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Optimal administration strategies of tranexamic acid to minimize blood loss during spinal surgery: results of a Bayesian network meta-analysis
Cao Z, Li Q, Guo J, Li Y, Wu J
Annals of medicine. 2022;54(1):2053-2063
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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.
PICO Summary
Population
Patients undergoing spinal surgery (33 studies, n= 3,302).
Intervention
Tranexamic acid (TXA).
Comparison
Various comparators: low-dose intravenous (IV), high-dose IV, low-dose topical, high-dose topical, combined use (IV plus topical), oral, local infiltration, multiple IV use before and after surgery, and placebo.
Outcome
The surface under the cumulative ranking analysis (SUCRA) and clustering rank analysis was performed for ranking the effects. Combination administration showed superior effects on reducing intraoperative bleeding (SUCRA 78.78%, weighted mean difference (MD) -129.67) than placebo, and was ranked as top in reducing postoperative bleeding (SUCRA 86.91%, MD -169.92), changes in haemoglobin (SUCRA 97.21%, MD -1.28), and perioperative blood transfusion (SUCRA 93.23%) simultaneously, and was shown as the best effectiveness and safety.
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The comparative efficacies of intravenous administration and intra-articular injection of tranexamic acid during anterior cruciate ligament reconstruction for reducing postoperative hemarthrosis: a prospective randomized study
Ma R, Wu M, Li Y, Wang J, Wang W, Yang P, Wang K
BMC musculoskeletal disorders. 2021;22(1):114
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).
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Combined use of tranexamic acid and rivaroxaban in posterior lumbar interbody fusion safely reduces blood loss and transfusion rates without increasing the risk of thrombosis-a prospective, stratified, randomized, controlled trial
Zhang L, Li Y, Liu D, Xiao X, Guan T, Yue H, Xue H, Zhou H, Jiao G, Wu W, et al
Int Orthop. 2020
Abstract
PURPOSE This prospective, stratified, randomized, single-blind, placebo-controlled multicentre study investigated the safety and effectiveness of reducing blood loss and preventing venous thromboembolism (VTE) during posterior lumbar interbody fusion (PLIF) in patients with stenosis or spondylolisthesis using the combination of tranexamic acid (TXA) and rivaroxaban. METHODS The Autar score was evaluated in patients after admission. Patients with an Autar score ≤ 10 were randomized to group A or B. Group A was the placebo-controlled group. Patients in group B were treated with 1 g TXA via intravenous injection and 1 g TXA for external use. Patients with an Autar score > 10 were randomized to group C or D. Patients in group C were treated with 10-mg rivaroxaban qd for 35 days after surgery. Patients in group D received the same treatment as those in group B intra-operatively and as those in group C post-operatively. RESULTS A total of 599 patients from eight hospitals participated in this clinical trial. The total blood loss, intra-operative blood loss, and drainage volume were reduced by the administration of TXA (group A vs group B, P < 0.01; group C vs group D, P < 0.01), and the blood transfusion rate was also decreased (group A vs group B, P < 0.01; group C vs group D, P < 0.01). There were no significant differences (P > 0.05) in the VTE incidence rates among group A and group B. In patients with high-risk thrombosis, the number of patients with VTE was only three and seven after the application of rivaroxaban. Epidural haematoma was not discovered in any patients in our trial. CONCLUSION The combined application of tranexamic acid and rivaroxaban significantly reduced the amount of blood loss and the transfusion rate during PLIF surgery and avoided an increase in the probability of thrombosis and the occurrence of epidural haematoma. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION ChiCTR-1800016430 2018-06-01.
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Tranexamic Acid for Blood Loss after Transforaminal Posterior Lumbar Interbody Fusion Surgery: A Double-Blind, Placebo-Controlled, Randomized Study
He B, Li Y, Xu S, Ou Y, Zhao J
BioMed research international. 2020;2020:8516504
Abstract
BACKGROUND Transforaminal lumbar interbody fusion (TLIF) may result in significant blood loss and an increase in blood transfusion. Though tranexamic acid (TXA) is widely studied for the hemostasis of arthroplasty, there is little information on the use of TXA for TLIF surgery. METHODS This prospective randomized, double-blind, placebo-controlled trial was conducted to study the influence of TXA (intravenous bolus of 10 mg/kg 15 minutes before skin incision followed by intravenous infusion of 6-8 mg/kg/h up to a total dose of 15 mg/kg during the surgery) on the blood loss and Enhanced Recovery After Surgery (ERAS) after TLIF surgery. 40 patients were randomized into two groups: TXA group (tranexamic acid) and control group (placebo). Baseline characteristics were comparable between the TXA group and the control group before the surgery. Outcomes assessed included blood loss, total postoperative drainage, time for drainage removal, time to ambulation, hospital stay after surgery, postoperative hemoglobin (Hb) one day after surgery, and adverse events. RESULTS Compared to patients in the control group after TLIF surgery, patients in the TXA group have significantly reduced intraoperative hemorrhage and time to ambulation after surgery but show similar hospital stay, postoperative drainage, time for drainage removal, postoperative Hb one day after surgery, and adverse events. CONCLUSIONS TXA shows important ability in controlling blood loss and promoting the ERAS after TLIF surgery.
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[Application of intravenous injection of tranexamic acid combined with local use of tranexamic acid cocktail in intertrochanteric fracture fixation]
Zhang Q, Xiang C, Chen X, Chen L, Chen Q, Jiang K, Chen L, Li Y, Wei P
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2020;34(4):463-468
Abstract
Objective: To explore the efficacy and safety of intravenous injection of tranexamic acid (TXA) combined with local use of TXA cocktail in intertrochanteric fracture fixation with proximal femoral nail antirotation (PFNA). Methods: Patients with intertrochanteric fractures who underwent close reduction and internal fixation with PFNA between February 2018 and March 2019 were enrolled in the study. Among them, 45 patients who met the selection criteria were included in the study and randomly allocated into 3 groups ( n=15). The patients in group A were not received TXA during perioperative period. The patients were intravenously injected of 1.0 g TXA before operation in group B and combined with local use of TXA cocktail during operation in group C. There was no significant difference in the age, gender, body mass index, fracture classification, disease duration, and complications between groups ( P>0.05). The perioperative blood loss and blood transfusion rate, the visual analogue scale (VAS) score before operation and at 12, 24, and 48 hours after operation, the levels of prostaglandin E2 (PGE2) and bradykinin (BK) before operation and at 1 and 3 days after operation, postoperative complications, and the maximum amplitude (MA) of thromboelastogram were recorded and compared between groups. Results: The total blood loss, hidden blood loss, and visible blood loss were significantly lower in groups B and C than those in group A ( P<0.05), and the total blood loss and hidden blood loss were significantly lower in group C than those in group B ( P<0.05). There was no significant difference in the blood transfusion rate, preoperative VAS scores and the levels of PGE2 and BK between groups ( P>0.05). The postoperative VAS scores and the levels of PGE2 and BK were significantly lower in group C than in groups A and B ( P<0.05). There was no significant difference in pre- and post-operative MA of thromboelastogram between groups ( P>0.05). The incidences of postoperative complications were 33.33% (5/15), 20.00% (3/15), and 13.33% (2/15) in groups A, B, and C, respectively, with no significant difference between groups ( chi (2)=1.721, P=0.550). Conclusion: For intertrochanteric fractures, application of intravenous injection of TXA combined with local use of TXA cocktail in PFNA fixation can reduce perioperative blood loss, relieve pain after operation, and do not increase the risk of complications.
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Efficacy of aminocaproic acid in the control of bleeding after total knee and hip arthroplasty: A systematic review and meta-analysis
Li Y, Wang J
Medicine. 2019;98(9):e14764
Abstract
BACKGROUND To assess the effectiveness and safety of intravenous aminocaproic acid for blood management after total knee and hip arthroplasty. METHODS Electronic databases: PubMed (1950.1-2018.8), EMBASE (1974.1-2018.8), the Cochrane Central Register of Controlled Trials (CENTRAL, 2017.10), Web of Science (1950.1-2018.8), and CNKI (1980.1-2018.8) were systematically searched for clinical controlled trials comparing intravenous aminocaproic acid and placebo after joint arthroplasties. Heterogeneity was assessed using the chi-square test and I-square statistic. The meta-analysis was performed using STATA 12.0 (College Station, TX). RESULTS Six studies with 756 patients were included. Our meta-analysis revealed that there were significant differences between aminocaproic acid and placebo in terms of total blood loss (SMD = -0.673, 95% CI: -0.825 to -0.520, P <.001), hemoglobin reduction (SMD = -0.689, 95% CI: -0.961 to -0.418, P <.001), drain output (SMD = -2.162, 95% CI: -2.678 to -1.646, P <.001) and transfusion rates (RD = -0.210, 95% CI: -0.280 to -0.141, P <.001). CONCLUSION Aminocaproic acid results in a significant reduction of total blood loss, postoperative hemoglobin decline and transfusion requirement in patients undergoing arthroplasties. Due to the limited quality of the evidence currently available, the results of our meta-analysis should be treated with caution.
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Oral tranexamic acid reduces blood loss in total-knee arthroplasty: A meta-analysis
Li H, Bai L, Li Y, Fang Z
Medicine. 2018;97((45)):e12924.
Abstract
BACKGROUND Postoperative hemorrhage following total-knee arthroplasty (TKA) remains an important topic. The objective of the meta-analysis is to assess the effectiveness of oral antifibrinolytics for blood management in patients undergoing TKA. METHODS We searched Medline (1966 to August 2018), PubMed (1966 to August 2018), Embase (1980 to August 2018), ScienceDirect (1985 to August 2018), and the Web of Science (1995 to August 2018) for randomized control trials (RCTs). To assess the heterogeneity of study trial and determine the model for analysis (random-effect model or fixed-effect model), I tests and Chi-squared were conducted. We utilized the STATA 12.0 (StataCorp, College Station, TX) to perform all statistical analyses. RESULTS A total of 5 RCTs met our inclusion criteria. This meta-analysis shows that there are significant differences between the 2 groups regarding total blood loss, hemoglobin reduction, and transfusion rates. In addition, no adverse effects were identified in treatment groups. CONCLUSION The oral form of antifibrinolytics in TKA is able to significantly decrease blood loss, postoperative hemoglobin reduction, as well as transfusion requirements. No increased risk of postoperative complications was observed. Higher quality RCTs is necessary to confirm our finding.
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Efficacy and safety of tranexamic acid in bilateral total knee replacement: a meta-analysis and systematic review
He P, Zhang Z, Li Y, Xu D, Wang H
Medical Science Monitor.. 2015;21:3634-42.
Abstract
BACKGROUND Tranexamic acid (TXA) has been well documented to reduce blood loss and transfusion requirements in patients undergoing unilateral total knee arthroplasty (TKA). However, the efficacy and safety of TXA in simultaneous bilateral TKA have not been clearly defined. The aim of our study was to systematically review the existing evidence regarding the role of TXA in patients undergoing simultaneous bilateral TKA. MATERIAL AND METHODS A systematic search of all studies published through June 2014 was performed using Medline, EMBASE, OVID, and other databases. All studies that compared the efficacy and safety of TXA administration in simultaneous bilateral TKA patients were identified. The data from the included trials were extracted and analyzed regarding blood loss and transfusion rates. The evidence quality levels of the selected articles were evaluated using a grading system. RESULTS Six studies were included, in which a total of 245 patients received TXA and 271 patients were controls. Overall, the results demonstrated that the use of TXA significantly reduced total blood loss by a mean of 371.1 ml (95% confidence interval (CI)=-412.12 to -330.09; p<0.001) and reduced the number of patients requiring blood transfusion (risk ratio (RR)=0.16; 95% CI=0.10 to 0.28; p<0.001). No significant differences in adverse effects such as deep vein thrombosis (DVT) or pulmonary embolism (PE) were noted in any group. CONCLUSIONS The intravenous use of TXA in patients undergoing simultaneous bilateral TKA is effective and safe and results in significantly reduced estimated blood loss and transfusion rates. No significant difference was observed in the incidence of side effects. Due to the limitations in the evidence quality of current meta-analyses, well-conducted, larger, high-quality randomized controlled trials (RCTs) are required.
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Tranexamic acid reducing blood transfusion in children undergoing craniosynostosis surgery
Song G, Yang P, Zhu S, Luo E, Feng G, Hu J, Li J, Li Y
Journal of Craniofacial Surgery. 2013;24((1):):299-303.
Abstract
BACKGROUND Surgical correction of craniosynostosis in children is associated with substantial intraoperative bleeding. Intraoperatively administered tranexamic acid (TXA) can lessen blood loss during orthopedic and cardiovascular surgery, but its efficacy in craniosynostosis surgery is uncertain. Therefore, a meta-analysis performed with published comparative studies was to determine whether TXA could reduce packed red blood cells (or erythrocytes) (PRBCs) transfused and blood loss during pediatric craniosynostosis surgery. METHODS Two PubMed and EMBASE electronic databases were searched until June 2012. Eligible studies were restricted in comparative controlled trials. RESULTS Four studies in 3 articles with 138 patients were included. The results showed that intraoperative administration of TXA can significantly reduce transfusion of PRBCs (weighed mean difference [WMD] = -10.81, 95% confidence interval [CI] = -16.84 to -4.78, P < 0.00001). In the level of blood loss, the meta-analysis on 4 studies showed that the difference was statistically significant (WMD = -20.53, 95% CI = -32.26 to -8.80, P = 0.0006) between the TXA groups and the control groups. However, the subgroup analysis on randomized controlled trials showed that TXA did not significantly reduce blood loss during surgery compared with the placebo group (WMD = -30.79, 95% CIs = -71.72 to 10.14, P = 0.14). CONCLUSIONS Tranexamic acid can significantly reduce the transfusion of PRBCs in children undergoing craniosynostosis surgery. However, there is a controversy on the efficacy of TXA in reducing blood loss. Therefore, new randomized controlled trials to assess the effects of TXA in children with craniosynostosis surgery should be conducted. Journal Article.
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10.
The effect of tranexamic acid on blood loss in orthognathic surgery: a meta-analysis of randomized controlled trials
Song G, Yang P, Hu J, Zhu S, Li Y, Wang Q
Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2013;115((5):):595-600.
Abstract
OBJECTIVE The objective of this article was to evaluate the efficacy of tranexamic acid on blood loss in orthognathic surgery. A meta-analysis was performed. STUDY DESIGN The PubMed and EMBASE electronic databases were searched until June 30, 2012. Eligible studies were restricted to randomized controlled trials (RCTs). RESULTS Four RCTs with 183 patients were included. The results showed that intraoperative blood loss in the tranexamic acid group was statistically reduced (weighted mean difference [WMD] = -93.56, 95% CI = -132.59-54.52, P < .00001). However, the postoperative levels of hemoglobin (Hb) and hematocrit (Hct) have no significant difference compared with placebo groups (WMD = 0.50, 95% CIs = -0.43-1.43, P = .29 and WMD = 0.18, 95% CIs = -1.64-1.99, P = .85, respectively). CONCLUSIONS This meta-analysis confirms that tranexamic acid can effectively reduce intraoperative blood loss in orthognathic surgery, especially by intravenous administration. But, tranexamic acid cannot affect postoperative levels of Hb and Hct. Copyright 2013 Elsevier Inc. All rights reserved.