Abstract

BACKGROUND Tranexamic acid (TXA) is widely used across surgical specialties to reduce perioperative bleeding. It has been shown to be effective in spinal surgery and lower limb arthroplasty. Among all languages, there are no systematic reviews or meta-analyses investigating its clinical effectiveness for all types of shoulder surgery. PURPOSE To investigate the clinical effectiveness of TXA in all types of shoulder surgery, including open and arthroscopic procedures. To investigate the effect of TXA on bleeding and non-bleeding-related outcomes. STUDY DESIGN Systematic review and meta-analysis. METHODS A protocol for the study was designed and registered with PROSPERO (CRD42020185482). The literature search included the MEDLINE, Embase, PsycINFO, and Cochrane Library databases. All randomized controlled trials evaluating the use of TXA against placebo, in all types of shoulder surgery, were included. Assessments were undertaken for risk of bias and certainty of evidence. The primary outcome was total blood loss. Secondary outcomes included those not directly related to bleeding. Data from comparable outcomes were pooled and analyzed quantitatively or descriptively, as appropriate. RESULTS Eight randomized controlled trials were included in the systematic review, and data from 7 of these studies were pooled in the meta-analysis. Pooled analysis demonstrated a significant reduction in 2 of 3 outcomes measuring perioperative bleeding with TXA compared with controls: estimated total blood loss (mean difference, -209.66 mL; 95% CI, -389.11 to -30.21; P = .02) and postoperative blood loss as measured by drain output (mean difference, -84.8 mL; 95% CI, -140.04 to -29.56; P = .003). Hemoglobin reduction was reduced but not statistically significant (mean difference, -0.33 g/dL; 95% CI -0.69 to 0.03; P = .07). This result became significant with sensitivity analysis excluding arthroscopic procedures. CONCLUSION This systematic review and meta-analysis indicated that TXA was effective in reducing blood loss in shoulder surgery. Larger randomized controlled trials with low risk of bias for specific surgical shoulder procedures are required. CLINICAL RELEVANCE TXA can be used across shoulder surgery to reduced perioperative blood loss. The use of TXA may have other beneficial features, including reduced postoperative pain and reduced operative time.

Abstract

BACKGROUND Melasma is one of the common pigmentary problems affecting females in our community, owing to the frequent use of hormonal contraceptives as well as our sunny climate. A lot of treatment options are available but none of them is completely satisfactory. Many patients prefer the use of topical preparations and minimally invasive methods. Tranexamic acid (TA) is a potential treatment option for hyperpigmentation with different delivery routes. AIM: We designed the study in order to evaluate the efficacy of TA in melasma using 2 different routes of delivery. PATIENTS AND METHODS A randomised clinical trial was performed on 60 female patients with melasma, they randomly divided into three groups; A, B and C. Group (A) patients received TA (4 mg/mL) intradermal injections every 2 weeks with, group B received TA (10 mg/mL) intradermal injections every 2 weeks, group C received TA cream (10% concentration) twice daily, treatment continued for 12 weeks in all groups. Melasma Area and Severity Index (MASI) scores were measured for each patient before and after completion of treatment. RESULTS The percentage of MASI score reduction was highest in group B (62.7%) versus (39.1%) in group A, while the percentage of MASI reduction was the lowest in group C (4.2%). CONCLUSION Tranexamic acid is a safe effective and well-tolerated treatment option for melasma patients. Intradermal injection of TA leads to better results than the topical application. Topical TA cream (even in a high concentration) produce fair improvement of melasma.

Abstract

INTRODUCTION Upper gastrointestinal (GI) bleeding is associated with increased morbidity and mortality. Tranexamic acid (TXA) is an antifibrinolytic agent which is licensed in the management of haemorrhage associated with trauma. It has been suggested that tranexamic acid may be able to play a role in upper GI bleeding. However, there is currently no recommendation to support this. AIM: The aim of this study was to synthesise available evidence of the effect of TXA on upper GI bleeding. METHODS AND MATERIALS A systematic review was conducted. PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for relevant studies. A random effects meta-analysis was performed to determine the risk ratio of primary and secondary outcomes pertaining to the use of TXA in upper GI bleeding. RESULTS A total of 8 studies were included in this systematic review. The total number of patients in all studies was 12994 including 4550 females (35%) and 8444 males (65%). The mean age of participants in 6 of the studies was 59.3; however the mean age for either intervention or placebo group was not reported in two of the studies. All studies reported on the effect of TXA on mortality, and the risk ratio was 0.95; however, with the 95% CI ranging from 0.80 to 1.13, this was not statistically significant. 6 of the studies reported on rebleeding rate, the risk ratio was 0.64, and with a 95% CI ranging from 0.47 to 0.86, this was statistically significant. 3 of the studies reported on the risk of adverse thromboembolic events, and the risk ratio was 0.93; however, the 95% CI extended from 0.62 to 1.39 and so was not statistically significant. 7 of the studies reported on the need for surgery, and the risk ratio was 0.59 and was statistically significant with a 95% CI ranging from 0.38 to 0.94. CONCLUSION In conclusion, the use of TXA in upper GI bleeding appears to have a beneficial effect in terms of decreasing the risk of re-bleeding and decreasing the need for surgery. However, we could not find a statistically significant effect on need for blood transfusions, risk of thromboembolic events, or effect on mortality. Future randomised controlled trials may elucidate these outcomes.

Abstract

BACKGROUND Hemarthrosis after anterior cruciate ligament (ACL) reconstruction can create many adverse joint effects. Tranexamic acid (TXA) can be used to minimize hemarthrosis and associated pain after ACL reconstruction. We aimed to compare the efficacies of intravenous (IV) administration and intra-articular (IA) injection of TXA during ACL reconstruction for reducing postoperative hemarthrosis. METHODS A total of 120 patients who underwent arthroscopic ACL reconstruction were included in this prospective and randomized study. All patients were randomized into three groups: IV group, IA group and placebo group. Patients in the IV group received intravenously administered TXA (15 mg/kg in 100 mL of saline solution) 10 min before tourniquet release; patients in the IA group received intra-articular TXA (15 mg/kg in 100 mL of saline solution) injected via the drainage tube; and patients in the placebo group received an equivalent volume of normal saline administered into the knee joint cavity and intravenously. Drainage tubes were removed 24 h after surgery, and all enrolled patients experienced a 4-week follow-up period. The drain output volume, visual analogue scale (VAS) score, patellar circumference, hemarthrosis grade and Lysholm score of all patients were recorded. RESULTS Both the IV group and the IA group had significantly lower drain output volumes at day 1, lower VAS scores at weeks 1 and 2, smaller patellar circumferences at weeks 1 and 2, and lower hemarthrosis grades at weeks 1 and 2 than the placebo group (p < 0.05). There were no significant differences in drain output volume, VAS score, patellar circumference or hemarthrosis grade between the IV group and the IA group at any time point (p > 0.05). No obvious differences in Lysholm score were observed between any pair of groups at week 4 (p > 0.05)). Neither infection nor deep vein thrombosis occurred in any group. CONCLUSIONS Both intravenous administration and intra-articular injection can reduce intra-articular hemarthrosis, joint pain and swelling during ACL reconstruction. No significant difference in the efficacies of reducing hemarthrosis, joint pain and swelling was found between intravenous administration and intra-articular injection. TRIAL REGISTRATION The study was registered by the Chinese Clinical Trial Registry (The comparative efficacies of intravenous administration and intra-articular injection of tranexamic acid during anterior cruciate ligament reconstruction; ChiCTR-INR-17012217 ; August 1, 2017).

Abstract

To compare the effects of oral ε-aminocaproic acid (EACA) as a hemostatic agent versus the use of oral tranexamic acid (TXA) administered in multiple doses pre and postsurgery in patients undergoing elective primary total hip arthroplasty (THA). We enrolled 102 patients that were randomly divided into two groups: received three oral doses of EACA (2000 mg per dose) or three oral doses of TXA (1300 mg per dose). The medication was given according to the following schedule: 2 h before surgery and 6 and 12 h after surgery. The variables analyzed to compare the effectiveness of the hemostatic agents were total blood loss, hidden blood loss, external blood loss, transfusion rate, intraoperative blood loss, decreases in hemoglobin and hematocrit values, surgical drainage output, visual analog scale, and surgical complications. There were no significant differences between any of the study variables for the group receiving oral TXA and the group receiving oral EACA (P > 0.05). Our study showed that the use of oral EACA was similar to its counterpart TXA regarding the evaluated parameters. TXA did not have superior blood conservation effects, safety profile, or differences in functional scales compared with EACA in THA. We consider the use of multiple oral doses of aminocaproic acid at the selected dose to be effective as a standard protocol to achieve less blood loss and a lower rate of transfusion and adverse events related to the medication in patients undergoing a THA.

Abstract

Objective: To compare the effectiveness of tranexamic acid (TXA) in reducing blood loss and decreasing surgery duration in craniomaxillofacial surgery. Methods: The literature was searched systematically for all comparative studies of the effect of TXA on craniomaxillofacial surgery with placebo to evaluate the efficacy of TXA in craniomaxillofacial surgery. The primary outcome was intraoperative blood loss, and secondary outcomes were postoperative hematocrit, postoperative hemoglobin, and operation duration. Results: This systematic review included 16 studies consisting of 958 patients. Meta-analysis revealed that compared with the placebo group, the TXA group showed a significant reduction in intraoperative blood loss of 139.81 mL (95% confidence interval, CI: -179.66 to -99.96 mL; p < 0.01), a shortening of the maxillary surgery duration of 15.48 min (95% CI: -21.03 to -9.92 min; p < 0.01), an elevation of the postoperative hemoglobin level of 0.74 mg/dL (95% CI: 0.42 to 1.07 mg/dL; p < 0.01), and a limited effect on increasing the postoperative hematocrit level of 1.77% (95% CI: 0.17 to 3.36; p = 0.03). Conclusion: The use of TXA in craniomaxillofacial surgery can effectively reduce intraoperative blood loss, maintain elevate postoperative hemoglobin and hematocrit levels, and reduce the operation duration.

Abstract

OBJECTIVES This study aims to investigate whether there was a difference between epinephrine (EPN) and tranexamic acid (TXA) in providing visual clarity during arthroscopic rotator cuff tear repair. PATIENTS AND METHODS This double-blind, prospective, randomized-controlled clinical study included a total of 90 patients (42 males, 48 females; mean age: 55.6±8.3 years; range, 18 to 69 years) in whom either EPN (EPN group, n=47) or TXA-diluted irrigation solutions (TXA group, n=43) were used during rotator cuff tear arthroscopy between December 2017 and November 2019. Arthroscopy was performed using irrigation fluid containing 0.33 mg of EPN per 1 L of saline in the EPN group and 0.42 mg of TXA per 1 L of saline in the TXA group. All procedures were performed by two specialized shoulder surgeons. Visual clarity (primary endpoint) was rated by the operating surgeon using the Visual Analog Scale (VAS) in the immediate postoperative period. Secondary endpoints included total operating time (TOT), potential thrombotic or thromboembolic side effects, mean arterial pressure (MAP), and total amount of irrigation fluid used. RESULTS There was no significant difference in the surgeon rated- VAS scores between the groups. The mean VAS score was 7.6±1.62 (range, 4 to 10) in the EPN group and 7.1±1.74 (range, 3 to 10) in the TXA group (p=0.59). No cardiac, thrombotic, or thromboembolic complications were observed in any of the groups. CONCLUSION Adding TXA to the irrigation fluid during the arthroscopic rotator cuff repair may provide similar visual quality to the EPN, as measured by VAS.

Abstract

BACKGROUND Tranexamic acid (TXA) was conducive in total knee arthroplasty (TKA) to reduce blood loss and transfusion demand. The purpose of this meta-analysis was to assess the efficacy and safety of different administration of TXA in primary TKA. METHODS Database PubMed, Medline, Web of Science and Embase were searched. The relative risks (RRs) with 95% confidence intervals (CIs) were calculated to analysis dichotomous outcomes. The mean differences (MD) with 95% CIs were calculated to analysis dichotomous outcomes. Data was analyzed using RevMan 5.3. RESULTS Twenty-eight randomized controlled trials (RCTs) studies were included in this meta-analysis involving a total of 4,200 participants. There were no obvious differences between oral, intravenous or topical TXA group in total blood loss (intravenous vs. topical: MD =11.55, 95% CI, -10.23 to 33.34, oral vs. intravenous or topical: MD =-52.25, 95% CI, -121.28 to 16.78), transfusion rate (intravenous vs. topical: RR =1.04, 95%CI, 0.64 to 1.69, oral vs. intravenous or topical: RR =0.75, 95% CI, 0.36 to 1.54), incidence of venous thrombotic events (VTE) (intravenous vs. topical: RR =1.43, 95% CI, 0.81 to 2.54). The topical TXA administration had significantly increased postoperative hemoglobin (HB) level compared with the intravenous TXA administration (MD =-0.37, 95% CIs, -0.47 to -0.26). In the combined group, the total blood loss (MD =-119.58, 95% CI, -181.68 to -57.49) and postoperative HB level (MD =0.54, 95% CI, 0.45 to 0.64) were more acceptable than the single-route group. CONCLUSIONS Combined administration of TXA can reduce total blood loss, postoperative HB drop compared with intravenous, topical or oral TXA alone. Oral administration of TXA is similar to intravenous or topical TXA use alone.

Abstract

BACKGROUND Even a small amount of bleeding during nose surgery can impair the surgeon's vision, prolong the duration of operation, and affect surgery quality; therefore, various techniques have been proposed to control the bleeding. The aim of this study was to compare the efficacy of the local use of tranexamic acid (TXA) in the dry field of surgery. METHOD This randomized, double-blinded, controlled trial was conducted in the operation room of Imam Reza Hospital, Tehran, Iran, from January 10, 2016 to February 8, 2017. Sixty patients with age range from 20 to 60 years and the American Society of Anesthesiologists physical status classes I candidates who require septoplasty enrolled. Patients were randomized through white and black cards to receive either syringes. Thirty patients in the intervention group received lidocaine + adrenaline + TXA and 30 patients in the control group received lidocaine + adrenaline. Bleeding volume accumulated in the suction chamber, the nasopharyngeal pack, and hemodynamic variations were measured. Surgeon's satisfaction scores and suitability of operation field were obtained from the surgeon by using the Likert scale and Boezaart grading scale, respectively. RESULTS The intervention group had a higher score of surgeon satisfaction [4.1 vs 3.16 in the control group (P = 0.001)] and fewer hemodynamic variations. The mean bleeding volume in the intervention was 187.23 ± 54.61 mL and in the control group was 341.22 ± 49.17 mL (P = 0.001). The mean Boezaart score (suitability of operation field) in the intervention group was 1.8 (score range: 1-3) and in the control group was 2.53 (score range: 2-4) and it was statistically significant (P = 0.001). CONCLUSION The local use of TXA + lidocaine + adrenaline is associated with reduced bleeding, greater surgeon satisfaction, reduced need for Karpol injection, and better hemodynamic stability.

Abstract

BACKGROUND The blood saving efficacy of TXA in cardiac surgery has been proved in several studies, but TXA dosing regimens were varied in those studies. Therefore, we performed this study to investigate if there is a dose dependent in-vivo effect of TXA on fibrinolysis parameters by measurement of fibrinolysis markers in adults undergoing cardiac surgery with CPB. METHODS A double-blind, randomized, controlled prospective trial was conducted from February 11, 2017 to May 05, 2017. Thirty patients undergoing cardiac valve surgery were identified and randomly divided into a placebo group, low-dose group and high-dose group by 1: 1: 1. Fibrinolysis parameters were measured by plasma levels of D-Dimers, plasminogen activator inhibitor-1 (PAI-1), thrombin activatable fibrinolysis inhibitor (TAFI), plasmin-antiplasmin complex (PAP), tissue plasminogen activator (tPA) and thrombomodulin (TM). Those proteins were measured at five different sample times: preoperatively before the TXA injection (T(1)), 5 min after the TXA bolus (T(2)), 5 min after the initiation of CPB (T(3)), 5 min before the end of CPB (T(4)) and 5 min after the protamine administration (T(5)). A Thrombelastography (TEG) and standard coagulation test were also performed. RESULTS Compared with the control group, the level of the D-Dimers decreased in the low-dose and high-dose groups when the patients arrived at the ICU and on the first postoperative morning. Over time, the concentrations of PAI-1, TAFI, and TM, but not PAP and tPA, showed significant differences between the three groups (P <  0.05). Compared with the placebo group, the plasma concentrations of PAI-1 and TAFI decreased significantly at the T3 and T4 (P <  0.05); TAFI concentrations also decreased at the T5 in low-dose group (P < 0.05). Compared with the low-dose group, the concentration of TM increased significantly at the T4 in high-dose group. CONCLUSIONS The in-vivo effect of low dose TXA is equivalent to high dose TXA on fibrinolysis parameters in adults with a low bleeding risk undergoing valvular cardiac surgery with cardiopulmonary bypass, and a low dose TXA regimen might be equivalent to high dose TXA for those patients. TRIAL REGISTRATION ChiCTR-IPR-17010303 , Principal investigator: Zhen-feng ZHOU, Date of registration: January 1, 2017.