Evaluation of Military Use of Tranexamic Acid and Associated Thromboembolic Events

Johnston, Luke R.; Rodríguez, Carlos J.; Elster, Eric A.; Bradley, Matthew John

doi:10.1001/jamasurg.2017.3821

Cited by 86 publications

(74 citation statements)

References 15 publications

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“…HR, hazard ratio; CI, confidence interval; HF, hyperfibrinolysis; SBP, systolic blood pressure;ISS, injury severity score; PT_INR, prothrombin time and international normalized ratio. (2020) 10:6980 | https://doi.org/10.1038/s41598-020-63724-y www.nature.com/scientificreports www.nature.com/scientificreports/ enhanced the occurrence of thrombotic events [30][31][32] . We believe that FIBTEM HF may have potential for use in selective TXA administration; however, additional research on the topic is needed.…”

Section: Discussionmentioning

confidence: 99%

FIBTEM Improves the Sensitivity of Hyperfibrinolysis Detection in Severe Trauma Patients: A Retrospective Study Using Thromboelastometry

Wang

Park

Bae

et al. 2020

Sci Rep

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Rotational thromboelastometry (ROTEM) can only detect high-degree hyperfibrinolysis (HF), despite being frequently used in trauma patients. We investigated whether considering FIBTEM HF (the presence of maximal lysis (ML) > 15%) could increase ROTEM-based HF detection's sensitivity. This observational cohort study was performed at a level 1 trauma centre. Trauma patients with an Injury Severity Score (ISS) > 15 who underwent ROTEM in the emergency department between 2016 and 2017 were included. EXTEM HF was defined as ML > 15% in EXTEM. We compared mortality rates between EXTEM HF, FIBTEM HF, and non-HF patient groups. Overall, 402 patients were included, of whom 45% were men (mean age, 52.5 years; mean ISS, 27). The EXTEM HF (n = 37), FIBTEM HF (n = 132), and non-HF (n = 233) groups had mortality rates of 81.1%, 22.3%, and 10.3%, respectively. The twofold difference in mortality rates between the FIBTEM HF and non-HF groups remained statistically significant after Bonferroni correction (P = 0.01). On multivariable Cox regression analysis, FIBTEM HF was independently associated with in-hospital mortality (adjusted hazard ratio 2.15, 95% confidence interval 1.21-3.84, P = 0.009). Here, trauma patients with FIBTEM HF had significantly higher mortality rates than those without HF. FIBTEM be a valuable diagnostic method to improve HF detection's sensitivity in trauma patients.

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Section: Discussionmentioning

confidence: 99%

FIBTEM Improves the Sensitivity of Hyperfibrinolysis Detection in Severe Trauma Patients: A Retrospective Study Using Thromboelastometry

Wang

Park

Bae

et al. 2020

Sci Rep

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“…Accordingly, TXA should only be started later than 3 h after injury if signs of trauma-induced coagulopathy (A5 EX < 35 mm or FIBTEM flat-line [CT FIB > 600 s]) or hyperfibrinolysis (EXTEM or FIBTEM maximum lysis [ML] ≥ 5% within 60 min) are present [105,[145][146][147]. However, it is still under debate whether prophylactic or therapeutic administration of TXA should be performed in hospitals with access to viscoelastic testing [145][146][147][148][149][150][151][152][153][154][155]. Physiologic fibrinolysis and fibrinolysis shutdown are defined in ROTEM as an EXTEM LI60 82-97.9% and ≥ 98%, respectively [156].…”

Section: In Trauma and Orthopedic Surgerymentioning

confidence: 99%

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

Görlinger

Pérez-Ferrer

Dirkmann

et al. 2019

Korean J Anesthesiol

178

138

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Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management ('theranostic' approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient's safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration. Fig. 1. ROTEM trace ('temogram') displaying the clinically most important parameters and their informative value. FDPs: fibrin (ogen) split products. Courtesy of Klaus Görlinger, Germany.

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“…While some studies have not identified an increase in incidence of VTE associated with TXA, others have found TXA to be an independent risk factor for increased incidence of VTE. 11,12,14,[17][18][19] Thus, there is a need to continue to further evaluate the safety of TXA use within the hospital trauma setting.…”

Section: Introductionmentioning

confidence: 99%

Safety and Efficacy of Hospital Utilization of Tranexamic Acid in Civilian Adult Trauma Resuscitation

Neeki

Dong

Toy

et al. 2020

WestJEM

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Introduction: Patients with trauma-induced coagulopathies may benefit from the use of antifibrinolytic agents, such as tranexamic acid (TXA). This study evaluated the safety and efficacy of TXA in civilian adults hospitalized with traumatic hemorrhagic shock. Methods: Patients who sustained blunt or penetrating trauma with signs of hemorrhagic shock from June 2014 through July 2018 were considered for TXA treatment. A retrospective control group was formed from patients seen in the same past five years who were not administered TXA and matched based on age, gender, Injury Severity Score (ISS), and mechanism of injury (blunt vs penetrating trauma). The primary outcome of this study was mortality measured at 24 hours, 48 hours, and 28 days. Secondary outcomes included total blood products transfused, hospital length of stay (LOS), intensive care unit LOS, and adverse events. We conducted three pre-specified subgroup analyses to assess outcomes of patients, including (1) those who were severely injured (ISS >15), (2) those who sustained significant blood loss (≥10 units of total blood products transfused), and (3) those who sustained blunt vs penetrating trauma. Results: Propensity matching yielded two cohorts: the hospital TXA group (n = 280) and a control group (n = 280). The hospital TXA group had statistically lower mortality at 28 days (1.1% vs 5%, odds ratio [OR] [0.21], (95% confidence interval [CI], 0.06, 0.72)) and used fewer units of blood products (median = 4 units, interquartile range (IQR) = [1, 10] vs median=7 units, IQR = [2, 12.5] for the hospital TXA and control groups, respectively, (95% CI for the difference in median, -3 to -1). There were no statistically significant differences between groups with regard to 24-hour mortality (1.1% vs 1.1%, OR = 1, 95% CI, 0.20, 5.00), 48-hour mortality (1.1% vs 1.4%, OR [0.74], 95% CI, 0.17, 3.37), hospital LOS (median= 9 days, IQR = (5, 16) vs median =12 days IQR = (6, 22.5) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-5 to 0)), and incidence of thromboembolic events (eg, deep vein thrombosis, pulmonary embolism) during hospital stay (0.7% vs 0.7% for the hospital TXA and control group, respectively, OR [1], 95% CI, 0.14 to 7.15). We conducted subgroup analyses on patients with ISS>15, patients transfused with ≥10 units of blood products, and blunt vs penetrating trauma. The results indicated lower 28-day mortality for ISS>15 (1.8% vs 7.1%, OR [0.23], 95% CI, 0.06 to 0.81) and blunt trauma (0.6% vs 6.3%, OR [0.09], 95% CI, 0.01 to 0.75); fewer units of blood products for penetrating trauma (median = 2 units, IQR = (1, 8) vs median = 8 units, IQR = (5, 15) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-6 to -3)), and ISS>15 (median = 7 units, IQR = (2, 14) vs median = 8.5 units, IQR = (4, 16) for the hospital TXA and control groups, respectively, 95% CI for the difference in median, -3 to 0). Conclusion: The current study demonstrates a statistically significant reduction in mortality after TXA administration at 28 days, but not at 24 and 48 hours, in patients with traumatic hemorrhagic shock.

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Evaluation of Military Use of Tranexamic Acid and Associated Thromboembolic Events

Abstract: Military medical personnel decreased missed opportunities to appropriately use TXA but also increased overuse. In addition, TXA administration was an independent risk factor for venous thromboembolism. A reevaluation of the use of TXA in combat casualties should be undertaken.

Cited by 86 publications

References 15 publications

FIBTEM Improves the Sensitivity of Hyperfibrinolysis Detection in Severe Trauma Patients: A Retrospective Study Using Thromboelastometry

FIBTEM Improves the Sensitivity of Hyperfibrinolysis Detection in Severe Trauma Patients: A Retrospective Study Using Thromboelastometry

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

Safety and Efficacy of Hospital Utilization of Tranexamic Acid in Civilian Adult Trauma Resuscitation

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