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Severely injured trauma patients with admission hyperfibrinolysis: Is there a role of tranexamic acid? Findings from the PROPPR trial
Khan M, Jehan F, Bulger EM, O'Keeffe T, Holcomb JB, Wade CE, Schreiber MA, Joseph B, PROPPR Study Group
The Journal of Trauma and Acute Care Surgery. 2018;85((5)):851-857.
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Abstract
INTRODUCTION Administration of tranexamic acid (TXA) in coagulopathy of trauma gained popularity after the CRASH-2 trial. The aim of our analysis was to analyze the role of TXA in severely injured trauma patients with admission hyperfibrinolysis. METHODS We reviewed the prospectively collected Pragmatic, Randomized Optimal Platelet and Plasma Ratios database. We included patients with admission hyperfibrinolysis (Ly30 >3%) on thromboelastography. Patients were stratified into two groups (TXA and No-TXA) and were matched in 1:2 ratio using propensity score matching for demographics, admission vitals, and injury severity. Primary outcome measures were 6-, 12-, and 24-hour and 30-day mortality; 24-hour transfusion requirements; time to achieve hemostasis; and rebleeding after hemostasis requiring intervention. Secondary outcome measures were thrombotic complications. RESULTS We analyzed 680 patients. Of those, 118 had admission hyperfibrinolysis, and 93 patients (TXA: 31 patients; No-TXA: 62 patients) were matched. Matched groups were similar in age (p = 0.33), gender (p = 0.84), race (p = 0.81), emergency department (ED) Glasgow Coma Scale (p = 0.34), ED systolic blood pressure (p = 0.28), ED heart rate (p = 0.43), mechanism of injury (p = 0.45), head Abbreviated Injury Scale score (p = 0.68), injury severity score (p = 0.56), and blood products ratio (p = 0.44). Patients who received TXA had a lower 6-hour mortality rate (34% vs. 13%, p = 0.04) and higher 24-hour transfusion of plasma (15 vs. 10 units, p = 0.03) compared with the No-TXA group. However, there was no difference in 12-hour (p = 0.24), 24-hour (p = 0.25), and 30-day mortality (p = 0.82). Similarly, there was no difference in 24-hour transfusion of RBC (p = 0.11) or platelets (p = 0.13), time to achieve hemostasis (p = 0.65), rebleeding requiring intervention (p = 0.13), and thrombotic complications (p = 0.98). CONCLUSION Tranexamic acid was associated with increased 6-hour survival but does not improve long-term outcomes in severely injured trauma patients with hemorrhage who develop hyperfibrinolysis. Moreover, TXA administration was not associated with thrombotic complications. Further randomized clinical trials will identify the subset of trauma patients who may benefit from TXA. LEVEL OF EVIDENCE Therapeutic study, level III.
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Tranexamic acid in shoulder arthroplasty: a systematic review and meta-analysis
Kirsch JM, Bedi A, Horner N, Wiater JM, Pauzenberger L, Koueiter DM, Miller BS, Bhandari M, Khan M
Jbjs Reviews. 2017;5((9):):e3
Abstract
BACKGROUND The role of tranexamic acid (TXA) in reducing blood loss following primary shoulder arthroplasty has been demonstrated in small retrospective and controlled clinical trials. This study comprehensively evaluates current literature on the efficacy of TXA to reduce perioperative blood loss and transfusion requirements following shoulder arthroplasty. METHODS PubMed, MEDLINE, CENTRAL, and Embase were searched from the database inception date through October 27, 2016, for all articles evaluating TXA in shoulder arthroplasty. Two reviewers independently screened articles for eligibility and extracted data for analysis. A methodological quality assessment was completed for all included studies, including assessment of the risk of bias and strength of evidence. The primary outcome was change in hemoglobin and the secondary outcomes were drain output, transfusion requirements, and complications. Pooled outcomes assessing changes in hemoglobin, drain output, and transfusion requirements were determined. RESULTS Five articles (n = 629 patients), including 3 Level-I and 2 Level-III studies, were included. Pooled analysis demonstrated a significant reduction in hemoglobin change (mean difference [MD], -0.64 g/dL; 95% confidence interval [CI], -0.84 to -0.44 g/dL; p < 0.00001) and drain output (MD, -116.80 mL; 95% CI, -139.20 to -94.40 mL; p < 0.00001) with TXA compared with controls. TXA was associated with a point estimate of the treatment effect suggesting lower transfusion requirements (55% lower risk); however, the wide CI rendered this effect statistically nonsignificant (risk ratio, 0.45; 95% CI, 0.18 to 1.09; p = 0.08). Findings were robust with sensitivity analysis of pooled outcomes from only Level-I studies. CONCLUSIONS Moderate-strength evidence supports use of TXA for decreasing blood loss in primary shoulder arthroplasty. Further research is necessary to evaluate the efficacy of TXA in revision shoulder arthroplasty and to identify the optimal dosing and route of administration of TXA in shoulder arthroplasty. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.