In this episode, I’ll discuss an article on the use of tranexamic acid to reduce transfusion in major noncardiac surgery.
Plenty of surgical protocols have incorporated the use of tranexamic acid to reduce the need for transfusion, especially in cardiac surgical procedures. A group of authors recently published a randomized, placebo-controlled trial in the New England Journal of Medicine examining the use of tranexamic acid in major noncardiac surgery.
Patients were enrolled if they were undergoing a noncardiac but major surgical procedure and were at high risk of needing a blood transfusion.
Example procedures were general, spine, orthopedic, thoracic, gynocologic, vascular, and more. Over 8000 patients were enrolled and 60% of the surgeries were oncologic in nature. Patients were assigned tranexamic acid or placebo and the coprimary effectiveness and safety outcomes were transfusion of red cells during the index hospitalization and diagnosis of venous thromboembolism within 90 days.
The tranexamic acid group received a red-cell transfusion 7.4% of the time vs 9.8% for placebo. This difference was statistically significant with a relative risk of 0.73 in favor of tranexamic acid.
Venous thromboembolism within 90 days occurred in 2.1% of patients in both groups, meeting noninferiority criteria for safety.
The authors concluded:
Among patients undergoing major noncardiac surgery, a hospital policy of tranexamic acid administration resulted in a lower incidence of red-cell transfusion than placebo administration, and tranexamic acid was noninferior to placebo with regard to diagnosis of venous thromboembolism.
There was some variability allowed with the tranexamic acid dosing which was as follows:
TXA 1 gram bolus (2 grams for patients over 100 kg) intravenously (IV) administered within 10 minutes of the first surgical incision, followed by 1 additional gram given intravenously at 2-4 hours of surgery or prior to skin closure, at the discretion of the anesthesiologist (e.g. IV bolus at 2-4 hours of surgery, at skin closure, or the 1 additional gram given as a continuous infusion throughout the surgical procedure).
The safety data is especially impressive given that if 60% of patients had surgery related to cancer, they must have been at high risk of thromboembolism so the fact that VTE occurred equally between groups suggests this is not a concern for tranexamic acid in this patient population.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
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