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Evaluation of the Safety and Effectiveness of Topical Intrapleural Application of Tranexamic Acid in Thoracic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Clin Appl Thromb Hemost. 2023 Jan-Dec;29:10760296231218215 doi: 10.1177/10760296231218215.
PICO Summary
POPULATION:

Patients undergoing thoracic surgery procedures (3 randomised controlled trials, n= 399).

INTERVENTION:

Topical intrapleural tranexamic acid (TXA).

COMPARISON:

Placebo.

OUTCOME:

The primary outcome of postoperative blood loss at 24 hours was significantly lower in patients who received TXA (mean difference [MD] -93.6 ml; 95% CI [-121.8, -65.4 ml], I(2)= 45%). The need for red blood cell transfusion was significantly lower in the topical TXA group compared to control (MD -0.5 units; 95% CI [-0.8, -0.3 units], I(2)= 60%). There was no significant difference in the hospital length of stay, (MD -0.3 days; 95% CI [-0.9, 0.4 days], I(2)= 0%). These results remained consistent after several sensitivity analyses.

Abstract
OBJECTIVES:

Bleeding remains a common complication post-thoracic surgery. Although intravenous tranexamic acid (TXA) has been shown to decrease blood loss, its use has been associated with adverse effects. Accordingly, topical TXA has been proposed as an alternative to reduce bleeding with fewer systemic complications.

METHODS:

We searched Medline, Embase, and Cochrane Central databases for randomized controlled trials (RCTs) comparing topical TXA versus control (i.e., placebo) in patients undergoing thoracic procedures. The primary outcome was total postoperative blood loss at 24 hours. Secondary outcomes included were the number of red blood cell (RBC) transfusions, and hospital length of stay (LOS). Meta-analyses were pooled using mean difference with inverse-variance weighting and random-effects.

RESULTS:

Out of the 575 unique studies that were screened, we identified three randomized controlled trials (RCTs) involving 399 patients. Out of the three RCTs analyzed, two studies, accounting for 67% of the total, were found to have a low risk of bias. The primary outcome of 24-h post-operative blood loss was significantly lower in patients who received TXA (mean difference [MD] -93.6 ml, 95% CI -121.8 to -65.4 ml, I2 = 45%). In addition, the need for RBC transfusion was significantly lower in the topical TXA group compared to control (MD -0.5 units, 95% CI -0.8 to -0.3 units, I2 = 60%). However, there was no significant difference in the hospital length of stay (LOS) (MD -0.3 days, 95% CI -0.9 to 0.4 days, I2 = 0%). These results remained consistent after several sensitivity analyses. The use of topical intrapleural tranexamic acid has also been found to be safe without any significant safety concerns.

CONCLUSION:

Topical intrapleural TXA reduces blood loss and the need for blood transfusions during thoracic surgery. In addition, there is no evidence of the increased safety concerns associated with its use. Larger trials are necessary to validate these findings and evaluate the safety and efficacy of different dosages.

Metadata
KEYWORDS: blood loss; thoracic surgery; topical intrapleural; tranexamic acid
MESH HEADINGS: Humans; Tranexamic Acid; Antifibrinolytic Agents; Thoracic Surgery; Blood Loss, Surgical; Administration, Topical; Randomized Controlled Trials as Topic; Postoperative Hemorrhage
Study Details
Study Design: Systematic Review
Language: eng
Credits: Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine