Use Of Tranexamic Acid Research Articles

Comparison of Intravenous Tranexamic Acid versus Combined Intravenous and Local Infiltration of Tranexamic Acid in Reducing Perioperative Blood Loss in Patients Undergoing Primary Unilateral Total Hip Arthroplasty: A Randomised Clinical Study

Introduction: The use of Tranexamic Acid (TXA) in primary unilateral Total Hip Arthroplasty (THA) is well documented. However, considering the potential side effects including deep vein thrombosis and pulmonary embolism, the ideal route of administration of TXA to patients undergoing THA is still not known. Aim: To compare the efficacy of single dose intravenous (i.v.) TXA administration versus combined intravenous and local infiltration of TXA in reducing the perioperative blood loss in primary unilateral THA patients. Materials and Methods: This prospective, randomised clinical study, was conducted in the Department of Anaesthesiology and Critical Care at Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India, between October 2020 to May 2021. 60 patients were randomly allocated into two groups: the combined group C (i.v. administration of 10 mg/kg of TXA combined with local infiltration of 600 mg TXA diluted to 60 mL with normal saline) and the single i.v. group S (i.v. administration of 10 mg/kg of TXA). The perioperative blood loss was calculated in terms of three variables- intraoperative blood loss, drainage blood loss and total blood loss. The number of postoperative blood transfusions noted. Student’s t-test and Fischer’s-exact tests were applied for statistical analysis. Results: A total of 60 patients scheduled to have primary unilateral THA. Both the groups were similar in demographic features, baseline biochemical values and procedural distribution. There was a statistically significant reduction in the (mean±SD) intraoperative blood loss (697.26±221.43 mL), drain blood volume (254.66±81.36 mL) and total blood loss (952.26±263.57 mL) in the combined group C when compared to the single group S. There was no statistically significant difference (p-value=0.671) in the postoperative blood transfusion rate between the two groups. Conclusion: Intravenous combined with local infiltration of TXA significantly reduced the perioperative blood loss in patients undergoing primary unilateral THA when compared to single dose intravenous administration of TXA.

Effect of Intravenous Tranexamic Acid in Reducing Blood Loss during and after Elective Caesarean Section in a Third Level Health Institution: A Randomized Controlled Study

Background: Blood loss during caesarean section (C/S) may lead to postpartum haemorrhage, and is one of the direct causes of maternal mortality and morbidity globally. Tranexamic acid is recommended in the treatment of postpartum haemorrhage (PPH) if oxytocin and other utertonics are ineffective in controlling PPH. In this centre it is not used prophylactically to reduce blood during caesarean section. Aim: To assess the effect of prophylactic intravenous tranexamic acid on blood loss during and after elective C/S at the University of Port Harcourt Teaching Hospital (UPTH). Methods: This was a prospective, single-blind, randomized, placebo-controlled interventional study conducted at the Obstetric theatre of UPTH from July 2020 to March 2021. Eligible women were randomized into two groups; seventy-two women received intravenous tranexamic acid while seventy-one women received a placebo. Socio-demographic data and the result of the study were collected through a proforma. Data collected was analyzed using Statistical Package for Social Sciences (SPSS) Version 22.0. The results were expressed in tables and charts as frequencies, percentages and mean. Chi-square test, Fisher’s exact, and T-test were used to determine the relationship between variables. P-value ≤ 0.05 was considered statistically significant. Results: The findings showed that tranexamic acid significantly reduced mean blood loss during and after C/S (p-value post-surgery was significantly lower in the tranexamic acid group (624.88 ± 200.76 ml) in comparison to the placebo group (864.24 ± 229.09 ml), p-value = 0.001. The mean post-C/S packed cell volume (PCV) was significantly higher among the tranexamic acid group (30.68% ± 2.80%) in comparison to the placebo group (28.07% ± 3.27%), t = 5.131, p-value = 0.0001. The maternal side effects were nausea and vomiting, 9 (12.5%) and 1 (1.4%) participants respectively. Conclusion: Tranexamic acid significantly reduced blood loss during and after elective C/S. Maternal side effects were less with tranexamic acid use.

Transfusion-reducing techniques decrease perioperative morbidity of Cesarean hysterectomy for placenta accreta spectrum

Placenta accreta spectrum (PAS) is associated with high rates of hemorrhage and serious morbidity. Transfusion-reducing techniques have been used successfully in cardiac surgery to decrease blood loss and blood utilization. The purpose of this study is to evaluate the impact of these techniques on perioperative morbidity for women undergoing Cesarean hysterectomy for PAS. This cohort study was performed at a tertiary center between 2011-2021 and compared women with prenatally-diagnosed PAS undergoing Cesarean hysterectomy with transfusion-reducing techniques to those having the procedure without. Emergent cases and those with incidentally encountered PAS at delivery were excluded. The treatment group protocol involved iron supplementation, tranexamic acid (TXA), the LigaSure vessel sealing system, intraoperative ultrasound-guided placental mapping, and intraoperative blood salvage (Cell Saver). Outcomes were estimated blood loss (EBL), rates of overall and large-volume transfusion (≥4 units packed red blood cells [pRBC]), and intensive care unit (ICU) utilization. Statistical analysis included chi-square, t-test, or Mann-Whitney U test, with p< 0.05 designated for statistical significance. Of the 55 patients studied, 35 were in the transfusing-reducing group and 20 were in the control group. Groups were similar in terms of age, body mass index, parity, and uterine surgical history; the transfusion-reducing group had higher use of iron, TXA, LigaSure, and placental mapping (Table 1). There was decreased EBL (median 1500 (750 – 2000mL) vs. 2750 (1850 – 3500mL), p < .001), overall transfusion (n=15 (43%) vs. n=17 (85%), p=.004), ≥4 units pRBC transfusion (n=5 (14%) vs. n=12 (60%), p< .001) and ICU admission (n=9 (26%) vs. n=18 (90%), p< .001) in the treatment group (Table 2). Surgical blood loss and blood transfusion can be safely reduced in patients undergoing scheduled Cesarean hysterectomy for suspected PAS by using the principles of transfusion-reducing surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

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.

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. 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. 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. 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.

Retrospective Study on transfusion requirements and deep vein thrombosis incidence with the use of Tranexamic acid on total knee replacement

BACKGROUND Total knee replacement is often associated with significant blood loss and increased rate of blood transfusion. Tranexamic acid is a potent anti-fibrinolytic agent and its use in major surgeries has shown to decrease blood loss as well as transfusion rates. It is used intravenous, oral and topical forms as well. This study aims to find out the effectiveness of systemic Tranexamic acid in terms of decrease in transfusion rate as well incidence of deep vein thrombosis (DVT) and thromboembolism.&#x0D; MATERIALS AND METHODS Total number of patients were 94 of which 58 had bilateral knees replacement and 36 patient underwent unilateral knee replacement over the period of 3 years (December 2018 –December 2021). All patients were screened for general condition as well as any coagulopathy pre –op. All patients were given IV form of Tranexamic acid followed by oral form for 3 days post operatively. Tourniquet was used in all cases and low molecular weight heparin (Clexane) 40 mg subcutaneous once a day for 1-2 days followed by oral aspirin was given for 6 weeks to all patients. SCD calf pumps were used for 4 to 5 days.&#x0D; RESULTS We found that incidence of blood transfusion was only 6.9% in our case series which was well within the incidence reported in varied literature on the use of Tranexamic acid in knee replacement surgery. There was no clinical feature of deep vein thrombosis / pulmonary embolism (DVT/PE) in any of our patients.&#x0D; CONCLUSION Use of Tranexamic acid is a safe and effective method for controlling blood loss and decreasing the transfusion rate after total knee replacement surgery. Its intravenous and oral forms are readily available and cost effective. Its use is not associated with DVT or PE.

USE OF ANTICOAGULANT DRUGS IN THE COMPLEX TREATMENT OF NONUNION OF TIBIA BONES

Relevance. Today there is no generally accepted scope of treatment for nonunion of the tibia. Treatment results are often unsatisfactory. The incomplete process of bone tissue repair is due to the presence of metabolic changes and vascular disorders. This suggests that the use of anti-clotting drugs in the complex treatment may contribute to better treatment results.&#x0D; Objective: to study the effectiveness of the use of antiplatelet drugs bemiparin and tranexamic acid in the complex repair of bone tissue.&#x0D; Materials and methods. 36 patients with tibia nonunion were treated. Complex therapy included surgical treatment (rehabilitation of inflammation and, if present, fistula sequestrectomy), fixation of fragments with ring fixators, antibacterial therapy according to generally accepted principles, conservative therapy of vascular disorders, correction of homeostasis. The comparison group consisted of 42 victims.&#x0D; To correct homeostasis before surgery, 750 mg of tranexamic acid solution was administered intravenously to reduce the risk of bleeding. In 6 hours after surgery, in order to prevent thrombosis, a prophylactic dose of bemiparin (Cibor) 25000 units was administered. The administration was carried out for 7 days. The state of blood homeostasis was assessed on 1, 3 and 7 days after surgery by the following indicators: platelet count, level of soluble fibrin-monomer complexes, prothrombin time, activated partial thromboplastin time, international normalized ratio.&#x0D; The condition of the tibia was assessed by the following indicators: the presence of fluid in the subfascial space, the condition of the fascia, muscles and blood vessels (assessed by ultrasound); asymmetry of the temperature of the feet and legs of healthy and injured limbs (using an infrared non-contact thermometer); the value of intratissue pressure on the tibia (using the Striker apparatus at certain points).&#x0D; The results of tibia treatment after fractures were evaluated using the anatomical and functional scale Modified Functional Evaluation System by Karlstrom-Olerud.&#x0D; Results. There was no significant blood loss during surgery and thromboembolic complications. Clinical data and indicators of intrafascial pressure in the outer and superficial posterior fascial compartments indicated the development of local hypertensive ischemic syndrome. The dynamics of foot thermoasymmetry, ultrasound data are characteristic of subcompensated functional disorders with the theoretical possibility of their recovery. The obtained data indicate a violation of blood flow with a high risk of possible thrombosis, which is an objective basis for the appointment of low molecular weight heparin. The dynamics of most of the examined indicators of blood homeostasis during the prescribed therapy did not differ statistically, but there was a tendency to shift the indicators to the recommended safe zone.&#x0D; Conclusions. Clinical data indicate the high efficacy of Cibor in the complex therapy of septic nonunions.

Effect of administration of tranexamic acid on blood loss and transfusion requirements in children undergoing posterior fossa tumor excision: a retrospective cohort study.

Surgical resection of posterior fossa tumors (PFT) in the pediatric age group often results in significant intraoperative blood loss. The primary objective was to assess the effect of tranexamic acid (TXA) on blood loss and transfusion requirement in pediatricpatients undergoing excision of PFT. In this retrospective study, all pediatric patients ≤ 18years, who underwent PFT resection over a period of 7years, were included. The patient and surgical characteristics, estimated blood loss (EBL), the need for blood and blood product transfusion, use of crystalloids, vasopressors, and any adverse events like seizures and thromboembolic events were recorded and compared between Group A who received TXA andGroup B who did not. The study included 50 patients, out of which 36 belonged to Group A and 14 to Group B. The median age was 8years (IQR, 2-17) and the mean BMI was 16.46 ± 4.11kg/m2. The mean EBL was 224.29 ± 110.36ml in group A (n = 36) and 362 ± 180.11ml in group B (n = 14) (p = 0.007). The intraoperative volume of crystalloid use was significantly higher in group B (p = 0.04). The requirement of blood and blood product transfusion was similar between the groups, but the volume of blood transfusion per kg body weight was higher in group B, 8.3 (IQR, 6.7-11.1)ml/kg in Group Aversus 10.5 (IQR, 8.1-16.1) ml/kg in Group B (p-value 0.3). The rates of complications noted in the form of seizures and thromboembolic events were comparable. The use of TXA in the pediatric population undergoing PFT resection aids in reducing blood loss during the surgery without increasing complications.

Oral tranexamic acid in the treatment of hyperpigmentation disorder beyond melasma: A review.

Tranexamic acid, a synthetic derivative of the amino acid lysine, is an antifibrinolytic, procoagulant agent approved by the Food and Drug Administration for the treatment of cyclic heavy menstrual bleeding and prevention of bleeding in patients with hemophilia undergoing tooth extraction. Oral tranexamic acid has been used off-label in dermatology in the treatment of melasma and other hyperpigmentation disorders. In a recent study, oral tranexamic acid was reviewed thoroughly in treating melasma, and its effectiveness was demonstrated. Their role in treating other hyperpigmentation disorders has also been tried in several studies. To review the evidence regarding the use of tranexamic acid in treating different types of hyperpigmentation disorders other than melasma. A comprehensive literature review was searched using the electronic online database "PubMed" and "google scholar" using key words "Postinflammatory hyperpigmentation," "lichen planus pigmentosus," "ashy dermatosis," "riehl melanosis". After that, a full-text review of the studies was performed. Oral tranexamic acid has been used in different types of hyperpigmentation disorder, including postinflammatory hyperpigmentation treatment and prevention, lichen planus pigmentosus, ashy dermatosis, and Riehl melanosis in a dose range from 250 mg per day to 1500 mg per day for a period range from 2 weeks to 6 months with variable efficacy and a good safety profile. Oral tranexamic acid is a promising treatment option in a different type of hyperpigmentation disorders refractory to topical treatment. However, more evidence from blinded randomized controlled trials and case-control studies is needed to determine their efficacy in treating various hyperpigmentation disorders.

Tranexamic Acid Use in Breast Surgery: A Systematic Review and Meta-Analysis.

The perioperative use of tranexamic acid (TXA) has become popular among plastic surgeons for a variety of surgical procedures. The aim of this study was to perform a systematic review and meta-analysis on the results reported in the literature regarding the effect of perioperative systemic TXA administration in breast surgery. The PubMed, MEDLINE, Embase, CENTRAL, and CINAHL databases were searched for both randomized clinical trials and observational studies. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio with corresponding 95% confidence interval. A total of five studies encompassing 1139 patients undergoing mastectomy with or without immediate implant or free flap-based breast reconstruction or breast-conserving surgery with or without axillary lymph node dissection were included. Perioperative intravenous administration of TXA significantly reduced the risk for hematoma (7.3% versus 12.9%; OR, 0.43; 95% CI, 0.23 to 0.81) and seroma formation (11.5% versus 19.9%; OR, 0.57; 95% CI, 0.35 to 0.92) in comparison to the control group. In the studies measuring the postoperative drainage amount, the mean difference was 132 mL (95% CI, 220 to 44 mL). No thromboembolic event occurred in either group. The weighted surgical-site infection rate was higher in the control group (3.1% versus 1.5%). However, these data were too sparse to perform comparative meta-analysis. Evidence of this study suggests that perioperative administration of TXA significantly reduces the risk for postoperative hematoma and seroma formation in breast surgery, whereas the risk for thromboembolic events and postoperative infection is not increased.

Use of Tranexamic Acid to Reduce PostOperative Bleeding in Orthopaedic Oncology

Background: Orthopaedic oncology often causes major blood losses that may put at risk patients’ hemodynamic balance and their overall clinical stability. To this date, transfusion therapy still represents the pivotal treatment to counterbalance the reduction in hemoglobin levels which occur after surgery. Although effective, transfusions are expensive and inevitably associated with a number of complications and therefore other solutions, such as procoagulative drugs, could play an important role to prevent massive blood losses.Material and methods: We reviewed the clinical intercourse of 37 patients who underwent major bone resection due to malignant tumors of the lower limb. Cases were divided in two different groups: group G1 consisting of 12 patients treated intraoperatively with tranexamic acid and group G2 which was made of 25 controls.Results: On average, patients treated with tranexamic acid (G1) required transfusion of 3.9 concentrated blood cells units during surgery and 0.9 units during the postoperative course. Other patients (G2), for their part, required on average 3.1 units intraoperatively and 2.1 units postoperatively. No significant difference was found in intraoperative transfusion rate (p=0.402). Instead, postoperative transfusions were significantly less frequent for patients treated with tranexamic acid (p=0.023). None of the 12 patients treated with tranexamic acid had evidence of Deep Vein Thrombosis.Conclusion: Our outcomes indicate that the use of TXA was effective in reducing blood losses also for major surgical interventions in orthopedic oncology.

The Usage of Intravenous Tranexamic Acid in Reduction Mammaplasty Safely Reduces Hematoma Rates.

Bleeding complications are not uncommon after breast reduction surgery, and recently, tranexamic acid (TXA) as an antifibrinolytic agent has been used in various surgical specialties as a way to minimizes such adverse outcomes. We elected to evaluate the effectiveness of intravenous (IV) intraoperative TXA in reduction mammoplasty patients. This is a retrospective chart review of clinical charts of all patients who received reduction mammoplasty by a single surgeon at Emory University Hospital or its affiliated Aesthetic Center from January 1, 2020, to March 1, 2022. Seventy-four consecutive breast reduction patients received 1-g IV TXA intraoperatively compared with 117 consecutive controls. The outcome of interest included 30-day postoperative bleeding complications. There was no significant difference in age ( P = 0.92), body mass index ( P = 0.98), percentage of smokers ( P = 0.56), operating time ( P = 0.87), estimated blood loss ( P = 0.90), or weight removed ( P = 0.98) between patients in each arm. There were 19 bleeding events (16.2%) in the non-TXA arm compared with 1 bleeding event (1.4%) in the TXA arm ( P = 0.0143). Of the 19, 6 (5.1%) were major events, and 13 were minor events (11.1%); the only bleeding event in the TXA arm was minor. Number needed to treat all bleeding events with use of TXA was 7, and the number needed to treat minor hematomas was 11. There was no significant difference in the rate of seroma, wound healing complications, infection, or nipple necrosis between the 2 arms ( P > 0.05). The use of IV TXA is a safe and effective way to reduce hematoma rates in patients receiving reduction mammoplasty.

Antifibrinolytics use during surgery for oncological spine diseases: A systematic review.

Data exist of the benefits of antifibrinolytics such as tranexamic acid (TXA) in general spine surgery. However, there are limited data of its use in oncological spine patients. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Cochrane, OVID, and Embase databases were searched. Search terms: "tranexamic acid", "aprotinin," "aminocaproic acid," "spine surgery," "spine tumors," and "spine oncology." Included studies were full text publications written in English with patients treated with either agent or who had surgery for oncological spine disease (OSD). Seven hundred results were reviewed form the different databases, seven were selected. A total of 408 patients underwent spine surgery for OSD and received antifibrinolytics. There was a male predominance (55.2%) and mean age ranged from 43 to 62 years. The most common tumor operated was metastatic renal cancer, followed by breast and lung. Most studies administered TXA as a bolus followed by an infusion during surgery. Median blood loss was of 667 mL (253.3-1480 mL). Patients with TXA required 1-2 units less of transfusion and had 56-63 mL less of postoperative drainage versus no TXA. The median incidence of deep venous thrombosis (DVT) was 2.95% (0-7.9%) and for pulmonary embolism (PE) was 4.25% (0-14.3%). The use of TXA reduced intraoperative blood loss, transfusions and reduced postoperative surgical drainage output compared to no TXA use in patients with OSD. In this review, we found that TXA may diminish intraoperative blood loss, the need for transfusion and postoperative drainage from surgical drains when used in OSD without major increase in rates of DVT or PE.

The Use of Tranexamic Acid in Hip Fracture Surgery-A Systematic Review and Meta-analysis.

To analyze the effect of intravenous tranexamic acid (TXA) on blood transfusion requirements in adult patients undergoing hip fracture surgery. Secondary aim was to evaluate the safety by assessing thromboembolic events. Cochrane Central Register of Controlled Trials, Medline, PubMed, and Embase were searched for randomized controlled trials published in English from 2010. Studies eligible for inclusion were randomized controlled trials that analyzed the use of intravenous TXA on blood transfusion requirement in hip fracture surgery. Titles and abstracts were screened and assessed for eligibility by 2 independent reviewers. Quality and risk of bias was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach and the Cochrane risk-of-bias tool (RoB2). Meta-analysis with random and fixed effect models was performed. Risk ratio (RR) was calculated for dichotomous outcomes and estimated with a 95% confidence interval (CI). For continuous data, the risk difference (RD) was estimated with a 95% CI. A total of 13 trials involving 1194 patients were included. Pooled results showed that patients in the TXA group had significantly lower transfusion requirements (RR 0.50, 95%CI 0.30-0.84, P = 0.009). Similar findings were observed in the subcohort of patients with transfusion threshold of Hb < 8g/dL, (RR 0.42, 95%CI 0.31-0.56, P < 0.0001). This risk reduction was not observed in the subcohort of patients with transfusion threshold of Hb 8.1-10g/dL who received TXA (RR 0.77, 95%CI 0.51-1.18, P = 0.23) and no statistically significant differences were found for total thromboembolic events (RR 0.01, 95%CI -0.02-0.04, P = 0.47). This meta-analysis demonstrated that intravenous TXA reduced blood transfusion rates and did not increase the risk of thromboembolic events. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Efficacy and Best Mode of Delivery for Tranexamic Acid in Post-Inflammatory Hyperpigmentation: A Systematic Review.

Post-inflammatory hyperpigmentation (PIH) is skin hyperpigmentation that occurs due to any inflammatory condition. Triggering the melanocytes by inflammation leads to melanin overproduction and deposition. Tranexamic acid (TXA) is an antifibrinolytic medication prescribed to treat bleeding. Recently, there are some studies about the use of TXA in the treatment of PIH. The aim of this study is to identify the efficacy and the best mode of delivery for tranexamic acid in the treatment of PIH. This systematic review is reported in accordance with PRISMA guidance. We included all relevant English-language studies that were published up to September 2022 in the following electronic databases: Cochrane Library, PubMed, Embase, and Google Scholar. The initial search yielded 61 articles, 9 of which were included after applying inclusion and exclusion criteria. The systematic review included a total of 196 patients who were over the age of 16 years old. Tranexamic acid was delivered orally in 4 studies, topically in 2 studies, and both simultaneously in 1 study. In addition, intradermal injection was used in 2 other studies. Almost all studies advocated the use of all routes for accelerating the clearance of hyperpigmentation with more favor towards topical and intradermal routes due to their mild reported side effects when compared to oral routes. Intradermal TXA is considered the best route, which exhibits fewer side effects with less cost and excellent outcomes, while oral TXA is found to be less preferable than other routes due to the incidence of undesirable adverse events.

The role of tranexamic acid in the management of postpartum haemorrhage.

In the last decades, tranexamic acid (TXA) has emerged as an essential tool in blood loss management in obstetrics. TXA prophylaxis for postpartum haemorrhage (PPH) has been studied in double-blind, placebo-controlled, randomized clinical trials (RCTs). Given the small observed preventive effect, the systematic use of TXA for vaginal and/or caesarean deliveries remains controversial. The result of a pharmacokinetic modelling suggests that relative to intravenous administration, intramuscular administration may be an equally effective alternative route for preventing PPH and may enable access to this drug in low-resource countries. Prophylaxis is currently studied in high-risk populations, such as women with prepartum anaemia or placenta previa. TXA effectively reduces blood loss and PPH-related morbidity and mortality during active PPH, as demonstrated by high-grade evidence from large RCTs. The drug has a good safety profile: in most cases, only mild gastrointestinal or visual adverse events may be observed. TXA use does not increase the risk of serious adverse events, such as venous or arterial thromboembolism, seizures, or acute kidney injury. The TRACES invivo analysis of biomarkers of TXA's antifibrinolytic effect have suggested that a dose of at least 1g is required for the treatment of PPH. The TRACES pharmacokinetic model suggests that because TXA can be lost in the haemorrhaged blood, a second dose should be administered if the PPH continues or if severe coagulopathy occurs. Future pharmacodynamic analyses will focus on the appropriateness of TXA dosing regimens with regard to the intensity of fibrinolysis in catastrophic obstetric events.

A REVIEW OF EUROPEAN GUIDELINES FOR PATIENT BLOOD MANAGEMENT WITH A PARTICULAR EMPHASIS ON ANTIFIBRINOLYTIC DRUG ADMINISTRATION FOR CARDIAC SURGERY

<h3>Introduction</h3> Patient blood management (PBM) is a proactive approach towards improving the quality and appropriateness of care. PBM has been recommended by the World Health Organization (WHO) since 2011. The aim is to manage anaemia and bleeding in surgical patients with the objective to minimise the need for transfusion. AntiVbrinolytics play a major role in cardiac surgery, where the risk of perioperative bleeding is high and affects most patients. AntiVbrinolytics effectively reduce bleeding, transfusions, re-operations, and associated morbidity and mortality. They represent an essential part of the pharmacological arsenal of PBM. The authors compared the current available European guidelines in PBM and analysed the place of different antiVbrinolytics in cardiac surgery, according to these guidelines. <h3>Methods</h3> A literature search on European PBM guidelines was performed in December 2020 and repeated in January 2021 using PubMed, Cochrane Database and Google Scholar databases. <h3>Results</h3> Thirteen documents were identiVed, from 6 countries (France, Germany, Italy, The Netherlands, Romania, UK), provided by European Commission or European and/or national learned societies. Of these 13 articles, 10 mentioned cardiac surgery, with 1 fully dedicated to it, and 8 were actual PBM guidelines. <h3>Discussion</h3> Despite the trend towards high-level PBM practices, and the implementation of PBM programs actively supported by the European Commission, national or international PBM guidelines for European countries appear to be both few and heterogeneous in form and content. At the European level, guidelines on bleeding management were published in 2017 by the ESAIC and those dedicated to cardiac surgery were published in 2018 jointly by the EACTS and the EACTA. All the current available guidelines follow and agree on the deVnition of PBM as deVned by the WHO, supported by three pillars: optimizing blood volume, minimising blood loss and optimizing the patient's tolerance to anaemia. Most of them were divided according to the three main surgical phases: preoperative, perioperative and post-operative. Anaemia management appears as a cornerstone of PBM in all guidelines, followed by limiting blood loss during surgical procedures to reduce transfusions and limit the risk of reoperation for bleeding. In this context, the European and national PBM guidelines all recommend the prophylactic use of antiVbrinolytics to avoid or reduce perioperative bleeding. However, they differ in the type of antiVbrinolytic recommended, when it should be given and how (bolus or infusion or both), including the dose and timing. Indeed, when mentioned, the dosing to be used generally differs from one guideline to another. Most guidelines recommend only the use of tranexamic acid. Aprotinin is rarely mentioned, partly because of its recent reintroduction in Europe (Table 1). The implementation of PBM practices in Europe is still challenging, as there is a real need for more homogenous guidance in PBM and in the use of antiVbrinolytics, especially in cardiac surgery. New clinical data to promote the use of antiVbrinolytics could be of interest to improve, accelerate and deploy PBM implementation at a large scale.

Peri-Operative Use of Transexamic Acid in Reduction of Post Operative Seroma Formation in Patients Undergoing Ventral Hernia Repair

Objective: To examine the efficacy of Intraoperative and postoperative IV transamine, in reducing postoperative seroma formation in patients undergoing ventral hernia repair. Study Design: Randomized controlled clinical trial Study place: Karachi Methodology: Eighty patients filled out the in-depth age, gender, and body mass index (BMI) registration forms. All of the patients ranged in age from fifteen to sixty. Patients were randomly assigned to either Group A (receiving 1 g of tranexamic acid Intraoperative and 500mg tranexamic acid 12 hours apart daily for 2 postoperative days) or Group B (not receiving any drug during or after surgery). Drainage volume was collected at postoperative day 1, 2, 3, 4, and 5 was recorded and were compared in both groups. Results: The Mean±S.D of age of the participants in both groups were 41.5± 9.9 and 42.75±9.7 years. Group A had 20% males and 80% female, while group B had 22% males and 78% females. The Mean±S.D of BMI of the participants in both groups were 26.8±3.4 and 25.3± 4.4kg/m2. A significant difference in the drainage volume between group A and B was observed at 1st (0.025), 2nd (0.001), 3rd (0.004) and 4th (0.003) day were observed. Practical implication: This study will help to determine how tranexamic acid is useful in reducing seroma after hernia repair Conclusion: Seroma development after ventral hernia surgeries may be minimized with the use of tranexamic acid. Keywords: Hernia, tranexamic acid, clinical trial, seroma, effectiveness, hernia repair

Topical Tranexamic Acid Can Be Used Safely Even in High Risk Patients: Deep Vein Thrombosis Examination Using Routine Ultrasonography of 510 Patients.

Background and Objectives: Previous studies regarding tranexamic acid (TXA) in total knee arthroplasty (TKA) investigated only symptomatic deep vein thrombosis (DVT), or did not include high risk patients. The incidence of DVT including both symptomatic and asymptomatic complications after applying topical TXA has not been evaluated using ultrasonography. Materials and Methods: The medical records of 510 patients who underwent primary unilateral TKA between July 2014 and December 2017 were retrospectively reviewed. Because TXA was routinely applied through the topical route, those who had a history of venous thromboembolism, myocardial infarction, or cerebral vascular occlusive disease, were not excluded. Regardless of symptom manifestation, DVT was examined at 1 week postoperatively for all patients using ultrasonography, and the postoperative transfusion rate was investigated. The study population was divided according to the use of topical TXA. After the two groups were matched based on the propensity scores, the incidence of DVT and the transfusion rate were compared between the groups. Results: Of the 510 patients, comprising 298 patients in the TXA group and 212 patients in the control group, DVT was noted in 22 (4.3%) patients. Two patients had DVT proximal to the popliteal vein. After propensity score matching (PSM), 168 patients were allocated to each group. In all, 11 patients in the TXA group and seven patients in the control group were diagnosed with DVT, which did not show a significant difference (p = 0.721). However, the two groups differ significantly in the transfusion rate (p < 0.001, 50.0% in the TXA group, 91.7% in the control group). Conclusions: The incidence of DVT, whether symptomatic or asymptomatic, was not affected by the use of topical TXA. The postoperative transfusion rate was reduced in the TXA group. Topical TXA could be applied safely even in patients who had been known to be at high risk.

Use of tranexamic acid in decreasing blood loss during and after delivery among women in Africa: a systematic review and meta-analysis.

Africa is a developing continent with a high maternal mortality rate. It is beneficial to implement interventions that alleviate the problem. As a result, this systematic review and meta-analysis was carried out to summarize evidence that will assist concerned bodies in proposing strategies to reduce maternal mortality due to post-partum hemorrhage. This systematic review and meta-analysis includes randomized control trials (RCT) studies searched from various databases (PubMed, Web of Sciences, SCOPUS, African Journal Online, Clinical trials, and African indexes Medics). Data synthesis and statistical analysis were conducted using a combination of review manager 5.3 and STATA Version 14 software. The effect measure utilized was the standardized mean difference for estimated mean blood loss and mean hemoglobin level. This systematic review and meta-analysis includes a total of 3308 women. The pooled standardized mean difference showed that tranexamic acid statistical significantly reduced the estimated amount of blood loss after vaginal delivery (standardized mean difference with 95% CI -0.93 [-1.45, -0.41]) and during and after cesarean delivery (standardized mean difference with 95% CI -1.93 [-2.40, -1.47]). Tranexamic acid has been found to be a good choice for reducing blood loss during and after delivery in Africa regardless of the mode of delivery. Tranexamic acid had no effect on hemoglobin levels before and after delivery. To reduce maternal mortality due to post-partum hemorrhage, it is critical to implement and strengthen interventions aimed at increasing tranexamic acid uptake in Africa.

Efficacy and Safety of Tranexamic Acid in Shoulder Arthroscopic Surgery: A Systematic Review and Meta-Analysis.

Visual clarity during shoulder arthroscopy can ensure an efficient and effective performance of the procedure, and it is highly related to bleeding without a tourniquet. Tranexamic acid (TXA) is widely used in adult reconstruction procedures; however, its use in shoulder arthroscopic operations is a relatively novel topic. To analyze the available literature on visual clarity, blood loss, pain control, functional outcomes, and complications after the administration of tranexamic acid in shoulder arthroscopic surgery. A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of shoulder arthroscopic surgery. The literature search included the MEDLINE, Embase, Web of Science, and Cochrane Library databases. The primary outcomes included visual clarity, blood loss, and visual analog scale scores for pain. Secondary outcomes were operative time, irrigation amount used, postoperative shoulder swelling, the need for pressure increase, mean arterial pressure (MAP), functional outcomes, postoperative adverse effects such as deep venous thrombosis, and pulmonary embolism. The outcomes were pooled to perform a meta-analysis. Seven prospective randomized controlled trials met the inclusion criteria for analysis. All of the included studies performed arthroscopic rotator cuff repair. No significant difference in visual clarity was observed (SMD (standardized mean difference), 0.45 [95% CI(confidence interval), -0.68, 1.59]; p = 0.44) nor in pain score (MD (mean difference), -0.46 [95% CI, -0.97, 0.05]; p = 0.08) between the TXA group and the control group. Two studies found no significant difference in blood loss between the TXA group and the control group. The meta-analysis from five studies demonstrated no significant difference between the TXA and control groups in operative time (MD, -3.51 [95% CI, -15.82, 8.80]; p = 0.58) or irrigation amount used (MD, -2.53 [95% CI, -5.93, 0.87]; p = 0.14). Two trials reported different statistical results in postoperative shoulder swelling. No significant differences regarding the need for pressure increase and MAP were reported between groups. No wound complications or infections or cardiac, thrombotic, or thromboembolic complications were recorded in either group. The use of intravenous or local TXA in shoulder arthroscopic surgery did not increase complications or thromboembolic events, but TXA had no obviously effect of reducing bleeding to obtain a clear visual field or pain release in patients undergoing shoulder arthroscopic surgery.