toronto, Canada; University Health Network, Women's College Hospital, Sinai Health System, Department of Anesthesia and Pain Management, Toronto, Canada; University Health Network, Peter Munk Cardiac Centre, Toronto, Canada
| | - Carla A Luzzi
- University Health Network, Toronto General Hospital, Department of Anesthesia and Pain Management, Toronto, Canada; University of Toronto, Temerty Faculty of Medicine, Department of Anesthesiology and Pain Medicine, Toronto, Canada
| | - Matthanja Bieze
- University Health Network, Toronto General Hospital, Department of Anesthesia and Pain Management, Toronto, Canada; University of Toronto, Temerty Faculty of Medicine, Department of Anesthesiology and Pain Medicine, Toronto, Canada
| | - Luiz Marcelo S Malbouisson
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Programa de Pós-graduação em Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, São Paulo, SP, Brazil; Universidade de São Paulo, Hospital das Clínicas, Divisão de Anestesiologia, São Paulo, SP, Brazil
| | - André P Schmidt
- Santa Casa de Porto Alegre, Serviço de Anestesia, Porto Alegre, RS, Brazil; Faculdade de Medicina da Universidade de São Paulo (FMUSP), Programa de Pós-graduação em Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, São Paulo, SP, Brazil; Hospital de Clínicas de Porto Alegre (HCPA), Serviço de Anestesia e Medicina Perioperatória, Porto Alegre, RS, Brazil; Hospital Nossa Senhora da Conceição, Serviço de Anestesia, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-graduação em Ciências Pneumológicas, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-graduação em Ciências Cirúrgicas, Porto Alegre, RS, Brazil.
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Mergoum AM, Mergoum AS, Larson NJ, Dries DJ, Cook A, Blondeau B, Rogers FB. Tranexamic Acid Use in the Surgical Arena: A Narrative Review. J Surg Res 2024; 302:208-221. [PMID: 39106732 DOI: 10.1016/j.jss.2024.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/02/2024] [Accepted: 07/07/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION Tranexamic acid (TXA) is a potent antifibrinolytic drug that inhibits the activation of plasmin by plasminogen. While not a new medication, TXA has quickly gained traction across a variety of surgical subspecialties to prevent and treat bleeding. Knowledge on the use of this drug is essential for the modern surgeon to continue to provide excellent care to their patients. METHODS A comprehensive review of the PubMed database was conducted of articles published within the last 10 y (2014-2024) relating to TXA and its use in various surgical subspecialties. Seminal studies regarding the use of TXA older than 10 y were included from the author's archives. RESULTS Indications for TXA are not limited to trauma alone, and TXA is utilized across a variety of surgical subspecialties from neurosurgery to hepatic surgery to control hemorrhage. Overall, TXA is well tolerated with common dose-dependent adverse effects, including headache, nasal symptoms, dizziness, nausea, diarrhea, and fatigue. More severe adverse events are rare and easily mitigated by not exceeding a dose of 50 mg/kg. CONCLUSIONS The administration of TXA as an adjunct to treat trauma saves lives. The ability of TXA to induce seizures is dose dependent with identifiable risk factors, making this serious adverse effect predictable. As for the potential for TXA to cause thrombotic events, uncertainty remains. If this association is proven to be real, the risk will likely be small, since the use of TXA is still advantageous in most situations because of its efficacy for a more common concern, bleeding.
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Affiliation(s)
| | - Adel S Mergoum
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | - Alan Cook
- Department of Surgery, University of Texas at Tyler School of Medicine, Tyler, Texas
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
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Money AJ, Dumont G, Sheppard S, Jackson JB, Spitnale M, Bakaes Y, Gauthier C, Grabowski G. A Retrospective Comparative Analysis on the Effect of Tranexamic Acid to Reduce Perioperative Blood Loss in Patients Undergoing Cervical Spine Surgery. Clin Spine Surg 2024; 37:E330-E334. [PMID: 38409675 DOI: 10.1097/bsd.0000000000001592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 01/22/2024] [Indexed: 02/28/2024]
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVE The purpose of this study is to assess the impact of intravenous TXA on blood loss outcomes in anterior, posterior, and combined approaches for elective cervical spine surgery. SUMMARY OF BACKGROUND DATA Tranexamic acid (TXA) has been shown to reduce blood loss in a variety of operations, such as lumbar spine surgery. However, limited studies have evaluated the efficacy of TXA in cervical spine surgery. METHODS We performed a retrospective review of a single surgeon's elective cervical spine operations between September 2011 and March 2017. Patients were divided into 3 groups: anterior approach, posterior approach, or combined approach. Patients were then further subdivided into TXA versus control groups based on whether they received TXA treatment. We performed multiple linear regressions to assess the relationship between the use of TXA and other dependent variables (number of vertebral levels treated, need for a vertebral corpectomy) on total perioperative blood loss, intraoperative estimated blood loss, postoperative drain output, total operative time, postoperative change in hemoglobin, and occurrence of transfusion and/or postoperative deep venous thrombus (DVT). RESULTS We found that the use of TXA statistically significantly reduced total perioperative blood loss ( P =0.04) and postoperative drain output ( P =0.004) in posterior surgical approach cervical spine surgery but did not statistically significantly impact any blood loss variables in anterior or combined surgical approaches to elective cervical spine surgery. The use of TXA was a significant predictor for a decrease in intraoperative ( P =0.02) and postoperative ( P <0.01) blood loss. CONCLUSIONS This study found that TXA statistically significantly decreased total blood loss and postoperative drain output when controlling for multiple confounding factors. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Adam J Money
- Department of Orthopaedic Surgery, Prisma Health Orthopaedics, Columbia, SC
| | - Guillaume Dumont
- Department of Orthopaedic Surgery, Lexington Medical Center Orthopaedics, Columbia, SC
| | - Sean Sheppard
- Department of Orthopaedics, Naval Medical Center San Diego, San Diego, CA
| | | | - Michael Spitnale
- Department of Orthopaedic Surgery, Prisma Health Orthopaedics, Columbia, SC
| | - Yianni Bakaes
- Department of Orthopaedic Surgery, University of South Carolina School of Medicine, Columbia, SC
| | - Chase Gauthier
- Department of Orthopaedics, University of South Carolina, Columbia, SC
| | - Gregory Grabowski
- Department of Orthopaedics, University of South Carolina, Columbia, SC
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Tian N, Sun Y, Liu Y, Jin J, Chen S, Han H, Zhang Y, Li Z. Safety assessment of tranexamic acid: real-world adverse event analysis from the FAERS database. Front Pharmacol 2024; 15:1388138. [PMID: 38863974 PMCID: PMC11165083 DOI: 10.3389/fphar.2024.1388138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/13/2024] [Indexed: 06/13/2024] Open
Abstract
Background In recent years, with the continuous expansion of the application scope of Tranexamic acid (TXA), its usage has surged. Despite numerous studies demonstrating its powerful efficacy, concerns regarding its adverse reactions persist, necessitating comprehensive safety assessment. This study analyzed real-world data from the U.S. Food and Drug Administration to investigate TXA-related adverse events, aiming to elucidate its safety and optimize patient treatment. Methods The adverse drug event data concerning TXA from 2004 Q1 to 2023 Q3 were collected. Following data standardization, a variety of signal quantification techniques, including the reporting odds ratios, proportional reporting ratios, Bayesian confidence propagation neural network, and empirical Bayes geometric mean were used for analysis. Results After analyzing 16,692,026 adverse event reports, a total of 1,574 cases of adverse events related to TXA were identified, spanning 23 system organ classes and 307 preferred terms. In addition to the common thrombosis-related Vascular disorders (n = 386) and Cardiac disorders (n = 377), adverse reactions in the Nervous system disorders category were also observed (n = 785), including Myoclonus (n = 70), Status epilepticus (n = 43), and Myoclonic epilepsy (n = 17). Furthermore, this study uncovered adverse effects such as Renal cortical necrosis, Hepatic cyst rupture, and Vascular stent stenosis, which were not previously mentioned in the instructions. Although these occurred infrequently, they exhibited high signal strength. Both Retinal artery occlusion and Vascular stent thrombosis disorder were frequent and exhibited high signal strength as well. It is worth noting that 78 cases of adverse reactions were caused by confusion between incorrect product administration. Conclusion Our research suggests that TXA has some adverse reactions that are being overlooked. As a cornerstone medication in hemorrhage treatment, it's crucial to monitor, identify, and address these adverse reactions effectively.
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Affiliation(s)
| | | | | | | | | | | | - Ying Zhang
- Department of Orthopaedics, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhiwei Li
- Correspondence: Zhiwei Li, ; Ying Zhang,
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Yamanouchi K, Funao H, Fujita N, Ebata S, Yagi M. Safety and Efficacy of Tranexamic Acid in Spinal Surgery: A Systematic Review and Meta-Analysis. Spine Surg Relat Res 2024; 8:253-266. [PMID: 38868794 PMCID: PMC11165496 DOI: 10.22603/ssrr.2023-0244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/14/2023] [Indexed: 06/14/2024] Open
Abstract
Background Tranexamic acid (TXA) has gained popularity in spinal surgery because of its potential to reduce blood loss. However, concerns regarding its safety and efficacy remain. This systematic review and meta-analysis aimed to evaluate the efficacy of TXA in reducing blood loss and its safety profile in spinal surgeries. Methods A comprehensive search was conducted in electronic databases for randomized controlled trials and prospective studies evaluating the use of TXA in spinal surgery. The primary outcomes were intraoperative and total estimated blood loss (EBL), and the secondary outcomes included the incidence and types of complications associated with TXA use. Meta-analyses were performed using random-effects models. Results Thirteen studies involving 1,213 participants were included in the meta-analysis. The use of TXA was associated with significant reductions in both intraoperative (mean difference: -46.56 mL [-73.85, -19.26], p<0.01]) and total EBL (mean difference: -210.17 mL [-284.93, -135.40], p<0.01) while also decreasing the need for blood transfusions (risk ratio: 0.68 [0.51, 0.90], p<0.01). No significant difference was found in the incidence and types of thrombotic complications when TXA was used in spinal surgery. Subgroup analysis showed consistent results in instrumentation and fusion surgery and different doses of TXA. Conclusions TXA is effective in reducing intraoperative and overall blood loss in spinal surgery without increasing the risk of complications. These findings support the use of TXA to improve patient outcomes. However, caution should be exercised because of the heterogeneity among the included studies. Further research is needed to confirm these findings and explore potential long-term complications.
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Affiliation(s)
- Kento Yamanouchi
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
| | - Naruhito Fujita
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
| | - Shigeto Ebata
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
| | - Mitsuru Yagi
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
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Luo H, Yang Y, Wang Z, Ma L, Xie C. Efficacy and safety of tranexamic acid in cervical spine surgery: a systematic review and meta-analysis. Front Neurol 2024; 15:1405773. [PMID: 38770522 PMCID: PMC11102962 DOI: 10.3389/fneur.2024.1405773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 04/25/2024] [Indexed: 05/22/2024] Open
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic drug associated with reduced blood loss in a range of surgical specialties. This meta-analysis aimed to compare the efficacy and safety of TXA in cervical surgery, focusing on its effects on intraoperative blood loss and related outcomes. Methods We searched the PubMed, EMBASE, Medline, and Cochrane Library databases to identify all literature related to TXA used in cervical spinal surgery. Intraoperative blood loss, postoperative drainage volume, total blood loss, postoperative hematological variables, and complications were analyzed. Results Eight trials met the inclusion criteria. The pooled results showed that intraoperative blood loss, total blood loss, and postoperative drainage volume were significantly lower in the TXA group than in the control group. The hemoglobin and hematocrit on postoperative day 1 was significantly higher in the TXA group than in the control group. There was no significant difference in complications between the two groups. Conclusion The available evidence indicates that TXA effectively reduces blood loss in cervical spinal surgery while maintaining a favorable safety profile, without increasing associated risks. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023459652.
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Affiliation(s)
- Hua Luo
- Department of Orthopedic, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Yu Yang
- Department of Orthopedic, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Zhitao Wang
- Department of Pharmacy, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Lingping Ma
- Department of Operation Room, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Chengxin Xie
- Department of Orthopedic, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
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Cartagena-Reyes MA, Silva-Aponte JA, Nazario-Ferrer GI, Benes GA, Choudhary A, Raad M, Frank SM, Musharbash FN, Jain A. The cost-utility of intraoperative tranexamic acid in adult spinal deformity patients undergoing long posterior spinal fusion. Spine Deform 2024; 12:587-593. [PMID: 38427155 DOI: 10.1007/s43390-023-00818-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 12/29/2023] [Indexed: 03/02/2024]
Abstract
PURPOSE This study aims to evaluate the cost-utility of intraoperative tranexamic acid (TXA) in adult spinal deformity (ASD) patients undergoing long posterior (≥ 5 vertebral levels) spinal fusion. METHODS A decision-analysis model was built for a hypothetical 60-year-old adult patient with spinal deformity undergoing long posterior spinal fusion. A comprehensive review of the literature was performed to obtain event probabilities, costs and health utilities at each node. Health utilities were utilized to calculate Quality-Adjusted Life Years (QALYs). A base-case analysis was carried out to obtain the incremental cost and effectiveness of intraoperative TXA. Probabilistic sensitivity analysis was performed to evaluate uncertainty in our model and obtain mean incremental costs, effectiveness, and net monetary benefits. One-way sensitivity analyses were also performed to identify the variables with the most impact on our model. RESULTS Use of intraoperative TXA was the favored strategy in 88% of the iterations. The mean incremental utility ratio for using intraoperative TXA demonstrated higher benefit and lower cost while being lower than the willingness-to-pay threshold set at $50,000 per quality adjusted life years. Use of intraoperative TXA was associated with a mean incremental net monetary benefit (INMB) of $3743 (95% CI 3492-3995). One-way sensitivity analysis reported cost of blood transfusions due to post-operative anemia to be a major driver of cost-utility analysis. CONCLUSION Use of intraoperative TXAs is a cost-effective strategy to reduce overall perioperative costs related to post-operative blood transfusions. Administration of intraoperative TXA should be considered for long fusions in ASD population when not explicitly contra-indicated due to patient factors.
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Affiliation(s)
- Miguel A Cartagena-Reyes
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Juan A Silva-Aponte
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Gabriel I Nazario-Ferrer
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Gregory A Benes
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Ananya Choudhary
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University, 1800 Orleans St., Zayed 6208, Baltimore, MD, 21287, USA
| | - Farah N Musharbash
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA.
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11
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Zahra W, Nayar SK, Bhadresha A, Jasani V, Aftab S. Safety of tranexamic acid in surgically treated isolated spine trauma. World J Orthop 2024; 15:346-354. [PMID: 38680673 PMCID: PMC11045465 DOI: 10.5312/wjo.v15.i4.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/07/2024] [Accepted: 03/19/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Tranexamic acid (TXA), a synthetic antifibrinolytic drug, effectively reduces blood loss by inhibiting plasmin-induced fibrin breakdown. This is the first study in the United Kingdom to investigate the effectiveness of TXA in the surgical management of isolated spine trauma. AIM To assess the safety of TXA in isolated spine trauma. The primary and secondary outcomes are to assess the rate of thromboembolic events and to evaluate blood loss and the incidence of blood transfusion, respectively. METHODS This prospective observational study included patients aged ≥ 17 years with isolated spine trauma requiring surgical intervention over a 6-month period at two major trauma centers in the United Kingdom. RESULTS We identified 67 patients: 26 (39%) and 41 (61%) received and did not receive TXA, respectively. Both groups were matched in terms of age, gender, American Society of Anesthesiologists grade, and mechanism of injury. A higher proportion of patients who received TXA had a subaxial cervical spine injury classification or thoracolumbar injury classification score > 4 (74% vs 56%). All patients in the TXA group underwent an open approach with a mean of 5 spinal levels involved and an average operative time of 203 min, compared with 24 patients (58%) in the non-TXA group who underwent an open approach with an average of 3 spinal levels involved and a mean operative time of 159 min. Among patients who received TXA, blood loss was < 150 and 150-300 mL in 8 (31%) and 15 (58%) patients, respectively. There were no cases of thromboembolic events in any patient who received TXA. CONCLUSION Our study demonstrated that TXA is safe for isolated spine trauma. It is challenging to determine whether TXA effectively reduces blood loss because most surgeons prefer TXA for open or multilevel cases. Further, larger studies are necessary to explore the rate, dosage, and mode of administration of TXA.
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Affiliation(s)
- Wajiha Zahra
- Trauma and Orthopedics Department, University Hospital of North Midlands NHS Trust, Stoke-on-Trent ST4 6QG, United Kingdom
| | - Sandeep Krishan Nayar
- Trauma and Orthopedics Department, Royal London Hospital, Barts Health Institute, London E1 1BB, United Kingdom
| | - Ashwin Bhadresha
- Trauma and Orthopedics Department, Royal London Hospital, Barts Health Institute, London E1 1BB, United Kingdom
| | - Vinay Jasani
- Craniospinal Services, University Hospital of North Midlands NHS Trust, Stoke-on-Trent ST4 6QG, United Kingdom
| | - Syed Aftab
- Spine Department, Royal London Hospital, Barts Health Institute, London E1 1BB, United Kingdom
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12
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Brown NJ, Pennington Z, Himstead AS, Yang CY, Chakravarti S, Gendreau J, Kurtz J, Shahrestani S, Pham MH, Osorio JA. Safety and Efficacy of High-Dose Tranexamic Acid in Spine Surgery: A Retrospective Single-Institution Series. World Neurosurg 2023; 177:e18-e25. [PMID: 37141940 DOI: 10.1016/j.wneu.2023.04.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE Currently, tranexamic acid (TXA) is the most widely used antifibrinolytic agent in spine surgery and has been proven to reduce perioperative blood loss. However, the safety of high-dose regimens remains in established. METHODS A retrospective chart review was performed to identify all adult patients who underwent spine surgery with high-dose TXA (50 mg/kg loading dose, mg/kg/h maintenance dose) between September 2019 and March 2020. RESULTS Thirty-six patients were treated with intraoperative high-dose TXA during the study period. The mean age was 56.6 (range: 22-82). Average body mass index was 27.2 (5.1) kg/m2. Average preoperative Charlson Comorbidity Index was 3.0 (2.7). The mean number of spinal levels operated on was 6.9 (4.3). Seven cases (19.4%) were revision surgeries. The mean intraoperative blood loss was 587.1 (900.0) mL, and total blood loss was 623.8 (991.9) mL. Postoperatively, time to ambulation was on average 1.7 (1.7) days. The mean total length of stay was 9.8 days (7.9, range 2-41). The most common indication for surgery was tumor (n = 9, 25%), followed by fracture (n = 8, 22.2%), deformity (n = 7, 19.4%), pseudarthrosis (n = 6, 16.7%), and symptomatic lumbar disc herniation (n = 2, 5.6%). There were no thromboembolic or other significant complications among the 36 patients. CONCLUSIONS This retrospective case series demonstrates that the use of high-dose TXA provides is potentially safe and efficacious in adult patients undergoing complex spine surgeries. However, further investigations are required before the true safety and optimal dosing can be determined for high-dose TXA.
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Affiliation(s)
- Nolan J Brown
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Zach Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander S Himstead
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Chen Yi Yang
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Sachiv Chakravarti
- Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland, USA
| | - Julian Gendreau
- Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland, USA
| | - Joshua Kurtz
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Shane Shahrestani
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Martin H Pham
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA
| | - Joseph A Osorio
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA.
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13
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Ye IB, Thomson AE, Smith RA, Pease TJ, Chowdhury N, Donahue J, Miseo V, Jauregui JJ, Cavanaugh DL, Koh EY, Ludwig SC. FLOSEAL Versus SURGIFLO in Lumbar Surgery: Similar Outcomes, Different Costs in a Matched Cohort Analysis. World Neurosurg 2023; 177:e425-e432. [PMID: 37356481 DOI: 10.1016/j.wneu.2023.06.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE Flowable gelatin-based matrices with thrombin for hemostatic control are commercially available as Floseal (Baxter International Inc.) and Surgiflo (Ethicon Inc.). The objective of this study is to compare the rate of blood transfusions following the use of Floseal and Surgiflo in lumbar spine surgery. METHODS Elective lumbar spine surgery patients between September 2019 and March 2021 were identified via CPT codes. Floseal 10 mL (N=102) and Surgiflo matrix 8 mL (N=108) cohorts excluded those younger than 18 years or those who underwent surgeries for infection, trauma, or tumor. The primary outcome was blood transfusion. Surgical complexity was controlled using the Surgical Invasiveness Index and Adult Spinal Deformity Invasiveness Score. The 1:1 propensity score matching was performed using demographic information, Surgical Invasiveness Index, Adult Spinal Deformity Invasiveness Score, and tranexamic acid use. RESULTS A total of 77 Floseal patients were propensity score matched with 77 Surgiflo patients. There was no difference in the rate of blood transfusion (p=0.441). There was also no difference in operative time, estimated blood loss, or postoperative hemoglobin levels. The Surgiflo cohort used more units per surgery (p=0.004) and cost $102.45 more per surgery. Switching to Floseal saves $102,450 per year per 1000 surgeries. CONCLUSIONS There was no difference in transfusion rates between using Floseal or Surgiflo for lumbar spine surgery. Surgiflo had higher usage per surgery and costs than Floseal.
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Affiliation(s)
- Ivan B Ye
- Spine Surgery Division, Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Alexandra E Thomson
- Spine Surgery Division, Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Ryan A Smith
- Spine Surgery Division, Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Tyler J Pease
- Spine Surgery Division, Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Navid Chowdhury
- Spine Surgery Division, Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Jack Donahue
- Spine Surgery Division, Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Vincent Miseo
- Spine Surgery Division, Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Julio J Jauregui
- Spine Surgery Division, Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Daniel L Cavanaugh
- Spine Surgery Division, Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Eugene Y Koh
- Spine Surgery Division, Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Steven C Ludwig
- Spine Surgery Division, Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA.
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14
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Akosman I, Lovecchio F, Fourman M, Sarmiento M, Lyons K, Memtsoudis S, Kim HJ. Is High-Dose Tranexamic Safe in Spine Surgery? A Systematic Review and Meta-Analysis. Global Spine J 2023; 13:2085-2095. [PMID: 36592635 PMCID: PMC10556905 DOI: 10.1177/21925682221148686] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
STUDY DESIGN Literature review and meta-analysis. OBJECTIVES Single-center series may be underpowered to detect whether high-dose (HD) tranexamic acid (TXA) confers a higher risk of complications. We sought to determine the safety and efficacy of HD TXA as compared to low-dose (LD) or placebo. METHODS A systematic literature review was performed to find studies where spine surgery patients were given HD TXA (loading dose ≥30 mg/kg). Complication rates were pooled, and meta-analyses performed on outcomes of interest. Articles were evaluated for risk of bias and a strength of evidence assessment was given for each conclusion. RESULTS Twenty three studies (n = 2331) were included. The pooled medical complication rate was 3.2% in pediatric patients, 8.2% in adults. Using lower dose TXA or placebo as the reference, meta-analysis showed no difference in medical complications (n = 1,723, OR 1.22 [95% CI, .78 to 1.22]; P = .388; I2 = 0%) or thrombotic events (n = 1158 patients, OR 1.27 [95% CI, .71 to 2.63]; P = .528; I2 = 0%). Compared to LD, HD TXA was associated with less intraoperative blood loss (823 patients, WMD = -285 [95% CI, -564 to -5.90]; P = .0454; I2 = 86%), fewer perioperative transfusions (n = 505, OR .28 [95% CI, .082 to .96]; P = .043; I2 = 76%) and lower perioperative transfusion volumes (n = 434, WMD -227.7 mL [95% CI, -377.3 to -78.02]; P = .0029; I2 = 0%). CONCLUSION Compared to LD TXA or placebo, there is moderate evidence that HD is not associated with an increased risk of medical complications. Compared to LD, there is moderate evidence that HD reduces transfusion requirements. High-Dose TXA can be safely utilized in healthy patients undergoing major spine surgery.
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Affiliation(s)
| | - Francis Lovecchio
- Department of Orthopaedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Mitchell Fourman
- Department of Orthopaedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Manuel Sarmiento
- Department of Orthopaedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Keith Lyons
- Department of Orthopaedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Stavros Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Spine Service, Hospital for Special Surgery, New York, NY, USA
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15
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Shin TJ, Hasnain F, Shay EO, Ye MJ, Matt BH, Elghouche AN. Treatment of post-tonsillectomy hemorrhage with nebulized tranexamic acid: A retrospective study. Int J Pediatr Otorhinolaryngol 2023; 171:111644. [PMID: 37423163 DOI: 10.1016/j.ijporl.2023.111644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE To evaluate the association of treatment with nebulized tranexamic acid (TXA) with rates of operative intervention in post-tonsillectomy hemorrhage (PTH). METHODS Single tertiary-referral center and satellite hospitals, retrospective cohort of adult and pediatric patients who were diagnosed with PTH in 2015-2022 and treated with nebulized TXA and standard care, compared with an age- and gender-matched control cohort treated with standard care. Patients were typically treated in the emergency department with a single dose of 500mg/5 mL TXA delivered via nebulizer. RESULTS 1110 total cases of PTH were observed, and 83 were treated with nebulized TXA. Compared to 249 age- and gender-matched PTH controls, TXA-treated patients had a rate of operating room (OR) intervention of 36.1% versus 60.2% (p < 0.0001) and a rate of repeat bleeding of 4.9% versus 14.2% (p < 0.02). The odds ratio for OR intervention with TXA treatment was 0.37 (95% CI 0.22, 0.63). There were no adverse effects identified with an average follow-up time of 586 days. CONCLUSION Treatment of PTH with nebulized TXA is associated with lower rates of operative intervention and lower rates of repeat bleeding events. Prospective studies are needed to further characterize efficacy and optimal treatment protocols. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Timothy J Shin
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA
| | - Fahad Hasnain
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Elizabeth O Shay
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael J Ye
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bruce H Matt
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alhasan N Elghouche
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA.
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16
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Tan H, Pan S, Wei C, Chen Z, Chen T. Comparative efficacy and safety of different hemostatic medications during spinal surgery: A network meta-analysis. Medicine (Baltimore) 2023; 102:e32923. [PMID: 36862901 PMCID: PMC9981439 DOI: 10.1097/md.0000000000032923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/20/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Significant blood loss is still one of the most frequent issues in spinal surgery. There were different hemostatic methods to prevent blood loss during spinal surgery. However, the optimal hemostatic therapy for spinal surgery is controversial. The purpose of this study was to assess the efficacy and safety of different hemostatic therapies in spinal surgery. METHODS Two independent reviewers conducted electronic literature searches in 3 electronic databases (PubMed, Embase, and Cochrane library database) as well as a manual search to identify eligible clinical studies from inception to Nov 2022. Studies that including different hemostatic therapy (tranexamic acid [TXA], epsilon-acetyl aminocaproic acid [EACA], and aprotinin [AP]) for spinal surgery were included. The Bayesian network meta-analysis was performed with a random effects model. The surface under the cumulative ranking curve (SUCRA) analysis was performed to determine the ranking order. All analyses were performed by R software and Stata software. P value less than .05 was identified as statistically significant. RESULTS Finally, a total of 34 randomized controlled trials met the inclusion criteria and finally included in this network meta-analysis. The SUCRA shows that TXA ranked first (SUCRA, 88.4%), AP ranked second (SUCRA, 71.6%), EACA ranked third (SUCRA, 39.9%), and placebo ranked the last (SUCRA, 0.3%) as for total blood loss. The SUCRA shows that TXA ranked first (SUCRA, 97.7%), AP ranked second (SUCRA, 55.8%), EACA ranked third (SUCRA, 46.2%), and placebo ranked the last (SUCRA, 0.2%) for need for transfusion. CONCLUSIONS TXA appears optimal in the reduction of perioperative bleeding and blood transfusion during spinal surgery. However, considering the limitations in this study, more large-scale, well-designed randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Haitao Tan
- Department of Spinal Surgery, The First Affiliated Hospital of Hainan Medical University (Hainan Province Clinical Medical Center), Haikou, China
| | - Songli Pan
- Department of Spinal Surgery, The First Affiliated Hospital of Hainan Medical University (Hainan Province Clinical Medical Center), Haikou, China
| | - Chuanchun Wei
- Department of Anesthesia and Operation, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Zhilin Chen
- Department of Breast surgery, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Tao Chen
- Department of Spinal Surgery, The First Affiliated Hospital of Hainan Medical University (Hainan Province Clinical Medical Center), Haikou, China
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17
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Schupper AJ, Kaufman M, Reidler JS, Arginteanu MS, Moore FM, Steinberger A, Syed ON, Yao KC, Gologorsky Y. Spinal deformity surgery in patients for whom blood transfusion is not an option: a single-center experience. J Neurosurg Spine 2023; 38:348-356. [PMID: 36866794 DOI: 10.3171/2022.11.spine221061] [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: 09/21/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Spinal deformity surgery is associated with significant blood loss, often requiring the transfusion of blood and/or blood products. For patients declining blood or blood products, even in the face of life-threatening blood loss, spinal deformity surgery has been associated with high rates of morbidity and mortality. For these reasons, patients for whom blood transfusion is not an option have historically been denied spinal deformity surgery. METHODS The authors retrospectively reviewed a prospectively collected data set. All patients declining blood transfusion who underwent spinal deformity surgery at a single institution between January 2002 and September 2021 were identified. Demographics collected included age, sex, diagnosis, details of any prior surgery, and medical comorbidities. Perioperative variables included levels decompressed and instrumented, estimated blood loss, blood conservation techniques used, length of surgery, length of hospital stay, and complications from surgery. Radiographic measurements included, where appropriate, sagittal vertical axis correction, Cobb angle correction, and regional angular correction. RESULTS Spinal deformity surgery was performed in 31 patients (18 male, 13 female) over 37 admissions. The median age at surgery was 41.2 years (range 10.9-70.1 years), and 64.5% had significant medical comorbidities. A median of 9 levels (range 5-16 levels) were instrumented per surgery, and the median estimated blood loss was 800 mL (range 200-3000 mL). Posterior column osteotomies were performed in all surgeries, and pedicle subtraction osteotomies in 6 cases. Multiple blood conservation techniques were used in all patients. Preoperative erythropoietin was administered prior to 23 surgeries, intraoperative cell salvage was used in all, acute normovolemic hemodilution was performed in 20, and perioperative administration of antifibrinolytic agents was performed in 28 surgeries. No allogenic blood transfusions were administered. Surgery was staged intentionally in 5 cases, and there was 1 unintended staging due to intraoperative blood loss from a vascular injury. There was 1 readmission for a pulmonary embolus. There were 2 minor postoperative complications. The median length of stay was 6 days (range 3-28 days). Deformity correction and the goals of surgery were achieved in all patients. Two patients underwent revision surgery during the follow-up period: one for pseudarthrosis and the other for proximal junctional kyphosis. CONCLUSIONS With proper preoperative planning and judicious use of blood conservation techniques, spinal deformity surgery may be performed safely in patients for whom blood transfusion is not an option. The same techniques can be applied widely to the general population in order to minimize blood loss and the need for allogeneic blood transfusion.
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Affiliation(s)
| | - Margit Kaufman
- and Departments of2Anesthesiology and Critical Care Medicine
| | - Jay S Reidler
- 3Orthopaedic Surgery, Mount Sinai Health System, New York, New York
- 4Orthopaedic Surgery, and
| | - Marc S Arginteanu
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Frank M Moore
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Alfred Steinberger
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Omar N Syed
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Kevin C Yao
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Yakov Gologorsky
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
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18
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Luan H, Liu K, Peng C, Tian Q, Song X. Efficacy and safety of tranexamic acid in posterior lumbar interbody fusion: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2023; 18:14. [PMID: 36604661 PMCID: PMC9817320 DOI: 10.1186/s13018-022-03493-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/30/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of tranexamic acid (TXA) in hemostasis in patients undergoing posterior lumbar interbody fusion (PLIF) by meta-analysis. METHODS This study was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42022354812). The databases PubMed, Cochrane Library, Web of Science, and Embase were searched for randomized controlled trial (RCT) papers on the use of TXA in patients with PLIF from database establishment to August 2022. Two researchers screened the literature, extracted data, evaluated the risk of bias of the included studies, recorded the authors, sample size, type of study design, and TXA dose of each study, and extracted the intraoperative blood loss, number of blood transfusions, total blood loss, drainage volume, operation time, and incidence of deep venous thrombosis in each study. Meta-analysis was performed using RevMan 5.4 software provided by Cochrane Library. RESULTS A total of 14 RCTs with a total of 1681 patients were included in this study, including 836 patients in the TXA group and 845 patients in the control group. The intraoperative blood loss [mean difference (MD) = - 125.97, 95% confidence interval (CI) (- 138.56, - 113.37), P < 0.0001] and less total blood loss [MD = - 204.28, 95% CI (- 227.38, - 181.18), P < 0.00001] in TXA group were lower than the control group. Statistical significance was also observed in postoperative drainage volume [MD = - 115.03, 95% CI (- 123.89, - 106.17), P < 0.00001], operation time [MD = - 8.10, 95% CI (- 14.49, - 1.71), P = 0.01], and blood transfusion rate [odds ratio (OR) = 0.30, 95% CI (0.23, 0.39), P < 0.00001]. However, there was no statistical difference observed in the incidence of deep venous thrombosis [OR = 0.83, 95% CI (0.56, 1.21), P = 0.33]. CONCLUSION The application of TXA in PLIF can reduce intraoperative blood loss, total blood loss, drainage volume, the incidence of transfusion events, and operation time without increasing the risk of deep venous thrombosis.
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Affiliation(s)
- Haopeng Luan
- grid.13394.3c0000 0004 1799 3993Department of Spine Surgery, The Six Affiliated Hospital of Xinjiang Medical University, Ürümqi, 830002 Xinjiang China
| | - Kai Liu
- grid.412631.3Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, 830054 Xinjiang China
| | - Cong Peng
- grid.13394.3c0000 0004 1799 3993Department of Spine Surgery, The Six Affiliated Hospital of Xinjiang Medical University, Ürümqi, 830002 Xinjiang China
| | - Qi Tian
- grid.412631.3Department of Bone Tumor Surgery, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, 830054 Xinjiang China
| | - Xinghua Song
- grid.13394.3c0000 0004 1799 3993Department of Spine Surgery, The Six Affiliated Hospital of Xinjiang Medical University, Ürümqi, 830002 Xinjiang China
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Avila MJ, Orenday-Barraza JM, Cavagnaro MJ, Strouse IM, Farhadi DS, Khan N, Hussein A, Baaj AA. Antifibrinolytics use during surgery for oncological spine diseases: A systematic review. Surg Neurol Int 2022; 13:567. [PMID: 36600747 PMCID: PMC9805626 DOI: 10.25259/sni_837_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 11/17/2022] [Indexed: 12/03/2022] Open
Abstract
Background Data exist of the benefits of antifibrinolytics such as tranexamic acid (TXA) in general spine surgery. However, there are limited data of its use in oncological spine patients. Methods A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Cochrane, OVID, and Embase databases were searched. Search terms: "tranexamic acid", "aprotinin," "aminocaproic acid," "spine surgery," "spine tumors," and "spine oncology." Included studies were full text publications written in English with patients treated with either agent or who had surgery for oncological spine disease (OSD). Results Seven hundred results were reviewed form the different databases, seven were selected. A total of 408 patients underwent spine surgery for OSD and received antifibrinolytics. There was a male predominance (55.2%) and mean age ranged from 43 to 62 years. The most common tumor operated was metastatic renal cancer, followed by breast and lung. Most studies administered TXA as a bolus followed by an infusion during surgery. Median blood loss was of 667 mL (253.3-1480 mL). Patients with TXA required 1-2 units less of transfusion and had 56-63 mL less of postoperative drainage versus no TXA. The median incidence of deep venous thrombosis (DVT) was 2.95% (0-7.9%) and for pulmonary embolism (PE) was 4.25% (0-14.3%). The use of TXA reduced intraoperative blood loss, transfusions and reduced postoperative surgical drainage output compared to no TXA use in patients with OSD. Conclusion In this review, we found that TXA may diminish intraoperative blood loss, the need for transfusion and postoperative drainage from surgical drains when used in OSD without major increase in rates of DVT or PE.
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Affiliation(s)
- Mauricio J. Avila
- Department of Neurosurgery, University of Arizona, Tucson, United States.,Corresponding author: Mauricio J. Avila, Department of Neurosurgery, University of Arizona, Tucson, Arizona, United States.
| | | | | | - Isabel M. Strouse
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, United States
| | - Dara S. Farhadi
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, United States
| | - Naushaba Khan
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, United States
| | - Amna Hussein
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, United States
| | - Ali A. Baaj
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, United States
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20
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Cao Z, Li Q, Guo J, Li Y, Wu J. Optimal administration strategies of tranexamic acid to minimize blood loss during spinal surgery: results of a Bayesian network meta-analysis. Ann Med 2022; 54:2053-2063. [PMID: 35862264 PMCID: PMC9307111 DOI: 10.1080/07853890.2022.2101687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Tranexamic acid (TXA) has been widely used for bleeding reduction in spinal surgery. Available evidence is insufficient to inform clinical decisions making and there remains a lack of comprehensive comparisons of dose regimens and delivery routes. This study is aimed to assess and compare different strategies regarding the involvement of TXA in spinal surgery for the optimal pathway of efficacy and safety. MATERIALS AND METHODS Cochrane Library, PubMed, Embase, Scopus and CNKI were searched for the period from January 1990 to October 2021. A random-effect model was built in the Bayesian network meta-analysis. The surface under the cumulative ranking analysis (SUCRA) and clustering rank analysis was performed for ranking the effects. RESULTS The current network meta-analysis incorporated data from 33 studies with 3302 patients. Combination administration showed superior effects on reducing intraoperative bleeding (SUCRA 78.78%, MD -129.67, 95% CI [(-222.33, -40.58)]) than placebo, and was ranked as top in reducing postoperative bleeding (SUCRA 86.91%, MD -169.92, 95% CI [(-262.71, -83.52)]), changes in haemoglobin (SUCRA 97.21%, MD -1.28, 95% CI [(-1.84, -0.73)]), and perioperative blood transfusion (SUCRA 93.23%, RR 0.10, 95% CI [(0.03, 0.25)]) simultaneously, and was shown as the best effectiveness and safety (cluster-rank value for IBL and VTE: 4057.99 and for TRF and VTE: 4802.26). CONCLUSIONS Intravenous (IV) plus topical administration of TXA appears optimal in the reduction of perioperative bleeding and blood transfusion, while the local infiltration administration is not effective for blood conservation. Further studies are required to verify the current findings.
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Affiliation(s)
- Ziqin Cao
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha, P. R. China
| | - Qiangxiang Li
- Ningxia Geriatric Disease Clinical Research Center, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, P. R. China.,National Clinical Research Center for Geriatric Disorders of Xiangya Hospital, Central South University (Sub-Center of Ningxia), Yinchuan, P. R. China.,Department of Hunan Institute of Geriatrics, Hunan People's Hospital, Changsha, P. R. China
| | - Jia Guo
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, P. R. China
| | - Yajia Li
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, P. R. China
| | - Jianhuang Wu
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha, P. R. China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, P. R. China
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21
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Clohisy JCF, Lenke LG, Dafrawy MHE, Wolfe RC, Frazier E, Kelly MP. Randomized, controlled trial of two tranexamic acid dosing protocols in adult spinal deformity surgery. Spine Deform 2022; 10:1399-1406. [PMID: 35751772 DOI: 10.1007/s43390-022-00539-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/28/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an anti-fibrinolytic effective in reducing blood loss in orthopedic surgery. The appropriate dosing protocol for adult spinal deformity (ASD) surgery is not known. The purpose of this study was to evaluate two TXA protocols [low dose (L): 10 mg/kg bolus, 1 mg/kg/hr infusion; high dose (H): 50 mg/kg, 5 mg/kg/hr] in complex ASD surgery. METHODS Inclusion criteria were ASD reconstructions with minimum 10 fusion levels or planned 3-column osteotomy (3CO). Standard demographic and surgical data were collected. Intraoperative estimated blood loss (EBL) was calculated by suction canisters minus irrigation plus estimated blood lost in sponges, estimated to the nearest 50 mL. Serious adverse events (SAE) were defined a priori as: venothromboembolic event (VTE), cardiac arrhythmia, myocardial infarction, renal dysfunction, and seizure. All SAE were recorded. Simple t tests compared EBL between groups. Mean EBL by total blood volume (TBV), transfusion volume, complications related to TXA were secondary outcomes. RESULTS Sixty-two patients were enrolled and 52 patients completed the study; 25 were randomized to H and 27 to L. Demographic and surgical variables were not different between the two groups. EBL was not different between groups (H: 1596 ± 933 cc, L: 2046 ± 1105 cc, p = 0.12, 95% CI: - 1022 to 122 cc). EBL as a percentage of TBV was lower for the high-dose group (H: 29.5 ± 14.8%, L: 42.5 ± 26.2%, p = 0.03). Intraoperative transfusion volume (H: 961 ± 505 cc, L: 1105 ± 808 cc, p = 0.5) and post-operative transfusion volume (H: 513 ± 305 cc, L: 524 ± 245 cc, p = 0.9) were not different. SAE related to TXA were not different (p = 0.7) and occurred in 2 (8%) H and 3 (11%) L. There was one seizure (H), 2 VTE, and 2 arrhythmias. CONCLUSION No differences in EBL, transfusion volume, nor SAE were observed between H and L dose TXA protocols. High dose was associated with decreased TBV loss (13%). Further prospective study, with pharmacologic analysis, is required to determine appropriate TXA dosage in ASD surgeries. LEVEL OF EVIDENCE Therapeutic Level II. TRIAL REGISTRATION The study was registered at Clinicaltrials.gov (NCT02053363) February 3, 2014.
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Affiliation(s)
- John C F Clohisy
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | | | - Rachel C Wolfe
- Perioperative Services and Surgical Critical Care, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Elfaridah Frazier
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael P Kelly
- Rady Children's Hospital, University of California, 3020 Children's Way, San Diego, CA, 92123, USA.
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22
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Lin GX, Chen CM, Zhu MT, Zheng L. The Safety and Effectiveness of Tranexamic Acid in Lumbar Interbody Fusion Surgery: An Updated Meta-analysis of Randomized Controlled Trials. World Neurosurg 2022; 166:198-211. [PMID: 36084620 DOI: 10.1016/j.wneu.2022.07.139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 07/29/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Several previous meta-analyses have been published, followed by additional randomized clinical trials investigating the effects of tranexamic acid (TXA) in patients undergoing posterior lumbar interbody fusion (PLIF) surgery. As a result, the purpose of this research is to present an updated quantitative analysis of the existing literature and to further explicate its effectiveness. METHODS PubMed, Embase, Web of Science, and Cochrane Library databases were searched for randomized controlled trials (RCTs) comparing the application of TXA and placebo in patients undergoing PLIF surgery from their establishment to December 31, 2021. Data on clinical outcomes, perioperative outcomes, and complications were collected. The summary statistics for continuous and dichotomous variables were derived as weighted mean difference (WMD) and relative risk (RR), respectively. RESULTS A total of 12 studies enrolling 1088 participants were included in this meta-analysis. The combined results revealed that TXA can decrease intraoperative blood loss (WMD: -84.83, P < 0.0001), total blood loss (WMD: -189.93, P < 0.00001), hidden blood loss (WMD: -134.69, P = 0.002), postoperative drainage (WMD: -100.71, P < 0.00001), postoperative hemoglobin loss (WMD: 6.21, P < 0.00001), operative time (WMD: -3.80, P = 0.007), hospital stay (WMD: -1.86, P = 0.001), and transfusion rates (RR: 0.41, P < 0.00001) in PLIF without increasing the risk of thromboembolic events (RR: 0.80, P = 0.43). CONCLUSIONS TXA can considerably decrease surgical blood loss, postoperative drainage, reduce operative times, hospital stays, and transfusion rates. Furthermore, the TXA group had lower postoperative hemoglobin drop values than the placebo group.
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Affiliation(s)
- Guang-Xun Lin
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China; The Third Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Chien-Min Chen
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan; Department of Leisure Industry Management, National Chin-Yi University of Technology, Taichung, Taiwan; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Tao Zhu
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Linfei Zheng
- Department of Neurosurgery, Fuzhou Second Hospital of Xiamen University, School of Medicine, Xiamen University, Fuzhou, China; Fuzhou Second Hospital, Fuzhou, China; Fujian Provincial Clinical Medical Research Center for First Aid and Rehabilitation in Orthopaedic Trauma (2020Y2014), Fuzhou, China.
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23
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Liu ZG, Yang F, Zhu YH, Liu GC, Zhu QS, Zhang BY. Is Tranexamic Acid Beneficial in Open Spine Surgery? and its Effects Vary by Dosage, Age, Sites, and Locations: A Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2022; 166:141-152. [PMID: 35843575 DOI: 10.1016/j.wneu.2022.07.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The role of tranexamic acid (TXA) in controlling blood loss during spine surgery remains unclear. With the publication of new randomized controlled trials (RCTs), we conducted a meta-analysis to determine the safety and efficacy of TXA in spine surgery. METHODS PubMed, Embase, Web of Science, and Cochrane databases were searched for relevant studies through 2022. Only RCTs were eligible for this study. The extracted data were analyzed using RevMan 5.3 software for meta-analysis. RESULTS Twenty RCTs including 1497 patients undergoing spine surgery were included in this systematic evaluation. Compared with the control group, TXA significantly reduced total blood loss (mean difference [MD] = - 218.96, 95% confidence interval [CI] = - 309.77 to - 128.14, P < 0.00001), perioperative blood loss (MD = - 90.54, 95% CI = - 139.33 to - 41.75, P = 0.0003), postoperative drainage (MD = - 102.60, 95% CI = - 139.51 to - 65.70, P < 0.00001)，reduced hospital stay (MD = - 1.42, 95% CI = - 2.71 to - 0.14, P = 0.03), reduced total blood transfusion volume (MD = - 551.06, 95% CI = - 755.90 to - 346.22, P < 0.00001), and international normalized ratio (MD = -0.03, 95% CI = -0.04 to -0.02, P < 0.00001). CONCLUSIONS Based on the meta-analysis of 20 RCTs, we demonstrated that TXA reduces blood loss in open spine surgery, decreases transfusion rates, and shortens hospital stays. The TXA administration during the perioperative period does not increase the incidence of postoperative complications.
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Affiliation(s)
- Zhen-Gang Liu
- Department of Orthopaedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Fan Yang
- Department of Orthopaedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Yu-Hang Zhu
- Department of Orthopaedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Guang-Chen Liu
- Department of Orthopaedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Qing-San Zhu
- Department of Orthopaedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Bo-Yin Zhang
- Department of Orthopaedics, China-Japan Union Hospital of Jilin University, Changchun, China.
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24
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Kanhere AP, Lambrechts MJ, Issa TZ, Karamian BA, Hendow CJ, Reddy YC, Slota PJ, D'Antonio ND, Kaye ID, Canseco JA, Woods BI, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. The Effect of Tranexamic Acid on Operative and Postoperative Blood Loss in Transforaminal Lumbar Interbody Fusions. World Neurosurg 2022; 166:e443-e450. [PMID: 35840090 DOI: 10.1016/j.wneu.2022.07.020] [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: 05/18/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The purpose of this retrospective cohort study was to evaluate the effect of tranexamic acid (TXA) on reducing perioperative blood loss and length of stay after transforaminal lumbar interbody fusion (TLIF). Spine surgery is associated with the potential for significant blood loss, and adequate hemostasis is essential to visualizing crucial structures during the approach and procedure. Although TXA use has been extensively studied in the pediatric and adult spinal deformity literature, there is a dearth of literature on its efficacy in reducing blood loss for patients who undergo 1- to 3-level TLIF. METHODS All patients requiring 1- to 3-level TLIF who received a preoperative loading dose of TXA were grouped and compared with patients who didn't receive TXA. Demographic, surgical, and laboratory values were collected and analyzed. Continuous and categorical variables were analyzed with χ2, Kruskal-Wallis, or analysis of variance tests, depending on normality and data type. Multiple linear regressions were developed to determine independent predictors of the estimated blood loss (EBL), total blood loss, drain output, and length of stay. Statistical significance was set at P < 0.05. RESULTS Patients who received preoperative TXA had more comorbidities (P = 0.006), longer surgery length (P < 0.001), and longer length of stay (P = 0.004). TXA was independently associated with a decreased day 0, 1, 2, and total drain output (P < 0.001, P = 0.001, P = 0.007, P < 0.001, respectively), but was not associated with a change in EBL, total blood loss, or length of stay. CONCLUSIONS The application of preoperative TXA for patients undergoing 1- to 3-level TLIF reduced drain output in the first 2 postoperative days, but it did not affect hospital length of stay, total blood loss, or EBL.
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Affiliation(s)
- Arun P Kanhere
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Tariq Ziad Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Chelsea J Hendow
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yashas C Reddy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Paul J Slota
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nicholas D D'Antonio
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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25
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Johns WL, Walley KC, Jackson B, Gonzalez TA. Tranexamic Acid in Foot and Ankle Surgery: A Topical Review and Value Analysis. Foot Ankle Spec 2022; 15:377-383. [PMID: 33401927 DOI: 10.1177/1938640020983639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tranexamic acid (TXA) has become a commonly used perioperative intervention in total joint arthroplasty, shoulder and knee arthroscopy, and spinal procedures in order to minimize blood loss, hematoma formation, hemarthrosis, and wound healing complications. There is a potential role for TXA use in foot and ankle procedures, with limited studies suggesting a potential benefit in minimizing postoperative wound complications and blood loss without an increased risk of thromboembolic events. In light of the profound clinical and financial impact of TXA use in other orthopaedic subspecialties and the early successes in foot and ankle surgery, we aim to provide more information about TXA and its use in foot and ankle surgery. Therefore, the purpose of this review is to perform a comprehensive literature review on the topic of TXA use in foot and ankle procedures in order to describe the pertinent available literature on the use of TXA in orthopaedic surgery and its implications specifically in foot and ankle surgery. It is our aim to identify potential benefits and shortcomings in the available evidence on TXA use for foot and ankle surgery in hopes to (1) best inform foot and ankle surgeons where beneficial and safe and (2) inspire further research on this topic as it relates to clinical management for foot and ankle patients.Levels of Evidence: Level IV.
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Affiliation(s)
- William L Johns
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Kempland C Walley
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Benjamin Jackson
- School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Tyler A Gonzalez
- School of Medicine, University of South Carolina, Columbia, South Carolina
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26
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Zheng B, Zheng B, Niu H, Wang X, Lv G, Li J, Wang J. Effect Analysis of Preoperative Intravenous Tranexamic Acid Combined With Intraoperative Immersion in Reducing Perioperative Blood Loss of One Stage Posterior Thoracolumbar Tuberculosis. Front Surg 2022; 9:852589. [PMID: 35813048 PMCID: PMC9260174 DOI: 10.3389/fsurg.2022.852589] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/06/2022] [Indexed: 11/16/2022] Open
Abstract
Background To investigate the efficacy and safety of preoperative intravenous tranexamic acid (TXA) combined with intraoperative immersion in reducing perioperative blood loss in one-stage posterior thoracolumbar tuberculosis. Methods All patients were divided into four groups: Group A received an intravenous drip of TXA before surgery, group B received multiple local immersions during the operation, group C received an intravenous drip combined with multiple local immersions, and the control group (group CG) were not treated with TXA during the same period. The total blood loss (TBL), intraoperative blood loss (IBL), hidden blood loss (HBL), postoperative drainage volume, maximum hemoglobin drop value (max Hb drop), liver and kidney function, coagulation indexes, blood transfusion rate, hospital stay and incidence of complications were compared among the four groups. Results TBL, IBL, HBL, max Hb drop, POD1 drainage, and POD2 drainage in group A, group B, and group C were significantly lower than those in group CG. TBL, IBL, HBL and max Hb drop were group C < group A < group B < group CG. The drainage volume of group C was significantly lower than that of the other groups. There was no significant difference in blood coagulation index (PT, D-D) or liver and kidney function (ALT, Cr) among the four groups. There was no difference in postoperative hospital stay between group A and group B, but it was significantly lower in group C than in the other three groups. All patients achieved satisfactory bone graft fusion at the last follow-up. Conclusion Preoperative intravenous drip of TXA combined with intraoperative multiple immersion can effectively reduce perioperative blood loss while not increasing the risk of thrombosis without affecting liver and kidney function, coagulation function or tuberculosis prognosis.
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Affiliation(s)
- Bowen Zheng
- Department of Spine Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Musculoskeletal Tumor Center, Peking University People's Hospital, Peking University, Beijing, China
| | - Boyv Zheng
- Department of Orthopedics Surgery, General Hospital of the Central Theater Command, Wuhan, China
| | - Huaqing Niu
- Department of Orthopedics Surgery, General Hospital of the Central Theater Command, Wuhan, China
| | - Xiaobin Wang
- Department of Spine Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Guohua Lv
- Department of Spine Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jing Li
- Department of Spine Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Correspondence: Jing Li Jingyu Wang
| | - Jingyu Wang
- Department of Spine Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
- Correspondence: Jing Li Jingyu Wang
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27
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Oyama R, Setsu N, Matsumoto Y, Endo M, Fujiwara T, Iida K, Nabeshima A, Nakashima Y. Efficacy and safety of tranexamic acid in patients undergoing surgery for bone and soft tissue tumors: a propensity score matching analysis. Jpn J Clin Oncol 2022; 52:1029-1038. [DOI: 10.1093/jjco/hyac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/23/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
The aim of this study was to investigate the efficacy and safety of tranexamic acid in patients undergoing surgery for bone and soft tissue tumors.
Methods
Data were retrospectively collected from 454 consecutive patients with bone and soft tissue tumors who underwent open biopsy, marginal resection, curettage or wide resection between January 2017 and December 2018. We performed propensity score matching of patients who received tranexamic acid with those who did not. The primary outcome variables were intra-operative, peri-operative and estimated blood loss (IBL, PBL and EBL, respectively).
Results
Tranexamic acid (+) and tranexamic acid (−) groups were defined according to whether patients received tranexamic acid or not. Among the 454 patients, open biopsy was performed in 102, marginal resection in 175, curettage in 54 and wide resection in 123. Intra-operative blood loss was significantly lower in the tranexamic acid (+) group than in the tranexamic acid (−) group for both marginal and wide resection (marginal resection: 17.3 vs. 70.3 g, respectively, P = 0.045; wide resection: 128.8 vs. 273.1 g, respectively, P = 0.023). Peri-operative blood loss and estimated blood loss were also significantly lower in the tranexamic acid (+) group for wide resection (peri-operative blood loss: 341.5 vs. 686.5 g, respectively, P = 0.0039; estimated blood loss: 320.7 vs. 550.6 ml, respectively, P = 0.030). No venous thromboembolism occurred in either group.
Conclusion
This study suggests that TXA administration safely and effectively reduces blood loss, in particular for wide resection, with no increase in the rate of adverse events.
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Affiliation(s)
- Ryunosuke Oyama
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nokitaka Setsu
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Orthopaedic Surgery, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Yoshihiro Matsumoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Makoto Endo
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshifumi Fujiwara
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keiichiro Iida
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akira Nabeshima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Lei T, Bingtao W, Zhaoqing G, Zhongqiang C, Xin L. The efficacy and safety of intravenous tranexamic acid in patients with posterior operation of multilevel thoracic spine stenosis: a prospective randomized controlled trial. BMC Musculoskelet Disord 2022; 23:410. [PMID: 35501751 PMCID: PMC9063045 DOI: 10.1186/s12891-022-05361-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/25/2022] [Indexed: 01/11/2023] Open
Abstract
Background This study was a randomized controlled trial to evaluate efficacy and safety of the usage of intravenous tranexamic acid during posterior operation of multilevel thoracic spine stenosis for controlling perioperative blood loss. Methods Sixty eight patients with multilevel thoracic spine stenosis were randomized into the tranexamic acid group receiving 15 mg/kg body weight before the skin incision was made and 1 mg/kg body weight per hour during operation or the control group receiving the same dose of placebo (0.9% sodium chloride solution) intravenously. Pedicle screw fixation, laminectomy and selective discectomy were performed. Intraoperative and perioperative total blood loss were compared. The necessity and amount for blood transfusion, blood coagulation function, durations of postoperative hospital stays were compared. The complications of tranexamic acid were also investigated such as cardiovascular and cerebrovascular events, lower limb venous thrombosis. Results There were no statistically significant differences in age, gender, body mass index, ASA status, pathology required surgery, preoperative hemoglobin, operation time, laminectomy segments and discectomy segments between the tranexamic acid and control groups. The intraoperative blood loss (455.9 ± 206.6 ml vs 580.6 ± 224.3 ml, p < 0.05) and total blood loss (675.3 ± 170.3 ml vs 936.8 ± 306.4 ml, p < 0.01) in tranexamic acid group were significant lower than those in control group. The means of blood unit transfused (2.5 ± 1.0 vs 4.7 ± 2.4, p < 0.05) and Hb reduction in 48 h (22.5 ± 3.4 g/L vs 25.3 ± 3.9 g/L, p < 0.01) were significantly lower in tranexamic acid group than that in control group. There were no statistically significant differences in blood coagulation function pre-operation or 48 h post-operation between the tranexamic acid and the control groups. The requirements for patients to receive blood transfusion were fewer and durations of post-operational hospital stays were shorter in the tranexamic acid group, however, the difference did not achieve statistical significance. There was no significant difference in superficial or deep venous thrombosis of lower limbs or deterioration of neurological function between tranexamic acid group and control group. Conclusions Application of intravenous tranexamic acid significantly reduces intraoperative and perioperative total blood loss without significant side effects in posterior operation of multilevel thoracic spine stenosis. Trial registration At Chinese Clinal Trial Registry. http://www.chictr.org.cn/, ChiCTR2100054221. Registered on 11/12/2021. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05361-2.
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Affiliation(s)
- Tan Lei
- Department of Orthopaedics, Peking University International Hospital, Life Park Road No 1 Life Science Park of Zhong Guancun, Changping District, Beijing, 102206, China
| | - Wen Bingtao
- Department of Orthopaedics, Peking University International Hospital, Life Park Road No 1 Life Science Park of Zhong Guancun, Changping District, Beijing, 102206, China
| | - Guo Zhaoqing
- Department of Orthopaedics, Peking University International Hospital, Life Park Road No 1 Life Science Park of Zhong Guancun, Changping District, Beijing, 102206, China
| | - Chen Zhongqiang
- Department of Orthopaedics, Peking University International Hospital, Life Park Road No 1 Life Science Park of Zhong Guancun, Changping District, Beijing, 102206, China
| | - Liu Xin
- Department of Orthopaedics, Peking University International Hospital, Life Park Road No 1 Life Science Park of Zhong Guancun, Changping District, Beijing, 102206, China.
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Brown NJ, Wilson B, Ong V, Gendreau JL, Yang CY, Himstead AS, Shahrestani S, Shlobin NA, Reardon T, Choi EH, Birkenbeuel J, Cohn SJ, Sahyouni R, Yang I. Use of Tranexamic Acid for Elective Resection of Intracranial Neoplasms: A Systematic Review. World Neurosurg 2022; 160:e209-e219. [PMID: 34995825 DOI: 10.1016/j.wneu.2021.12.117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND As an established antifibrinolytic agent, tranexamic acid (TXA) has garnered widespread use during surgery to limit intraoperative blood loss. In the field of neurosurgery, TXA is often introduced in cases of traumatic brain injury or elective spine surgeries; however, its role during elective cranial surgeries is not well established. We report a systematic review of the use of TXA in elective surgical resection of intracranial neoplasms. METHODS We performed this systematic review following PRISMA guidelines to identify studies investigating the use of TXA in elective neurosurgical resection of intracranial neoplasms. Variables extracted included patient demographics, surgical indications, type of surgery performed, TXA dose and route of administration, operative duration, blood loss, transfusion rate, postoperative hemoglobin level, and complications. RESULTS After careful screening, 4 articles (consisting of 682 patients) met our inclusion/exclusion criteria. The studies included 2 prospective cohort studies, 1 retrospective cohort study, and 1 case series. A χ2 test of pooled data demonstrated that patients administered TXA had a significantly decreased need for blood transfusions during surgery (odds ratio, 0.6273; 95% confidence interval, 0.4254-0.9251; P = 0.018). Mean total blood loss was 821.9 mL in the TXA group and 1099.0 mL in the control group across the studies. There was no significant difference in postoperative hemoglobin levels, with a mean of 11.4 g/dL in both the TXA and control groups. CONCLUSIONS These results support the use of intraoperative TXA in tumor resection. However, its role in tumor resection has been less well investigated compared with its use in other areas of neurosurgery.
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Affiliation(s)
- Nolan J Brown
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Bayard Wilson
- Department of Neurological Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Vera Ong
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Julian L Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA.
| | - Chen Yi Yang
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Alexander S Himstead
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Shane Shahrestani
- Keck School of Medicine of USC, Los Angeles, California, USA; Medical Scientist Training Program, California Institute of Technology, Pasadena, California, USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Taylor Reardon
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, Kentucky, USA
| | - Elliot H Choi
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Jack Birkenbeuel
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Sebastian J Cohn
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ronald Sahyouni
- Department of Neurological Surgery, University of California San Diego, La Jolla, California, USA
| | - Isaac Yang
- Department of Neurological Surgery, University of California Los Angeles, Los Angeles, California, USA
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Synthesis and Hemostatic Activity of New Amide Derivatives. Molecules 2022; 27:molecules27072271. [PMID: 35408669 PMCID: PMC9000710 DOI: 10.3390/molecules27072271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 03/25/2022] [Accepted: 03/26/2022] [Indexed: 11/24/2022] Open
Abstract
Eight dipeptides containing antifibrinolytic agents (tranexamic acid, aminocaproic acid, 4-(aminomethyl)benzoic acid, and glycine—natural amino acids) were synthesized in a three-step process with good or very good yields. DMT/NMM/TsO− (4-(4,6-dimethoxy-1,3,5-triazin-2-yl)-4-methylmorpholinium toluene-4-sulfonate) was used as a coupling reagent. Hemolysis tests were used to study the effects of the dipeptides on blood components. Blood plasma clotting tests were used to examine their effects on thrombin time (TT), prothrombin time (PT), and the activated partial thromboplastin time (aPTT). The level of hemolysis did not exceed 1%. In clotting tests, TT, PT, and aPTT did not differentiate any of the compounds. The prothrombin times for all amides 1–8 were similar. The obtained results in the presence of amides 1–4 and 8 were slightly lower than for the other compounds and the positive control, and they were similar to the results obtained for TA. In the case of amide 3, a significantly decreased aPTT was observed. The aPTTs observed for plasma treated with amide 3 and TA were comparable. In the case of amide 6 and 8, TT values significantly lower than for the other compounds were found. The clot formation and fibrinolysis (CFF) assay was used to assess the influence of the dipeptides on the blood plasma coagulation cascade and the fibrinolytic efficiency of the blood plasma. In the clot formation and fibrinolysis assay, amides 5 and 7 were among the most active compounds. The cytotoxicity and genotoxicity of the synthesized dipeptides were evaluated on the monocyte/macrophage peripheral blood cell line. The dipeptides did not cause hemolysis at any concentrations. They exhibited no significant cytotoxic effect on SC cells and did not induce significant DNA damage.
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Li Y, Zhang Y, Fang X. Acute normovolemic hemodilution in combination with tranexamic acid is an effective strategy for blood management in lumbar spinal fusion surgery. J Orthop Surg Res 2022; 17:71. [PMID: 35123513 PMCID: PMC8817589 DOI: 10.1186/s13018-022-02950-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/21/2022] [Indexed: 11/11/2022] Open
Abstract
Background The retrospective study was designed to compare the effectiveness and safety of acute normovolemic hemodilution (ANH), tranexamic Acid (TXA), and a combination of ANH and TXA in lumbar spinal fusion surgery. Methods Data of 120 patients underwent multi-level posterior spinal fusion for treating degenerative lumbar disease between June 2013 and December 2017 was collected, retrospectively. Four treatment strategies were enrolled, including ANH, TXA, a combination of ANH and TXA, and without any patient blood management. Intraoperative blood loss, hemoglobin and PCV at the end of surgery and at the postoperative first day, and postoperative drain collection, and intraoperative and postoperative transfusion and rate of transfusion were also collected. Results Intraoperative blood loss and postoperative drain collection of the TXA group, ANH combined with TXA group were statistically lower than those in the control group and ANH group (P < 0.05). Intraoperative and postoperative transfusion amount and rate of intra-operative allogenic transfusion of the ANH group, TXA group, and ANH combined with TXA group were statistically lower than those of the control group (P < 0.05). Hemoglobin and PCV at postoperative the first day in the ANH group, TXA group, and ANH combined with TXA group were significant higher than those in the control group (P < 0.05). The combination of TXA and ANH group achieved the lowest intraoperative blood loss, postoperative drain collection and allogenic transfusion rate. Conclusion A combination of TXA and ANH might be an effective strategy for reducing the rate of transfusion and blood loss in patients underwent lumbar spinal fusion surgery.
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Rodríguez-García FA, Sánchez-Peña MA, de Andrea GT, Villarreal-Salgado JL, Álvarez-Trejo HJ, Medina-Quintana VM, García-Valenzuela SE, Morfin-Meza KE, Fierro-Rodríguez DA, Dorado-Hernández E, Bonilla-Catalán PV, Ramos-Maciel J, Romero-Algara E, Jiménez-Pavón KE, Torres-Salazar QL. Efficacy and Safety of Tranexamic Acid for the Control of Surgical Bleeding in Patients Under Liposuction. Aesthetic Plast Surg 2022; 46:258-264. [PMID: 34351508 DOI: 10.1007/s00266-021-02486-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/18/2021] [Indexed: 11/27/2022]
Abstract
Liposuction remains one of the most frequently performed cosmetic surgical procedures and its popularity is increasing every year. However, since its inception, justified concerns regarding patient safety have placed limits on the volume of fat that can be aspirated, influenced by hemodynamic fluctuations and blood loss during liposuction. Tranexamic acid (TXA) is an antifibrinolytic agent that competitively inhibits the conversion of plasminogen to plasmin, thus preventing the binding and degradation of fibrin. Despite the existence of evidence of the effectiveness of TXA in orthopedic and cardiac surgeries, there is little evidence of its use in liposuction. The objective of this study was to evaluate the efficacy and safety of tranexamic acid in the control of surgical bleeding in patients undergoing liposuction, through a prospective, open, randomized and controlled clinical trial. Two groups of 25 participants each were formed to whom the application of TXA in a tumescent solution prior to liposuction or liposuction with the traditional technique was randomly assigned. The results showed a decrease in blood loss reflected by the differences in the final hematocrit values, as well as decrease in the same per aspirated volume (p = 0.003). No adverse events were found related with the TXA application and no blood transfusions were required in this group, in contrast to the control group where the need for blood transfusion was present in 20% of the intervened participants. LEVEL OF EVIDENCE II: 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)
- F A Rodríguez-García
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional "Dr. Valentín Gómez Farias", Av. Soledad Orozco 203, El Capullo, 45100, Zapopan, Guadalajara, Jalisco, México
| | - M A Sánchez-Peña
- Hospital INNOVARE, Av. Verona 7412, Villa Verona, Zapopan, Jalisco, México
| | | | - J L Villarreal-Salgado
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional "Dr. Valentín Gómez Farias", Av. Soledad Orozco 203, El Capullo, 45100, Zapopan, Guadalajara, Jalisco, México
| | - H J Álvarez-Trejo
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional "Dr. Valentín Gómez Farias", Av. Soledad Orozco 203, El Capullo, 45100, Zapopan, Guadalajara, Jalisco, México
| | - V M Medina-Quintana
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional "Dr. Valentín Gómez Farias", Av. Soledad Orozco 203, El Capullo, 45100, Zapopan, Guadalajara, Jalisco, México
| | - S E García-Valenzuela
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional "Dr. Valentín Gómez Farias", Av. Soledad Orozco 203, El Capullo, 45100, Zapopan, Guadalajara, Jalisco, México
| | - K E Morfin-Meza
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional "Dr. Valentín Gómez Farias", Av. Soledad Orozco 203, El Capullo, 45100, Zapopan, Guadalajara, Jalisco, México
| | - D A Fierro-Rodríguez
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional "Dr. Valentín Gómez Farias", Av. Soledad Orozco 203, El Capullo, 45100, Zapopan, Guadalajara, Jalisco, México
| | - E Dorado-Hernández
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional "Dr. Valentín Gómez Farias", Av. Soledad Orozco 203, El Capullo, 45100, Zapopan, Guadalajara, Jalisco, México
| | - P V Bonilla-Catalán
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional "Dr. Valentín Gómez Farias", Av. Soledad Orozco 203, El Capullo, 45100, Zapopan, Guadalajara, Jalisco, México
| | - J Ramos-Maciel
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional "Dr. Valentín Gómez Farias", Av. Soledad Orozco 203, El Capullo, 45100, Zapopan, Guadalajara, Jalisco, México
| | - E Romero-Algara
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional "Dr. Valentín Gómez Farias", Av. Soledad Orozco 203, El Capullo, 45100, Zapopan, Guadalajara, Jalisco, México
| | - K E Jiménez-Pavón
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional "Dr. Valentín Gómez Farias", Av. Soledad Orozco 203, El Capullo, 45100, Zapopan, Guadalajara, Jalisco, México
| | - Q L Torres-Salazar
- Universidad Juárez del Estado de Durango, Calle Paloma No.806, Colonia Fátima, 34060, Durango, Durango, México.
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Kim HJ, Zuckerman SL, Cerpa M, Yeom JS, Lehman RA, Lenke LG. Incidence and Risk Factors for Early Postoperative Complications and Mortality Following Adult Spinal Deformity Surgery: Data From the National Surgical Quality Improvement Program From 2011 to 2013. Clin Spine Surg 2021; 34:E566-E574. [PMID: 34108369 DOI: 10.1097/bsd.0000000000001214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 04/14/2020] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective cohort analysis using the American College of Surgeons National Surgical Quality Improvement Program database. OBJECTIVE The objective of this study was to investigate the incidence and risk factors of perioperative complications and mortality in patients undergoing adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA Although ASD surgery has been associated with a relatively high complication rate, a focus on perioperative complications in a large cohort has rarely been reported. MATERIALS AND METHODS In the database of the 2011-2013 American College of Surgeons National Surgical Quality Improvement Program database, a cohort of patients (n=1484) above 20 years and underwent ASD surgery was established by primary and other Current Procedural Terminology and International Classification of Disease, Ninth Revision codes. The incidences of perioperative (within 30 d postsurgery) minor/major complications and mortality was investigated. Risk factors for minor/major complications and mortality were assessed using logistic regression modeling. RESULTS Of 1484 patients undergoing ASD surgery, the overall complication rate was 15.8% (minor complications: 8.2%; major complications: 10.4%), and the mortality rate was 0.6% (9 patients). After multivariate analysis, dependent functional status [P=0.003; odds ratios (ORs), 4.838], anterior or anterior+posterior approaches (P=0.001; OR, 2.022), and prolonged operative time (>5 h) (P=0.004; OR, 1.821) were associated with an increased risk of minor complications. Male sex (P=0.013; OR, 1.567), osteotomy procedure (P=0.008; OR, 1.674) and prolonged operative time (>5 h) (P<0.001; OR, 2.142) were associated with an increased risk of major complications. The American Society of Anesthesiologists 4 status (P=0.009; OR, 34.697) was a strong risk factor for mortality. CONCLUSIONS After ASD surgery, the rates of minor complications, major complications, and mortality was 8.2%, 10.4%, and 0.6%, respectively. While mortality depended on patient physical status represented by the American Society of Anesthesiologists 4, minor and major complications were associated with male sex, dependent functional status, and surgical factors such as osteotomy procedure, prolonged operative time (>5 h), and having an anterior surgical approach. Therefore, this information may be helpful in surgical counseling and preoperative surgical planning.
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Affiliation(s)
- Ho-Joong Kim
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seoul, Republic of Korea
- Department of Orthopedic Surgery, Division of Spinal Surgery, The Och Spine Hospital at New York-Presbyterian/Allen Hospital, Columbia University, New York, NY
| | - Scott L Zuckerman
- Department of Orthopedic Surgery, Division of Spinal Surgery, The Och Spine Hospital at New York-Presbyterian/Allen Hospital, Columbia University, New York, NY
| | - Meghan Cerpa
- Department of Orthopedic Surgery, Division of Spinal Surgery, The Och Spine Hospital at New York-Presbyterian/Allen Hospital, Columbia University, New York, NY
| | - Jin S Yeom
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Ronald A Lehman
- Department of Orthopedic Surgery, Division of Spinal Surgery, The Och Spine Hospital at New York-Presbyterian/Allen Hospital, Columbia University, New York, NY
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Division of Spinal Surgery, The Och Spine Hospital at New York-Presbyterian/Allen Hospital, Columbia University, New York, NY
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Brown NJ, Choi EH, Gendreau JL, Ong V, Himstead A, Lien BV, Shahrestani S, Ransom SC, Tran K, Tafreshi AR, Sahyouni R, Chan A, Oh MY. Association of tranexamic acid with decreased blood loss in patients undergoing laminectomy and fusion with posterior instrumentation: a systematic review and meta-analysis. J Neurosurg Spine 2021; 36:686-693. [PMID: 34740174 DOI: 10.3171/2021.7.spine202217] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tranexamic acid (TXA) is an antifibrinolytic agent associated with reduced blood loss and mortality in a wide range of procedures, including spine surgery, traumatic brain injury, and craniosynostosis. Despite this wide use, the safety and efficacy of TXA in spine surgery has been considered controversial due to a relative scarcity of literature and lack of statistical power in reported studies. However, if TXA can be shown to reduce blood loss in laminectomy with fusion and posterior instrumentation, more surgeons may include it in their armamentarium. The authors aimed to conduct an up-to-date systematic review and meta-analysis of the efficacy of TXA in reducing blood loss in laminectomy and fusion with posterior instrumentation. METHODS A systematic review and meta-analysis, abiding by PRISMA guidelines, was performed by searching the databases of PubMed, Web of Science, and Cochrane. These platforms were queried for all studies reporting the use of TXA in laminectomy and fusion with posterior instrumentation. Variables retrieved included patient demographics, surgical indications, involved spinal levels, type of laminectomy performed, TXA administration dose, TXA route of administration, operative duration, blood loss, blood transfusion rate, postoperative hemoglobin level, and perioperative complications. Heterogeneity across studies was evaluated using a chi-square test, Cochran's Q test, and I2 test performed with R statistical programming software. RESULTS A total of 7 articles were included in the qualitative study, while 6 articles featuring 411 patients underwent statistical analysis. The most common route of administration for TXA was intravenous with 15 mg/kg administered preoperatively. After the beginning of surgery, TXA administration patterns were varied among studies. Blood transfusions were increased in non-TXA cohorts compared to TXA cohorts. Patients administered TXA demonstrated a significant reduction in blood loss (mean difference -218.44 mL; 95% CI -379.34 to -57.53; p = 0.018). TXA administration was not associated with statistically significant reductions in operative durations. There were no adverse events reported in either the TXA or non-TXA patient cohorts. CONCLUSIONS TXA can significantly reduce perioperative blood loss in cervical, thoracic, and lumbar laminectomy and fusion procedures, while demonstrating a minimal complication profile.
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Affiliation(s)
- Nolan J Brown
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Elliot H Choi
- 2Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Julian L Gendreau
- 3Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland
| | - Vera Ong
- 4Department of Neurosurgery, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii
| | - Alexander Himstead
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Brian V Lien
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Shane Shahrestani
- 5Keck School of Medicine of University of Southern California, Los Angeles, California.,6Medical Scientist Training Program, California Institute of Technology, Pasadena, California
| | - Seth C Ransom
- 7College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Katelynn Tran
- 8University of Southern California, Los Angeles, California
| | - Ali R Tafreshi
- 9Department of Neurological Surgery, Geisinger Health System, Danville, Pennsylvania; and
| | - Ronald Sahyouni
- 10Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Alvin Chan
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Michael Y Oh
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
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Pennington Z, Ehresman J, Schilling A, Feghali J, Hersh AM, Hung B, Kalivas EN, Lubelski D, Sciubba DM. Influence of tranexamic acid use on venous thromboembolism risk in patients undergoing surgery for spine tumors. J Neurosurg Spine 2021; 35:663-673. [PMID: 34388705 DOI: 10.3171/2021.1.spine201935] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/04/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with spine tumors are at increased risk for both hemorrhage and venous thromboembolism (VTE). Tranexamic acid (TXA) has been advanced as a potential intervention to reduce intraoperative blood loss in this surgical population, but many fear it is associated with increased VTE risk due to the hypercoagulability noted in malignancy. In this study, the authors aimed to 1) develop a clinical calculator for postoperative VTE risk in the population with spine tumors, and 2) investigate the association of intraoperative TXA use and postoperative VTE. METHODS A retrospective data set from a comprehensive cancer center was reviewed for adult patients treated for vertebral column tumors. Data were collected on surgery performed, patient demographics and medical comorbidities, VTE prophylaxis measures, and TXA use. TXA use was classified as high-dose (≥ 20 mg/kg) or low-dose (< 20 mg/kg). The primary study outcome was VTE occurrence prior to discharge. Secondary outcomes were deep venous thrombosis (DVT) or pulmonary embolism (PE). Multivariable logistic regression was used to identify independent risk factors for VTE and the resultant model was deployed as a web-based calculator. RESULTS Three hundred fifty patients were included. The mean patient age was 57 years, 53% of patients were male, and 67% of surgeries were performed for spinal metastases. TXA use was not associated with increased VTE (14.3% vs 10.1%, p = 0.37). After multivariable analysis, VTE was independently predicted by lower serum albumin (odds ratio [OR] 0.42 per g/dl, 95% confidence interval [CI] 0.23-0.79, p = 0.007), larger mean corpuscular volume (OR 0.91 per fl, 95% CI 0.84-0.99, p = 0.035), and history of prior VTE (OR 2.60, 95% CI 1.53-4.40, p < 0.001). Longer surgery duration approached significance and was included in the final model. Although TXA was not independently associated with the primary outcome of VTE, high-dose TXA use was associated with increased odds of both DVT and PE. The VTE model showed a fair fit of the data with an area under the curve of 0.77. CONCLUSIONS In the present cohort of patients treated for vertebral column tumors, TXA was not associated with increased VTE risk, although high-dose TXA (≥ 20 mg/kg) was associated with increased odds of DVT or PE. Additionally, the web-based clinical calculator of VTE risk presented here may prove useful in counseling patients preoperatively about their individualized VTE risk.
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Affiliation(s)
- Zach Pennington
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - Jeff Ehresman
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - Andrew Schilling
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - James Feghali
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - Andrew M Hersh
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - Bethany Hung
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - Eleni N Kalivas
- 2Department of Pharmacy, Division of Critical Care and Surgery Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Daniel Lubelski
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
| | - Daniel M Sciubba
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine; and
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Chen Q, Zhou Q, Feng J, Zhang Q, Li Y, Zhang J, Ren Y, Chen L, Wei P. [Study on the safety and effectiveness of low-dose tranexamic acid in operation of multi-level continuous thoracic ossification of ligament flavum]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:873-877. [PMID: 34308596 DOI: 10.7507/1002-1892.202101084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the safety and effectiveness of low-dose tranexamic acid (TXA) in operation of multi-level continuous thoracic ossification of ligament flavum (TOLF). Methods A clinical data of 26 patients who underwent operation for multi-level continuous TOLF and met the selection criteria between July 2015 and January 2019 was retrospectively analyzed. Among them, 13 cases (group A) were received intravenous infusion of TXA (10 mg/kg) at 15 minutes before operation, and maintained the infusion at 1 mg/(kg·h) until the end of the operation; 13 cases (group B) were received the same dose of normal saline before and during operation. There was no significant difference in gender, age, body mass index, diseased segment, and preoperative hemoglobin, platelet count, activated partial thromboplastin time, prothrombin time, international normalized ratio (INR) between the two groups ( P>0.05). The hemoglobin, platelet count, activated partial thromboplastin time, prothrombin time, INR, the number of deep vein thrombosis of the lower extremities, operation time, intraoperative blood loss, postoperative drainage volume, total blood loss, and the time of drainage tube extubation in the two groups were recorded and compared. Results All operations in the two groups were successfully completed. Compared with group B, the operation time and time of drainage tube extubation in group A were shortened, and the intraoperative blood loss, postoperative drainage volume, and total blood loss were reduced. The differences between the two groups were significant ( P<0.05). None of the two groups received blood transfusion, and the hemoglobin level of group A at 24 hours after operation was significantly higher than that of group B ( t=5.062, P=0.000). The incisions in both groups healed and sutures were removed within 2 weeks after operation, and no complications occurred. There was no significant difference between the two groups in activated partial thromboplastin time, prothrombin time, INR, and platelet count at 24 hours after operation ( P>0.05). Conclusion In multi-level continuous TOLF operation, intravenous administration of low-dose TXA can effectively reduce blood loss, shorten postoperative drainage time, and does not increase the risk of complications.
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Affiliation(s)
- Qian Chen
- Department of Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan, 637000, P.R.China
| | - Qingsong Zhou
- Department of Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan, 637000, P.R.China
| | - Junfei Feng
- Department of Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan, 637000, P.R.China
| | - Qingyan Zhang
- Department of Lower Limbs, Sichuan Provincial Orthopedic Hospital, Chengdu Sichuan, 610041, P.R.China
| | - Yuling Li
- Department of Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan, 637000, P.R.China
| | - Jianguang Zhang
- Department of Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan, 637000, P.R.China
| | - Yuqing Ren
- Department of Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan, 637000, P.R.China
| | - Lu Chen
- Department of Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan, 637000, P.R.China
| | - Peng Wei
- Department of Orthopedics, Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan, 637000, P.R.China
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Perioperative Tranexamic Acid for ACTH-Secreting Pituitary Adenomas: Implementation Protocol Results and Trial Prospectus. World Neurosurg 2021; 153:e359-e364. [PMID: 34229096 DOI: 10.1016/j.wneu.2021.06.111] [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: 05/26/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Primary resection of adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma has become a front-line standard-of-care treatment for Cushing disease. However, surgical intervention can be challenging because of elevated blood pressure, as well as direct cortisol impacts on endothelial cells, vascular permeability, and tissue friability-potentially resulting in increased intraoperative bleeding. Tranexamic acid (TXA) is a well-studied, widely used intravenous hemostatic; however, the potential benefit during resection of ACTH-secreting pituitary adenoma is unstudied. The purpose of this study was to define an institutional protocol for perioperative administration of TXA in patients undergoing endoscopic endonasal approach for resection of ACTH-secreting pituitary adenoma, and to study the implementation of our novel protocol in a prospective fashion. METHODS Criteria for preoperative TXA were defined by age, medical history, and risk factors. Descriptive statistics were reported for all patients receiving perioperative TXA. RESULTS Thirty patients met inclusion criteria and underwent perioperative administration of TXA, using a standardized dosing protocol of a 10 mg/kg bolus in 30 minutes prior to incision, followed by maintenance infusion of 2 mg/kg/hour for the duration of the procedure. No incidence of myocardial infarction or postoperative thromboembolic events were noted. Subjective assessments indicated satisfaction with the patient selection protocol, and meaningful reduction in the extent of intraoperative bleeding. CONCLUSIONS Perioperative TXA represents a potentially efficacious approach for control of intraoperative bleeding during endonasal resection of ACTH-secreting tumors. Careful preoperative patient selection is emphasized, given the potential for thromboembolic complications; however, initial experience with our institutional protocol suggests a favorable risk/benefit profile when this treatment is applied judiciously.
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Halpern LM, Bronson WE, Kogan CJ. A New Low Dose of Tranexamic Acid for Decreasing the Rate of Blood Loss in Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. J Pediatr Orthop 2021; 41:333-337. [PMID: 33826563 DOI: 10.1097/bpo.0000000000001820] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies have demonstrated that the use of tranexamic acid (TXA) reduces blood loss and transfusion requirements in children undergoing scoliosis surgery. Although TXA is safe and effective, significant adverse events have been reported. Using the lowest effective dose of TXA is advisable. We evaluated a new low dosing regimen for TXA based on an improved pharmacokinetic model and therapeutic plasma concentration. The purpose of this study is to evaluate the effectiveness of this new low dosing regimen in reducing blood loss and transfusion requirements in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion when compared with a control group who did not receive TXA. METHODS We retrospectively reviewed 90 consecutive patients with idiopathic scoliosis undergoing posterior spinal fusion at our institution from 2017 to 2020. Forty patients received TXA at the new dosing regimen (10 mg/kg load, 5 mg/kg/h infusion) and 50 patients were in the non-TXA control group. The same 2 orthopaedic surgeons, working as a team, performed all surgical procedures. We assessed the use of TXA as an independent risk factor for estimated blood loss and transfusion requirement after adjusting for age, surgical duration, body mass index, major coronal curve, and sex. RESULTS A comparison of the intraoperative cumulative blood loss in the 2 groups showed a significantly lower blood loss in the TXA group. (583.5±272.0 vs. 479.5±288.7 mL, P=0.03) This difference persisted when blood loss was calculated as percent of total blood volume and per vertebral level. Transfusion requirements were lower in the TXA group (4/50 patients vs. 0/40 patients, P=0.13). No patient in the TXA group required a blood transfusion during their hospitalization. CONCLUSION This study is the first to provide evidence that a new low dosing regimen of TXA can significantly reduce blood loss and transfusion requirements for idiopathic scoliosis patients and supports the need for a prospective, randomized clinical trial to confirm these findings. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Affiliation(s)
| | | | - Clark J Kogan
- Center for Interdisciplinary Statistical Education and Research, Washington State University, Pullman, WA
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BECCHETTI F, NASTO LA, KOTZEVA S. Blood loss management in pediatric spinal surgery for scoliosis. MINERVA ORTHOPEDICS 2021; 72. [DOI: 10.23736/s2784-8469.20.04050-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
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Rebai L, Mahfoudhi N, Fitouhi N, Daghmouri MA, Bahri K. Intraoperative tranexamic acid use in patients undergoing excision of intracranial meningioma: Randomized, placebo-controlled trial. Surg Neurol Int 2021; 12:289. [PMID: 34221620 PMCID: PMC8247750 DOI: 10.25259/sni_177_2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/01/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Intracranial meningioma resection is associated with substantial intraoperative bleeding. Intraoperative tranexamic acid (TXA) use can reduce bleeding in a variety of surgical procedures. The objective of this study was to evaluate the effects of TXA treatment on blood loss and transfusion requirements in patient undergoing resection of intracranial meningioma. Methods: We conducted a prospective, randomized double-blind clinical study. The patient scheduled to undergo excision of intracranial meningioma were randomly assigned to receive intraoperatively either intravenous TXA or placebo. Patients in the TXA group received intravenous bolus of 20 mg/kg over 20 min followed by an infusion of 1 mg/kg/h up to surgical wound closure. Efficacy was evaluated based on total blood loss and transfusion requirements. Postoperatively, thrombotic complications, convulsive seizure, and hematoma formation were noted. Results: Ninety-one patients were enrolled and randomized: 45 received TXA (TXA group) and 46 received placebo (group placebo). Total blood loss was significantly decreased in TXA group compared to placebo (283 ml vs. 576 ml; P < 0.001). Transfusion requirements were comparable in the two groups (P = 0.95). The incidence of thrombotic complications, convulsive seizure, and hematoma formation was similar in the two groups. Conclusion: TXA significantly reduces intraoperative blood loss, but did not significantly reduced transfusion requirements in adults undergoing resection of intracranial meningioma.
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Affiliation(s)
- Lotfi Rebai
- Department of Anesthesiology and Critical Care Ben Arous, University of Tunis El Manar, Tunisia
| | - Nahed Mahfoudhi
- Department of Anesthesiology and Critical Care Ben Arous, University of Tunis El Manar, Tunisia
| | - Nizar Fitouhi
- Department of Anesthesiology and Critical Care Ben Arous, University of Tunis El Manar, Tunisia
| | - Mohamed Aziz Daghmouri
- Department of Anesthesiology and Critical Care Ben Arous, University of Tunis El Manar, Tunisia
| | - Kamel Bahri
- Department of Neurosurgery, Traumatology and Severe Burns Center, Ben Arous, University of Tunis El Manar, Tunisia
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Wong J, George RB, Hanley CM, Saliba C, Yee DA, Jerath A. Tranexamic acid: current use in obstetrics, major orthopedic, and trauma surgery. Can J Anaesth 2021; 68:894-917. [PMID: 33993459 DOI: 10.1007/s12630-021-01967-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE In this Continuing Professional Development module, we review the practical pharmacology of tranexamic acid and its clinical use in trauma, obstetrics, and major orthopedic surgery. PRINCIPAL FINDINGS Tranexamic acid is a synthetic drug that inhibits fibrinolysis. Multiple clinical trials in various clinical settings have shown that it can reduce blood loss, transfusion rates, and bleeding-associated mortality. In trauma and obstetrical bleeding, early tranexamic acid administration (< three hours) may have greater clinical benefits. Overall, tranexamic acid use appears safe with no significant increase of thromboembolic or seizure events. Nevertheless, current evidence has limitations related to wide heterogeneity in dose, route, and timing of drug administration, as well as generalizability of the large-scale trial findings to higher income nations. CONCLUSIONS Tranexamic acid is an efficacious and safe pharmacological-based blood conservation technique in the management of clinically significant hemorrhage. All anesthesiologists should have a good understanding of the pharmacotherapeutic properties and perioperative role of tranexamic acid therapy both inside and outside of the operating room. The use of tranexamic acid is likely to continue to rise with endorsement by various clinical guidelines and healthcare organizations. Further quantitative research is needed to evaluate optimal dosing and drug efficacy in these clinical scenarios.
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Affiliation(s)
- Jean Wong
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network and Women's College Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Ronald B George
- Department of Anesthesia and Perioperative Care, UCSF, San Francisco, CA, USA
| | - Ciara M Hanley
- Department of Anesthesia, Sunnybrook Health Science Centre, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Chadi Saliba
- Department of Anesthesia, Sunnybrook Health Science Centre, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Doreen A Yee
- Department of Anesthesia, Sunnybrook Health Science Centre, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Angela Jerath
- Department of Anesthesia, Sunnybrook Health Science Centre, Toronto, ON, Canada.
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Sunnybrook Research Institute, Sunnybrook Health Science Centre, Toronto, ON, Canada.
- Toronto General Hospital Research Institute, Toronto, ON, Canada.
- Institute of Clinical Evaluative Sciences, Toronto, ON, Canada.
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Shi P, Wang J, Cai T, Chen D, Wang S, Feng X, Wang Y, Zhang W, Zhang L. Safety and Efficacy of Topical Administration of Tranexamic Acid in High-Risk Patients Undergoing Posterior Lumbar Interbody Fusion Surgery. World Neurosurg 2021; 151:e621-e629. [PMID: 33940262 DOI: 10.1016/j.wneu.2021.04.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We sought to evaluate the safety and efficacy of topical administration of tranexamic acid (TXA) in high-risk patients undergoing posterior lumbar interbody fusion (PLIF) surgery. METHODS In this single-center, retrospective cohort study, a total of 120 patients with lumbar degenerative disease who had a previous history of cardiovascular or cerebrovascular embolism and who underwent single-level PLIF surgery between December 2018 and December 2019 were included and allocated to 2 groups according to whether they had been administered TXA. In the TXA group (n = 60), the wound surface was topically soaked with TXA (1 g in 100 mL of saline solution) for 5 minutes before wound closure. In the control group (n = 60), the wound surface was topically soaked with the same volume of normal saline. SPSS software, version 26.0, was employed to analyze demographics including surgical traits, blood loss, drainage, length of hospital stays (LOS), blood biochemical indices, prethrombotic state molecular markers, coagulation function, and adverse events. RESULTS Total blood loss, visible blood loss, postoperative drainage, removal time of drainage tube, and LOS were significantly lower in the TXA group than in the control group. However, there was no significant difference between the 2 groups in hidden blood loss, hepatorenal function, coagulation function, prethrombotic state molecular markers, transfusion rate, or complications during the perioperative period. CONCLUSIONS In single-level PLIF surgery, topical administration of TXA could significantly reduce total blood loss, visible blood loss, postoperative drainage, removal time of drainage tube, and LOS without increasing the risk of thromboembolic events in high-risk patients with prior histories of thrombosis.
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Affiliation(s)
- Pengzhi Shi
- Department of Orthopedics, Dalian Medical University, Dalian, China
| | - Junwu Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Tongchuan Cai
- Department of Orthopedics, Dalian Medical University, Dalian, China
| | - Dong Chen
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Shuguang Wang
- Department of Orthopedics, Dalian Medical University, Dalian, China
| | - Xinmin Feng
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yongxiang Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Wenjie Zhang
- Department of Orthopedics, International Zhuang Hospital, Guangxi University of Traditional Chinese Medicine, Nanning, China
| | - Liang Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China.
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Taeuber I, Weibel S, Herrmann E, Neef V, Schlesinger T, Kranke P, Messroghli L, Zacharowski K, Choorapoikayil S, Meybohm P. Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality: A Systematic Review, Meta-analysis, and Meta-regression. JAMA Surg 2021; 156:e210884. [PMID: 33851983 PMCID: PMC8047805 DOI: 10.1001/jamasurg.2021.0884] [Citation(s) in RCA: 176] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/14/2021] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Tranexamic acid (TXA) is an efficient antifibrinolytic agent; however, concerns remain about the potential adverse effects, particularly vascular occlusive events, that may be associated with its use. OBJECTIVE To examine the association between intravenous TXA and total thromboembolic events (TEs) and mortality in patients of all ages and of any medical disciplines. DATA SOURCE Cochrane Central Register of Controlled Trials and MEDLINE were searched for eligible studies investigating intravenous TXA and postinterventional outcome published between 1976 and 2020. STUDY SELECTION Randomized clinical trials comparing intravenous TXA with placebo/no treatment. The electronic database search yielded a total of 782 studies, and 381 were considered for full-text review. Included studies were published in English, German, French, and Spanish. Studies with only oral or topical tranexamic administration were excluded. DATA EXTRACTION AND SYNTHESIS Meta-analysis, subgroup and sensitivity analysis, and meta-regression were performed. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. MAIN OUTCOMES AND MEASURES Vascular occlusive events and mortality. RESULTS A total of 216 eligible trials including 125 550 patients were analyzed. Total TEs were found in 1020 (2.1%) in the group receiving TXA and 900 (2.0%) in the control group. This study found no association between TXA and risk for total TEs (risk difference = 0.001; 95% CI, -0.001 to 0.002; P = .49) for venous thrombosis, pulmonary embolism, venous TEs, myocardial infarction or ischemia, and cerebral infarction or ischemia. Sensitivity analysis using the risk ratio as an effect measure with (risk ratio = 1.02; 95% CI, 0.94-1.11; P = .56) and without (risk ratio = 1.03; 95% CI, 0.95-1.12; P = .52) studies with double-zero events revealed robust effect size estimates. Sensitivity analysis with studies judged at low risk for selection bias showed similar results. Administration of TXA was associated with a significant reduction in overall mortality and bleeding mortality but not with nonbleeding mortality. In addition, an increased risk for vascular occlusive events was not found in studies including patients with a history of thromboembolism. Comparison of studies with sample sizes of less than or equal to 99 (risk difference = 0.004; 95% CI, -0.006 to 0.014; P = .40), 100 to 999 (risk difference = 0.004; 95% CI, -0.003 to 0.011; P = .26), and greater than or equal to 1000 (risk difference = -0.001; 95% CI, -0.003 to 0.001; P = .44) showed no association between TXA and incidence of total TEs. Meta-regression of 143 intervention groups showed no association between TXA dosing and risk for venous TEs (risk difference, -0.005; 95% CI, -0.021 to 0.011; P = .53). CONCLUSIONS AND RELEVANCE Findings from this systematic review and meta-analysis of 216 studies suggested that intravenous TXA, irrespective of dosing, is not associated with increased risk of any TE. These results help clarify the incidence of adverse events associated with administration of intravenous TXA and suggest that TXA is safe for use with undetermined utility for patients receiving neurological care.
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Affiliation(s)
- Isabel Taeuber
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, Frankfurt, Germany
| | - Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tobias Schlesinger
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Leila Messroghli
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Suma Choorapoikayil
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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George S, Ramchandran S, Mihas A, George K, Mansour A, Errico T. Topical tranexemic acid reduces intra-operative blood loss and transfusion requirements in spinal deformity correction in patients with adolescent idiopathic scoliosis. Spine Deform 2021; 9:1387-1393. [PMID: 33844193 DOI: 10.1007/s43390-021-00337-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 03/17/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE To evaluate the effectiveness of the use of topical tranexamic acid (tTXA) in spinal deformity correction in AIS patients METHODS: Sixty consecutive operative AIS patients were reviewed from a single institution and divided into two groups with similar demographics. Standardized peri-operative blood salvage techniques were utilized in all 60 patients. In the latter 30 patients, tTXA soaked sponges (1 g mixed in 500 ml Normal Saline) was utilised for wound packing during the entire surgical procedure compared to dry sponges as used in the former 30 patients. Both the groups were compared for the magnitude of deformity corrected, EBL per level fused, total EBL, blood transfused, drain output and peri-operative events. RESULTS Sixty AIS patients (mean age 14.4 yrs, 43 females, mean BMI 21.5, mean levels 10.7) were included. Both groups achieved similar change in Coronal Cobb correction. The EBVL (Estimated blood volume loss) % lost in the topical TXA group was 38% less than the control group (11.2 vs. 18.3%, p = 0.006). Similarly, the EBL/level was significantly lower in the topical TXA group (41 ± 30 ml vs. 57 ± 26 ml, p = 0.03). Three of 30 patients in the control group required at least 1 unit of blood transfusion, whereas only 1 patient in the topical TXA group required transfusion (10 vs. 3.3%, p = 0.001). No differences were noted in post-operative drain output, change in hemoglobin levels, and peri-operative complication rates. CONCLUSION When used as an adjunct to the conventional blood salvage techniques in spinal deformity correction procedures, the use of tTXA resulted in reduced operative blood loss, and blood transfusion requirements.
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Affiliation(s)
- Stephen George
- Department of Orthopedic Surgery, Center for Spinal Disorders, Nicklaus Children's Hospital, Miami, FL, 33155, USA
| | - Subaraman Ramchandran
- Department of Orthopedic Surgery, Center for Spinal Disorders, Nicklaus Children's Hospital, Miami, FL, 33155, USA.
| | - Alexander Mihas
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Kevin George
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Ali Mansour
- Department of Orthopedic Surgery, Center for Spinal Disorders, Nicklaus Children's Hospital, Miami, FL, 33155, USA
| | - Thomas Errico
- Department of Orthopedic Surgery, Center for Spinal Disorders, Nicklaus Children's Hospital, Miami, FL, 33155, USA
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Mihas A, Ramchandran S, Rivera S, Mansour A, Asghar J, Shufflebarger H, George S. Safe and effective performance of pediatric spinal deformity surgery in patients unwilling to accept blood transfusion: a clinical study and review of literature. BMC Musculoskelet Disord 2021; 22:204. [PMID: 33607982 PMCID: PMC7896412 DOI: 10.1186/s12891-021-04081-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pediatric deformity surgery traditionally involves major blood loss. Patients refusing blood transfusion add extra clinical and medicolegal challenges; specifically the Jehovah's witnesses population. The objective of this study is to review the safety and effectiveness of blood conservation techniques in patients undergoing pediatric spine deformity surgery who refuse blood transfusion. METHODS After obtaining institutional review board approval, we retrospectively reviewed 20 consecutive patients who underwent spinal deformity surgery and refused blood transfusion at a single institution between 2014 and 2018. We collected pertinent preoperative, intraoperative and most recent clinical and radiological data with latest follow-up (minimum two-year follow-up). RESULTS Twenty patients (13 females) with a mean age of 14.1 years were identified. The type of scoliotic deformities were adolescent idiopathic (14), juvenile idiopathic (1), neuromuscular (3) and congenital (2). The major coronal Cobb angle was corrected from 55.4° to 11.2° (80% correction, p < 0.001) at the latest follow-up. A mean of 11.4 levels were fused and 5.6 levels of Pontes osteotomies were performed. One patient underwent L1 hemivertebra resection and three patients had fusion to pelvis. Estimated blood loss, percent estimated blood volume loss, and cell saver returned averaged 307.9 mL, 8.5%, and 80 mL, respectively. Average operative time was 214 min. The average drop in hemoglobin after surgery was 2.9 g/dL. The length of hospital stay averaged 5.1 days. There were no intraoperative complications. Three postoperative complications were identified, none related to their refusal of transfusion. One patient had in-hospital respiratory complication, one patient developed a late infection, and one patient developed asymptomatic radiographic distal junctional kyphosis. CONCLUSIONS Blood conservation techniques allow for safe and effective spine deformity surgery in pediatric patients refusing blood transfusion without major anesthetic or medical complications, when performed by an experienced multidisciplinary team. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Alexander Mihas
- Florida International University Herbert Wertheim College of Medicine, 11200 SW 8th Street, Miami, FL, 33199, USA
| | - Subaraman Ramchandran
- Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA.
| | - Sebastian Rivera
- Department of Orthopedic Surgery, Jackson Memorial Hospital, University of Miami, 1611 NW 12th Avenue, Miami, FL, 33136, USA
| | - Ali Mansour
- Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA
| | - Jahangir Asghar
- Cantor Spine Institute, 3000 Bayview Drive Suite 200, Fort Lauderdale, FL, 33306, USA
| | - Harry Shufflebarger
- Paley Orthopedic and Spine Institute at St. Mary's Medical Center, 901 45th Street, West Palm Beach, FL, 33407, USA
| | - Stephen George
- Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA
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A clinical calculator for predicting intraoperative blood loss and transfusion risk in spine tumor patients. Spine J 2021; 21:302-311. [PMID: 33007469 DOI: 10.1016/j.spinee.2020.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/05/2020] [Accepted: 09/24/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Surgery for vertebral column tumors is commonly associated with intraoperative blood loss (IOBL) exceeding 2 liters and the need for transfusion of allogeneic blood products. Transfusion of allogeneic blood, while necessary, is not benign, and has been associated with increased rates of wound complication, venous thromboembolism, delirium, and death. PURPOSE To develop a prediction tool capable of predicting IOBL and risk of requiring allogeneic transfusion in patients undergoing surgery for vertebral column tumors. STUDY DESIGN/SETTING Retrospective, single-center study. PATIENT SAMPLE Consecutive series of 274 patients undergoing 350 unique operations for primary or metastatic spinal column tumors over a 46-month period at a comprehensive cancer center OUTCOME MEASURES: IOBL (in mL), use of intraoperative blood products, and intraoperative blood products transfused. METHODS We identified IOBL and transfusions, along with demographic data, preoperative laboratory data, and surgical procedures performed. Independent predictors of IOBL and transfusion risk were identified using multivariable regression. RESULTS Mean age at surgery was 57.0±13.6 years, 53.1% were male, and 67.1% were treated for metastatic lesions. Independent predictors of IOBL included en bloc resection (p<.001), surgical invasiveness (β=25.43 per point; p<0.001), and preoperative albumin (β=-244.86 per g/dL; p=0.011). Predictors of transfusion risk included preoperative hematocrit (odds ratio [OR]=0.88 per %; 95% confidence interval [CI, 0.84, 0.93]; p<0.001), preoperative MCHgb (OR=0.88 per pg; 95% CI [0.78, 1.00]; p=0.048), preoperative red cell distribution width (OR=1.32 per %; 95% CI [1.13, 1.55]; p<0.001), en bloc resection (OR=3.17; 95%CI [1.33, 7.54]; p=0.009), and surgical invasiveness (OR=1.08 per point; [1.06; 1.11]; p<0.001). The transfusion model showed a good fit of the data with an optimism-corrected area under the curve of 0.819. A freely available, web-based calculator was developed for the transfusion risk model (https://jhuspine3.shinyapps.io/TRUST/). CONCLUSIONS Here we present the first clinical calculator for intraoperative blood loss and transfusion risk in patients being treated for primary or metastatic vertebral column tumors. Surgical invasiveness and preoperative microcytic anemia most strongly predict transfusion risk. The resultant calculators may prove clinically useful for surgeons counseling patients about their individual risk of requiring allogeneic transfusion.
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Khiabani K, Ahmadfar M, Labafchi A, Gosheh MR, Samieirad S. Is Preoperative Administration of Tranexamic Acid Effective on Blood Loss Reduction in Mandibular Fracture Surgeries? A Triple-Blind Randomized Clinical Trial. J Oral Maxillofac Surg 2021; 79:429.e1-429.e7. [PMID: 33035492 DOI: 10.1016/j.joms.2020.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 08/24/2020] [Accepted: 09/01/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Hemorrhage is one of the significant factors that cause adverse reactions and complications during trauma management. This study aimed to investigate the effectiveness of preoperative tranexamic acid (TXA) administration on intraoperative blood loss in mandibular fracture surgeries. MATERIALS AND METHODS The authors implemented a triple blinded randomized clinical trial. All healthy young patients who suffered from bilateral displaced mandibular angle and body fractures were included in this study. All operations were performed using open reduction and internal fixation by the same surgical team. The eligible subjects were randomly divided into 2 equal groups. The anesthesiology staff administered the intravenous TXA (20 mg/kg) to the intervention group and 20 mL of intravenous normal saline (0.09%) in the control group, 30 minutes preoperatively. The study outcome variables included intraoperative blood loss and hemoglobin loss. The data were statistically analyzed in SPSS, version 20 (SPSS Inc, Chicago, IL). RESULTS Fifty patients, including 31 males (62%) and 19 females (38%), with the mean age of 28 ± 5.6 years were studied. The mean blood loss was 360.57 ± 173.5 mL and 560.9 ± 248.07 mL in the TXA and control groups, respectively. This difference was statistically significant (P = .008). In addition, the mean drop in hemoglobin value was 0.91 ± 0.33 mg/dL in the intervention group and 1.44 ± 0.45 mg/dL in the control group, with a significant difference (P = .001). No adverse effect was observed in the TXA cases. CONCLUSIONS TXA is a safe and effective drug for reducing intraoperative blood loss in patients who underwent mandibular fracture open reduction and internal fixation surgeries.
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Affiliation(s)
- Kazem Khiabani
- Associate Professor, Department of Oral & Maxillofacial Surgery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Majid Ahmadfar
- Oral & Maxillofacial Surgeon, Private Practice, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Labafchi
- Dentist, Student Research Committee, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Reza Gosheh
- Assistant Professor, Department of Anesthesiology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Sahand Samieirad
- Associate Professor, Oral and Maxillofacial Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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Shrestha IK, Ruan TY, Lin L, Tan M, Na XQ, Qu QC, Chen JC, Si YY, Tao JP. The efficacy and safety of high-dose tranexamic acid in adolescent idiopathic scoliosis: a meta-analysis. J Orthop Surg Res 2021; 16:53. [PMID: 33446219 PMCID: PMC7807519 DOI: 10.1186/s13018-020-02158-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Background This study aimed to evaluate the efficacy and safety of using high-dose intravenous tranexamic acid (TXA) to reduce blood loss in idiopathic scoliosis surgery. Methods This study was a meta-analysis, which consisted of retrospective cohort studies (RCSs) and randomized control trials (RCTs) found by searching electronic databases, namely PubMed, Web of Science, The Cochrane Central Register of Controlled Trials (CENTRAL), and the Google Scholar Database, dating from 1960 to 2019. The points of interest included total blood loss, a need for transfusion and transfusion criteria, surgery time, and the evidence of intraoperative and postoperative complications, such as seizures or thromboembolic events. The weighted mean differences (WMD) and 95% confidence interval (CI) of blood loss in the TXA intervention group compared to the control or placebo group were extracted and combined using the random effects model. Results In this meta-analysis, there was a total of three RCSs and two RCTs, which involved 334 patients. The results showed that blood loss is significantly reduced, with a weighted mean difference in the TXA group (WMD = − 525.14, P = 0.0000, CI ranged from − 839.83, − 210.44, I2 = 82%). Heterogeneity was assessed using the random effects model. Conclusions A high dose of intravenous TXA reduced blood loss during adolescent idiopathic scoliosis surgery and did not lead to any significant thromboembolic event. Therefore, a high dose appears to be effective and safe for adolescent idiopathic scoliosis surgery. However, more high-quality research based on larger randomized controlled trials is still needed.
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Affiliation(s)
- Indra K Shrestha
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Tian-Yi Ruan
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Lan Lin
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Miao Tan
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Xue-Qing Na
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Qi-Cai Qu
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Jian-Chun Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China
| | - Yong-Yu Si
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China.
| | - Jian-Ping Tao
- Department of Anesthesiology, The Second Affiliated Hospital of Kunming Medical University, No.374 of Dianmian Avenue, Wuhua District, Kunming, 650101, Yunnan, China.
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Two Doses of Tranexamic Acid Reduce Blood Loss in Primary Posterior Lumbar Fusion Surgery: A Randomized-controlled Trial. Clin Spine Surg 2020; 33:E593-E597. [PMID: 32349059 DOI: 10.1097/bsd.0000000000000999] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Tranexamic acid (TXA) has been widely used in hip and knee arthroplasty to reduce perioperative blood loss and blood transfusion, but the dosage and efficacy of TXA in posterior lumbar spinal surgery are not fully clear. The aim of this study was to investigate the efficacy and safety of TXA and to determine whether 2 doses of TXA could reduce the blood loss in primary single-segment or double-segment posterior lumbar fusion surgery. MATERIALS AND METHODS A total of 150 patients with lumbar degenerative disease undergoing posterior lumbar interbody fusion surgery between October 2017 and February 2019 were randomized to 3 groups. Group A was treated with 0.9% normal saline solution without TXA, group B was treated with a 15 mg/kg loading dose intravenous infusion 30 minutes before surgery, and group C was treated with a 15 mg/kg loading dose intravenous infusion 30 minutes before surgery; then, the same dose was administered again 3 hours later. The assessed outcomes were the operation time, the total blood loss, the hidden blood loss, postoperative drainage, blood transfusions, incidence of venous thromboembolism, and incision infection. RESULTS The total blood loss, the hidden blood loss, and postoperative drainage were the lowest in group C. The amount of intraoperative blood loss was similar among the 3 groups. The hemoglobin and hematocrit values of the third postoperative day were the highest in group C. No significant differences in the incidence of complications and adverse events from TXA use were observed among the 3 groups. The use of TXA, the operation time, and the number of fusion segments were identified as risk factors related to total blood loss. CONCLUSION Two doses of TXA significantly reduced the total blood loss, the hidden blood loss and postoperative drainage, and decreased hemoglobin and hematocrit drop in patients undergoing posterior lumbar fusion without increasing the risk of complications.
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Dunn LK, Chen CJ, Taylor DG, Esfahani K, Brenner B, Luo C, Buell TJ, Spangler SN, Buchholz AL, Smith JS, Shaffrey CI, Nemergut EC, Durieux ME, Naik BI. Postoperative Low-Dose Tranexamic Acid After Major Spine Surgery: A Matched Cohort Analysis. Neurospine 2020; 17:888-895. [PMID: 33401867 PMCID: PMC7788407 DOI: 10.14245/ns.2040114.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/22/2020] [Accepted: 05/08/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE This was a retrospective, cohort study investigating the efficacy and safety of continuous low-dose postoperative tranexamic acid (PTXA) on drain output and transfusion requirements following adult spinal deformity surgery. METHODS One hundred forty-seven patients undergoing posterior instrumented thoracolumbar fusion of ≥ 3 vertebral levels at a single institution who received low-dose PTXA infusion (0.5-1 mg/kg/hr) for 24 hours were compared to 292 control patients who did not receive PTXA. The cohorts were propensity matched based on age, sex, American Society of Anesthesiologist physical status classification, body mass index, number of surgical levels, revision surgery, operative duration, and total intraoperative TXA dose (n = 106 in each group). Primary outcome was 72-hour postoperative drain output. Secondary outcomes were number of allogeneic blood transfusions. RESULTS There was no significant difference in postoperative drain output in the PTXA group compared to control (660 ± 420 mL vs. 710 ± 490 mL, p = 0.46). The PTXA group received significantly more crystalloid (6,100 ± 3,100 mL vs. 4,600 ± 2,400 mL, p < 0.001) and red blood cell transfusions postoperatively (median [interquartile range]: 1 [0-2] units vs. 0 [0-1] units; incidence rate ratio [95% confidence interval], 1.6 [1.2-2.2]; p = 0.001). Rates of adverse events were comparable between groups. CONCLUSION Continuous low-dose PTXA infusion was not associated with reduced drain output after spinal deformity surgery. No difference in thromboembolic incidence was observed. A prospective dose escalation study is warranted to investigate the efficacy of higher dose PTXA.
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Affiliation(s)
- Lauren K. Dunn
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Davis G. Taylor
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Kamilla Esfahani
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Brian Brenner
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Charles Luo
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Thomas J. Buell
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Sarah N. Spangler
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Avery L. Buchholz
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Justin S. Smith
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Christopher I. Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Edward C. Nemergut
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Marcel E. Durieux
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Bhiken I. Naik
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
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