Topical and low-dose intravenous tranexamic acid in cyanotic cardiac surgery

Abstract

Background Coagulopathy is a major problem in surgery for cyanotic congenital heart disease. Tranexamic acid has been used both topically and systemically and plays a vital role in pediatric cardiac surgery by reducing blood loss and blood product requirement. We aimed to determine the anti-fibrinolytic effectiveness of low-dose systemic or topical tranexamic acid or a combination of both. Methods Seventy-five patients were divided in 3 groups of 25. Group A patients were given tranexamic acid 20 mg kg intravenously after sternotomy and 20 mg kg after heparin reversal. Group B patients were given tranexamic acid 50 mg kg in 20 mL of saline intrapericardially before sternal closure, with the drain clamped for 20 min. Group C patients were given tranexamic acid 20 mg kg intravenously after sternotomy and 50 mg kg intrapericardially before sternal closure. A number of clinical variables were recorded in the first 3 postoperative days. Ventilator time, intensive care unit stay, and outcome were also recorded. Results Chest tube drainage and blood product requirements were lowest in group C. Blood urea and serum creatinine levels were higher in groups A and C ( p < 0.05). Intensive care unit stay and ventilator time were similar in all 3 groups. No patient died and none had a seizure or other neurological event or thromboembolic complication postoperatively. Conclusion The combination of low-dose intravenous and topical tranexamic acid reduces postoperative blood loss and blood product requirement without incurring neurological, renal or thromboembolic complications. We recommend the routine use of topical and low-dose systemic tranexamic acid in cyanotic pediatric cardiac surgery.

Decreasing Postoperative Blood Loss by Topical vs. Intravenous Tranexamic Acid in Open Cardiac Surgery (DEPOSITION) study: Results of a pilot study

“…Between 2000 to 2016, seven small RCTs comparing the IP application of TxA vs placebo were reported in cardiac surgery . In all these trials, except one using a small dose, topical application of TxA significantly reduced the 24‐hour postoperative blood loss.…”

“…Between 2000 to 2016, seven small RCTs comparing the IP application of TxA vs placebo were reported in cardiac surgery. [16][17][18][19][20][21][22][23][24][25] In all these trials, except one using a small dose, topical application of TxA significantly reduced the 24-hour postoperative blood loss. We performed a meta-analysis of these trials and confirmed the substantial reduction in 24-hour blood loss with topical application of TxA.…”

“…Topical TxA is effective in controlling bleeding in noncardiac surgery . In addition, when compared with placebo, intrapericardial (IP) application of TxA significantly reduced the 24‐hour postoperative blood loss in patients undergoing cardiac surgery . This effect was not observed when a small dose (1 g diluted in 100 mL normal saline) of IP TxA was used with on‐pump CABG patients, suggesting that it is dose dependent .…”

“…[13][14][15] In addition, when compared with placebo, intrapericardial (IP) application of TxA significantly reduced the 24-hour postoperative blood loss in patients undergoing cardiac surgery. [16][17][18][19][20][21][22][23][24] This effect was not observed when a small dose (1 g diluted in 100 mL normal saline) of IP TxA was used with on-pump CABG patients, suggesting that it is dose dependent. 25 No studies hitherto have compared the effectiveness of topical application directly with the IV administration of TxA.…”

Comparison Between Intravenous Boluses Versus Infusion of Tranexamic Acid (TXA) To Reduce Bleeding In Paediatric Cyanotic Congenital Heart Disease (CHD) Surgeries

“…They concluded that the combination of low dose systemic TXA and topical TXA intrapericadially before chest closure was the best. 22 In a clinical review, William and colleagues observed that practice of TXA as antifibrinolytic in intra-op and peri-op settings has strong pharmacological and clinical grounds. They found that TXA can be used effectively in adult cardiac surgery, paediatric cardiac and non-cardiac surgery, orthopaedic surgery, neurosurgery, hepatic surgery, and gynaecology and obstetrics surgeries.…”