In this episode, I’ll discuss tranexamic acid for controlling iatrogenic bleeding during flexible bronchoscopy.
While pharmacists are not typically present when a bronchoscopy takes place, medications are involved both to help the patient tolerate the procedure and to address issues that come up as a result of the procedure. One such complication of flexible bronchoscopy is bleeding. The typical first-line treatment for iatrogenic bleeding from bronchoscopy is to apply cold saline through the center channel of the bronchoscope to achieve hemostasis. When this is not effective, epinephrine is usually applied in the same manner using a few milliliters of a 1:10000 solution.
A group of researchers recently published in the journal Chest a cluster-randomized, double blind, single center trial comparing epinephrine with tranexamic acid for the treatment of iatrogenic bleeding after flexible bronchoscopy.
Patients who experienced bleeding first received the standard application of 5 mL cold saline up to 3 times and if hemostasis was not achieved, they received up to 3 more applications of either 0.2 mg of epinephrine or 100 mg of tranexamic acid. The protocol did allow for crossover to the opposite group if those 3 applications were ineffective.
130 patients were split evenly between the groups. The exact same number of patients in each group (83%) achieved hemostasis. The mean number of applications for both groups was 1.8 before hemostasis was achieved, and the severity of bleeding was similar between groups. The tranexamic acid group had numerically superior results in the cohort of patients with severe bleeding, but this was not statistically significant.
The authors did not observe any adverse events in either group that were judged to be drug-related.
The authors concluded:
We found no significant difference between adrenaline and TXA for controlling non-catastrophic iatrogenic endobronchial bleeding after cold saline failure, adding to the body of evidence that TXA can be used safely and effectively during FB.
This study is likely going to prompt pulmonologists to seek the inclusion of tranexamic acid on bronchoscopy carts so that it is available if needed during a procedure. The study did not analyze the cost differences between the two groups and it is likely that tranexamic acid would prove to be more expensive than epinephrine. Given equal efficacy and adverse event rates, a preference should be given to the less expensive medication however the stocking of tranexamic acid on bronchoscopy carts may still be justified.
The study protocol did allow crossover between groups if 3 applications of the study medication did not control the bleeding. In the 11 patients in the study who had tranexamic acid used after the failure of 3 applications of cold saline and 3 applications of epinephrine, 100% of these patients achieved hemostasis. This is a small number of patients and it is not clear if it represents a synergy between epinephrine and tranexamic acid, but it does seem to justify having both medications readily available for the treatment of iatrogenic bleeding after flexible broncoscopy.
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