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Efficacy and Safety of Tranexamic Acid in Major Non-Cardiac Surgeries at High Risk for Transfusion: A Systematic Review and Meta-Analysis

Rady Faculty of Health Sciences, Max Rady College of Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba; Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Manitoba; Rady Faculty of Health Sciences, College of Pharmacy, University of Manitoba, Winnipeg, Manitoba. Electronic address: bhouston@cancercare.mb.ca. Rady Faculty of Health Sciences, Max Rady College of Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba. Rady Faculty of Health Sciences, Max Rady College of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba. Rady Faculty of Health Sciences, Max Rady College of Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba; Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Manitoba. Rady Faculty of Health Sciences, College of Pharmacy, University of Manitoba, Winnipeg, Manitoba. Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Department of Medicine, University of Ottawa, Ottawa, Ontario. George & Fay Yee Center for Healthcare Innovation, University of Manitoba/Winnipeg Regional Health Authority, Winnipeg, Manitoba. George & Fay Yee Center for Healthcare Innovation, University of Manitoba/Winnipeg Regional Health Authority, Winnipeg, Manitoba; Department Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba. University of Manitoba, MHIKNET program, Winnipeg, Manitoba. Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario. Universite Laval / CHU de Quebec - Universite Laval Research Centre, Quebec, Quebec. Rady Faculty of Health Sciences, Max Rady College of Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba; Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Manitoba; Rady Faculty of Health Sciences, College of Pharmacy, University of Manitoba, Winnipeg, Manitoba.

Transfusion medicine reviews. 2019
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PICO Summary

Population

Adult patients undergoing a non-cardiac and non-hip and knee arthroplasty surgeries at high-risk for RBC transfusion, (69 studies, n=6157).

Intervention

Intraoperative IV tranexamic acid (TXA).

Comparison

Placebo, usual care and active comparators.

Outcome

TXA reduces both the proportion of patients transfused RBCs (relative risk (RR) 0.59 and the volume of RBC transfused (MD -0.51 RBC units) when compared to placebo or usual care. TXA was not associated with differences in deep vein thrombosis, pulmonary embolism, all-cause mortality, hospital length of stay, need for re-operation due to hemorrhage, myocardial infarction, stroke or seizure. In patients undergoing a broad range of non-cardiac and non-hip and knee arthroplasty surgeries at high risk for RBC transfusion, perioperative TXA reduced exposure to RBC transfusion. No differences in thrombotic outcomes were identified; however, summary effect estimates were limited by lack of systemic screening and short duration of follow-up.
Abstract
Tranexamic acid (TXA) reduces transfusion requirements in cardiac surgery and total hip and knee arthroplasty, where it has become standard of care. Our objective is to determine the efficacy and safety of TXA in other surgeries associated with a high risk for red blood cell (RBC) transfusion. We identified randomized controlled trials in Medline, Embase, CENTRAL, and CAB abstracts from inception to June 2019. We included trials evaluating intraoperative IV TXA in adult patients undergoing a non-cardiac and non-hip and knee arthroplasty surgeries at high-risk for RBC transfusion, defined as a baseline transfusion rate ≥5% in comparator arm. We assessed risk of bias using the Cochrane Risk of Bias tool. We used GRADE methodology to assess certainty of evidence. From 8565 citations identified, we included 69 unique trials, enrolling 6157 patients. TXA reduces both the proportion of patients transfused RBCs (relative risk (RR) 0.59; 95% confidence interval (CI) 0.48 to 0.72; low certainty evidence) and the volume of RBC transfused (MD -0.51 RBC units; 95%CI -0.13 to -0.9 units; low certainty evidence) when compared to placebo or usual care. TXA was not associated with differences in deep vein thrombosis, pulmonary embolism, all-cause mortality, hospital length of stay, need for re-operation due to hemorrhage, myocardial infarction, stroke or seizure. In patients undergoing a broad range of non-cardiac and non-hip and knee arthroplasty surgeries at high risk for RBC transfusion, perioperative TXA reduced exposure to RBC transfusion. No differences in thrombotic outcomes were identified; however, summary effect estimates were limited by lack of systemic screening and short duration of follow-up.
Study details
Study Design : Systematic Review
Language : eng
Credits : Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine