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1.
Tranexamic acid in bleeding reduction and operative time of nasal surgeries: systematic review and meta-analysis
Goncalves, P. E., Ferreira, F. J. S., Lima, A. S., Moreira, D. C., de Oliveira Santos, B. F., Melo, N. A. D., Beer-Furlan, A., Oliveira, A. M. P.
European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2023
Abstract
PURPOSE Our study goal is to review the efficacy of tranexamic acid in reducing blood loss and operative time in nasal surgeries. METHODS We included randomized clinical trials using oral or intravenous tranexamic acid, excluded non-randomized studies, topic administration, coagulopathy, and using other drugs interfering in the coagulation cascade. Online databases, National Library of Medicine (MEDLINE-PubMED), Latin American and Caribbean Literature on Health Sciences (Lilacs), Cochrane Library, Embase and Google Scholar were used to perform the search. The review was registered in PROSPERO by no CRD42022310977. Two authors, independently, selected the articles meeting the inclusion criteria. They extracted the data and used RevMan 5 software to perform the meta-analysis. RESULTS Our search resulted in 16 RCTs that were included in the meta-analysis totalizing 1108 patients. Studies were evaluated resulting in a low risk of bias for the five domains. The use of tranexamic acid resulted in significant reduction in duration of surgery (DOS) and intraoperative blood loss (IBL) had significant reduction. The level of evidence according to GRADE System was high in all studies and variables. CONCLUSION Tranexamic acid has an important role in reducing intraoperative blood loss and duration of surgery. Our study has some limitations due to the low number of RCTs available in the literature.
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2.
Tranexamic Acid in Patients Undergoing Rhinoplasty: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials
Gutierrez, R. W. H., Gobbo, H. R., Heringer, Ldfl
Aesthetic plastic surgery. 2023
Abstract
BACKGROUND Rhinoplasty is one of the most popular aesthetic plastic surgeries worldwide. The effects of tranexamic acid (TXA) in patients undergoing rhinoplasty are still being studied to guide a better management. METHODS We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) analyzing the effects of TXA in patients undergoing rhinoplasty. The outcomes evaluated were blood loss, postoperative edema, postoperative ecchymosis, surgery duration and surgeon satisfaction. RESULTS Eleven studies comprising 841 patients were included. Overall, TXA reduced total blood loss regardless of dose and administration route (MD = - 39.37 mL; 95% CI = - 62.70 to - 16.05 mL; p = 0.0009; I(2) = 92%), using intravenous 10 mg/kg of TXA preoperatively (MD = - 16.30 mL; 95% CI = - 29.49 to - 2.57 mL; p = 0.02; I(2) = 61%) and using 1 g of oral TXA preoperatively (MD = - 61.70 mL; 95% CI = - 83.02 to - 40.39 mL; p < 0.00001; I(2) = 0%). TXA also decreased edema (MD = - 0.78; 95% CI = - 1.28 to - 0.27 points; p = 0.003; I(2) = 80%) and ecchymosis (MD = - 1.13; 95% CI = - 1.99 to -0.28; p = 0.01; I(2) = 93%) on postoperative day one (POD 1). Surgeon satisfaction was increased (SMD = 1.55; 95% CI = 0.33 to 2.77; p = 0.01; I(2) = 95%). However, there was no difference in surgery duration (SMD = - 0.26; 95% CI = - 0.56 to 0.04; p = 0.09; I(2) = 36%). CONCLUSION This study found a significant reduction in blood loss, periorbital edema and periorbital ecchymosis, along with an improvement in surgeon satisfaction. These results hold the potential to optimize the rhinoplasty management by plastic surgeons. LEVEL OF EVIDENCE I This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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3.
Tranexamic acid for the reduction of bleeding during functional endoscopic sinus surgery
Lourijsen, E., Avdeeva, K., Gan, K. L., Pundir, V., Fokkens, W.
The Cochrane Database of Systematic Reviews. 2023;2(2):Cd012843
Abstract
BACKGROUND Chronic rhinosinusitis, with or without nasal polyps, can have a major impact on a person's quality of life. Treatment is usually conservative and may include nasal saline, intranasal corticosteroids, antibiotics or systemic corticosteroids. If these treatments fail endoscopic sinus surgery can be considered. During surgery, visibility of the surgical field is important for the identification of important anatomic landmarks and structures that contribute to safety. Impaired visualisation can lead to complications during surgery, inability to complete the operation or a longer duration of surgery. Different methods are used to decrease intraoperative bleeding, including induced hypotension, topical or systemic vasoconstrictors or total intravenous anaesthesia. Another option is tranexamic acid, an antifibrinolytic agent, which can be administered topically or intravenously. OBJECTIVES To assess the effects of peri-operative tranexamic acid versus no therapy or placebo on operative parameters in patients with chronic rhinosinusitis (with or without nasal polyps) who are undergoing functional endoscopic sinus surgery (FESS). SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 10 February 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing intravenous, oral or topical tranexamic acid with no therapy or placebo in the treatment of patients (adults and children) with chronic rhinosinusitis, with or without nasal polyps, undergoing FESS. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Primary outcome measures were surgical field bleeding score (e.g. Wormald or Boezaart grading system), intraoperative blood loss and significant adverse effects (seizures or thromboembolism within 12 weeks of surgery). Secondary outcomes were duration of surgery, incomplete surgery, surgical complications and postoperative bleeding (placing of packing or revision surgery) in the first two weeks after surgery. We performed subgroup analyses for methods of administration, different dosages, different forms of anaesthesia, use of thromboembolic prophylaxis and children versus adults. We evaluated each included study for risk of bias and used GRADE to assess the certainty of the evidence. MAIN RESULTS We included 14 studies in the review, with a total of 942 participants. Sample sizes in the included studies ranged from 10 to 170. All but two studies included adult patients (≥ 18 years). Two studies included children. Most studies had more male patients (range 46.6% to 80%). All studies were placebo-controlled and four studies had three treatment arms. Three studies investigated topical tranexamic acid; the other studies reported the use of intravenous tranexamic acid. For our primary outcome, surgical field bleeding score measured with the Boezaart or Wormald grading score, we pooled data from 13 studies. The pooled result demonstrated that tranexamic acid probably reduces the surgical field bleeding score, with a standardised mean difference (SMD) of -0.87 (95% confidence interval (CI) -1.23 to -0.51; 13 studies, 772 participants; moderate-certainty evidence). A SMD below -0.70 represents a large effect (in either direction). Tranexamic acid may result in a slight reduction in blood loss during surgery compared to placebo with a mean difference (MD) of -70.32 mL (95% CI -92.28 to -48.35 mL; 12 studies, 802 participants; low-certainty evidence). Tranexamic acid probably has little to no effect on the development of significant adverse events (seizures or thromboembolism) within 24 hours of surgery, with no events in either group and a risk difference (RD) of 0.00 (95% CI -0.02 to 0.02; 8 studies, 664 participants; moderate-certainty evidence). However, there were no studies reporting significant adverse event data with a longer duration of follow-up. Tranexamic acid probably results in little difference in the duration of surgery with a MD of -13.04 minutes (95% CI -19.27 to -6.81; 10 studies, 666 participants; moderate-certainty evidence). Tranexamic acid probably results in little to no difference in the incidence of incomplete surgery, with no events in either group and a RD of 0.00 (95% CI -0.09 to 0.09; 2 studies, 58 participants; moderate-certainty evidence) and likely results in little to no difference in surgical complications, again with no events in either group and a RD of 0.00 (95% CI -0.09 to 0.09; 2 studies, 58 participants; moderate-certainty evidence), although these numbers are too small to draw robust conclusions. Tranexamic acid may result in little to no difference in the likelihood of postoperative bleeding (placement of packing or revision surgery within three days of surgery) (RD -0.01, 95% CI -0.04 to 0.02; 6 studies, 404 participants; low-certainty evidence). There were no studies with longer follow-up. AUTHORS' CONCLUSIONS There is moderate-certainty evidence to support the beneficial value of topical or intravenous tranexamic acid during endoscopic sinus surgery with respect to surgical field bleeding score. Low- to moderate-certainty evidence suggests a slight decrease in total blood loss during surgery and duration of surgery. Whilst there is moderate-certainty evidence that tranexamic acid does not lead to more immediate significant adverse events compared to placebo, there is no evidence regarding the risk of serious adverse events more than 24 hours after surgery. There is low-certainty evidence that tranexamic acid may not change postoperative bleeding. There is not enough evidence available to draw robust conclusions about incomplete surgery or surgical complications.
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4.
Tranexamic acid in head and neck procedures: a systematic review and meta-analysis of randomized controlled trials
Alsubaie, H. M., Abu-Zaid, A., Sayed, S. I., Pathak, K. A., Almayouf, M. A., Albarrak, M., Aldhahri, S. F., Al-Qahtani, K. H.
European Archives of Oto-Rhino-Laryngology : Official Journal of the European Federation of Oto-Rhino-Laryngological Societies (Eufos) : Affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2022;279(5):2231-2238
Abstract
OBJECTIVE We conducted a meta-analysis of all randomized controlled trials (RCTs) that examined the benefits of tranexamic acid (TXA) among cancer patients undergoing head and neck (H&N) procedures. METHODS We screened five databases from inception until 20 June 2021 and evaluated the risk of bias of the eligible studies. We pooled continuous outcomes using the weighted mean difference (WMD) with 95% confidence interval (CI). RESULTS Five studies, comprising seven RCTs, met the inclusion criteria. This meta-analysis included a total of 540 patients; 265 and 275 patients were assigned to the TXA and control group, respectively. Overall, the included RCTs revealed a low risk of bias. The volume of postoperative bleeding was significantly lower in favor of the TXA group compared with the control group (n = 7 RCTs, WMD = - 51.33 ml, 95% CI [- 101.47 to - 1.2], p = 0.04). However, no significant difference was found between both groups regarding the volume of intraoperative bleeding (n = 6 RCTs, WMD = - 3.48 ml, 95% CI [- 17.11 to 10.15], p = 0.62), postoperative hemoglobin (n = 3 RCTs, WMD = 0.42 mg/dl, 95% CI [- 0.27 to 1.11], p = 0.23), duration of drainage tube removal (n = 4 RCTs, MD = - 0.41 days, 95% CI [- 1.14 to 0.32], p = 0.27), and operation time (n = 6 RCTs, WMD = 1.59 min, 95% CI [- 10.09 to 13.27], p = 0.79). TXA was safe and did not culminate in thromboembolic events or major coagulation derangements. CONCLUSION TXA administration is safe and significantly reduces the volume of postoperative bleeding. However, no difference is identified between TXA and control groups regarding the volume of intraoperative bleeding, postoperative hemoglobin level, duration of drainage tube removal, and operation time.
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5.
Tranexamic Acid in sinus and nasal surgery: an up-to-date meta-analysis
Yap D, Shakir A, Hunt A
The Journal of laryngology and otology. 2021;:1-25
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6.
The efficacy of Tranexamic Acid Administration in Patients Undergoing Tonsillectomy: An Updated Meta-Analysis
Kuo CC, DeGiovanni JC, Carr MM
The Annals of otology, rhinology, and laryngology. 2021;:34894211045264
Abstract
OBJECTIVE There is controversy regarding the efficacy and safety of tranexamic acid (TXA) in reducing tonsillectomy-related hemorrhage. We conducted a systematic review and meta-analysis to evaluate the prophylactic role of TXA in tonsillectomy. METHODS We searched 6 databases to identify studies that directly compare the effect of TXA versus controls in tonsillectomy patients. Standardized mean difference was applied to summate the findings across the studies. Dichotomous data were expressed as relative risk. RESULTS Ten studies representing a total of 111 898 patients were included. The pooled results showed a significant reduction of intraoperative blood loss by 39.02 ml (SMD = -1.05, 95% CI: -1.91 to -0.20, P = .016) and the rate of post-tonsillectomy hemorrhage (RR = 0.42, 95% CI: 0.28 to 0.65, P < .0001), with no significant difference in reduction of further intervention risk (RR = 0.78, 95% CI: 0.45 to 1.35, P = .373). CONCLUSIONS Overall, this study indicates that TXA may reduce blood loss and frequency of post-operative hemorrhage associated with tonsillectomy. Further large, high-quality clinical trials are still needed to explore TXA's effect on post-tonsillectomy hemorrhage and the safety of its use.
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7.
Role of Tranexamic Acid in Reducing Intraoperative Blood Loss and Postoperative Edema and Ecchymosis in Primary Elective Rhinoplasty: A Systematic Review and Meta-analysis
McGuire C, Nurmsoo S, Samargandi OA, Bezuhly M
JAMA facial plastic surgery. 2019
Abstract
Importance: Blood loss from surgical procedures is a major issue worldwide as the demand for blood products is increasing. Tranexamic acid is an antifibrinolytic agent commonly used to reduce intraoperative blood loss. Objective: To systematically examine the role of tranexamic acid in reducing intraoperative blood loss and postoperative edema and ecchymosis among patients undergoing primary elective rhinoplasty. Data Sources: A systematic review and meta-analysis was undertaken in an academic medical setting using Medline, Embase, and Google Scholar from inception to June 30, 2018. All references of included articles were screened for potential inclusion. The search was mapped to Medical Subject Headings, and the following terms were used to identify potential articles: reconstruction or rhinoplasty and tranexamic acid or anti-fibrinolysis or antifibrinolysis and bleeding or ecchymosis or bruising or edema or complications. Study Selection: The population of interest consisted of adult patients undergoing primary elective rhinoplasty. The intervention was the use of tranexamic acid. The control group was composed of patients receiving a placebo. Primary outcomes were intraoperative blood loss and postoperative edema and ecchymosis. In vitro or animal studies were excluded, and only English-language articles were included. Data Extraction and Synthesis: The PRISMA guidelines were followed, and articles were assessed using the Cochrane Collaboration's tool for assessing risk of bias and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Random-effects meta-analysis was performed to determine the overall effect size. Main Outcomes and Measures: The primary outcomes were intraoperative blood loss and postoperative edema and ecchymosis. Results: Five studies (comprising 332 patients) were included in the qualitative analysis, all of which were randomized clinical trials published within the past 5 years. The mean (SD) patient age was 27 (7) years (age range, 16-42 years), while the mean (SD) sample size was 66 (19) (range, 50-96). Meta-analysis of 4 studies (271 patients) indicated that tranexamic acid treatment resulted in a mean reduction in intraoperative blood loss of -41.6 mL (95% CI, -69.8 to -13.4 mL) compared with controls (P = .004). Three studies indicated that postoperative edema and ecchymosis were reduced with tranexamic acid treatment compared with controls; however, there was no significant difference compared with corticosteroid use. Four studies were considered of high methodological quality, with a low risk of bias. The overall quality of evidence was high. Conclusions and Relevance: Tranexamic acid has the ability to significantly reduce intraoperative blood loss and postoperative edema and ecchymosis among patients undergoing primary elective rhinoplasty. Level of Evidence: 4.
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8.
Does topical application of tranexamic acid reduce intraoperative bleeding in sinus surgery during general anesthesia?
Kang H, Hwang SH
Brazilian journal of otorhinolaryngology. 2019
Abstract
INTRODUCTION Tranexamic acid is a hemostatic agent, which inhibits fibrin degradation, which may be beneficial in controlling bleeding during surgery. OBJECTIVES The purpose of this study was to provide a meta-analysis and review of the effects of tranexamic acid on hemorrhage and surgical fields and side effects on patients during endoscopic sinus surgery. METHODS Two authors independently searched six databases (Medline, SCOPUS, Embase, Web of Science, Google Scholar and Cochrane library) from the start of article collection until July 2018. Postoperative complications such as intraoperative bleeding, operative time, hypotension, nausea, vomiting, and coagulation profile were included in the analysis of tranexamic acid (Treatment Group) and placebo (Control Group) during the operation. RESULTS The amount of blood loss during surgery was statistically lower in the treatment group compared to the placebo group, and the surgical field quality was statistically higher in the treatment group than in the placebo group. On the other hand, there was no significant difference in operation time, hemodynamics, or coagulation profile between groups. In addition, tranexamic acid had no significant effect on vomiting and thrombosis compared to the Control Group. CONCLUSION This meta-analysis has shown that topical administration of tranexamic acid can reduce the amount of bleeding during surgery and improve the overall quality of the surgery. Hemodynamic instability during surgery, vomiting after surgery, or abnormal clotting profile were not reported. Additional studies are needed to confirm the results of this study because there are fewer studies.
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9.
Tranexamic Acid Decreases Blood Transfusion Burden in Open Craniosynostosis Surgery Without Operative Compromise
Lu VM, Goyal A, Daniels DJ
The Journal of Craniofacial Surgery. 2018;30((1):):120-126.
Abstract
In the surgical management of craniosynostosis, there is a high red blood cell (RBC) transfusion burden due to the small blood volume of the patients combined with significant blood loss that can occur with open surgery (OS). Tranexamic acid (TXA) is an antifibrinolytic which has been shown to decrease such a burden in particular surgeries. The aim of this study was to compare the operative outcomes of craniosynostosis OS which did and did not utilize TXA. Searches of 7 electronic databases from inception to February 2018 were conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. There were 206 articles screened against selection criteria for inclusion. Relevant data were extracted and analyzed using meta-analysis of proportions. A total of 9 comparative studies were included for meta-analysis. Compared with the control cohort, craniosynostosis OS utilizing TXA demonstrated significantly lower intraoperative RBC transfusion volumes (mean difference, -8.25 mL/kg; P < 0.001), blood loss (mean difference, -10.96 mL/kg; P < 0.001) and postoperative RBC transfusion incidence (odds ratio, OR, 0.12; P = 0.005). Fresh frozen plasma and crystalloid transfusion, operation time, length of stay, and complications were not significantly different with TXA use. Based on the comparative evidence currently available, TXA significantly decreased RBC transfusion burden during craniosynostosis OS without operative compromise. There is significant heterogeneity in reported TXA regimes in the literature. Future studies that are larger, randomized, and account for these factors will further enhance the authors' understanding.
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10.
Efficacy of tranexamic acid on operative bleeding in endoscopic sinus surgery: A meta-analysis and systematic review
Kim DH, Kim S, Kang H, Jin HJ, Hwang SH
The Laryngoscope. 2018
Abstract
OBJECTIVES Tranexamic acid might help control bleeding during surgery because of antifibrinolytic characteristics. We aimed to evaluate the effectiveness of systemic tranexamic acid compared to control in blood loss, operative time, and surgical field and incidence of postoperative emesis and thromboembolism in endoscopic sinus surgery. METHODS Two authors independently searched six databases (PubMed, SCOPUS, Embase, the Web of Science, Google Scholar, and the Cochrane database) from their inception to July 2018. The included studies compared perioperative tranexamic acid administration (treatment group) with a placebo, and the outcomes of interest were intraoperative morbidities, including surgical time, operative bleeding, and hypotension; postoperative morbidities such as nausea and vomiting; and coagulation profiles. RESULTS Seven studies comprising 562 participants were reviewed in this study. Operative time (standardized mean difference (SMD) = -0.60; 95% confidence interval (CI)[-0.93, -0.29]) and intraoperative blood loss (SMD = -0.66; 95% CI [-0.86, -0.46]) were statistically lower in the treatment group than placebo group; and the quality of the surgical field (SMD = -0.80; 95% CI [-1.12; -0.48]) and surgeon satisfaction (SMD = 1.74; 95% CI [1.36; 2.13]) were statistically higher in the treatment group than the placebo group. By contrast, there were no significant differences in the hemodynamic (SMD = 0.08; 95% CI [-0.20; 0.37]) and coagulation profiles (SMD = -0.18; 95% CI [-0.42, 0.07]) of the two groups. Additionally, tranexamic acid had no significant effect on emetic or thrombotic events compared to placebo. CONCLUSION This meta-analysis showed that the systemic administration of tranexamic acid could decrease operative time and blood loss intraoperatively, increasing the satisfaction of surgeons. It did not provoke intraoperative hemodynamic instability, postoperative emetic events, or coagulation profile abnormality. Only a small number of studies were enrolled, so further trials are needed to confirm the results of this study. LEVEL OF EVIDENCE IA. Laryngoscope, 2018.