A Comparative Analysis of Tranexamic Acid Dosing Strategies in Traumatic Major Hemorrhage

Abstract

Introduction Tranexamic acid (TXA) is a life-saving treatment for traumatic hemorrhage, but the optimal dosing regimen remains unknown. Different doses and treatment strategies have been proposed, including single bolus, repeated bolus or bolus plus infusion. The aim of this study was to determine the effect of different TXA dosing strategies on clinical outcomes in bleeding trauma patients. Methods Secondary analysis of a perpetual cohort study from a UK Level 1 trauma center. Adult patients who activated the local major hemorrhage protocol and received TXA were included. The primary outcome was 28-day mortality. Secondary outcomes were 24-hour mortality, multiple organ dysfunction syndrome (MODS), venous thromboembolism (VTE) and ROTEM fibrinolysis. Results Over an 11-year period, 525 patients were included. Three dosing groups were identified: 1 g bolus only (n = 317), 1 g bolus +1 g infusion over 8 hours (n = 80), and 2 g bolus (n = 128). Demographics and admission physiology were similar, but there were differences in injury severity (median ISS: 25, 29 & 25); and admission systolic blood pressure (median SBP: 99, 108, 99 mmHg) across the 1 g, 1 g + 1 g and 2 g groups. 28-day mortality was 21% in each treatment group. The incidence of MODS was significantly higher in the bolus plus infusion group (84%) vs 1 g bolus (64%) and 2 g bolus (62%) group, p = 0.002, but on multivariable analysis was non-significant. VTE rates were similar in the 1 g bolus (4%), 2 g bolus (8%) and bolus plus infusion groups (7%). There was no difference in ROTEM Maximum Lysis at 24 hours: 5% in both the 1 g and 2 g bolus groups vs 4% in bolus plus infusion group. Conclusion Clinical outcomes and 24-hour fibrinolysis state were equivalent across three different dosing strategies of TXA. Single bolus administration is likely preferable to a bolus plus infusion regimen. Level of Evidence Level IV, Therapeutic/Care Management