Tranexamic acid for major spinal surgery

Abstract

IntroductionMajor spinal surgery has the potential for massive blood loss [20]. Concerns surrounding the accompanying blood transfusions have spawned considerable interest in reducing peri-operative blood loss. Improved surgical techniques and peri-operative management may reduce blood requirements, but the majority of patients are still subjected to blood transfusions [26]. The prophylactic administration of synthetic antifibrinolytics, including tranexamic acid, has therefore been investigated for improving haemostasis for orthopaedic surgery. The goal of this review is to discuss synthetic antifibrinolytics briefly and explore their role in major spinal surgery. Review of haemostasisA discussion of antifibrinolytics requires a brief synopsis of the normal haemostatic process. Injury to blood vessels initiates the four components of haemostasis. First, the blood vessel attempts to vasoconstrict to reduce blood loss. Subsequent to this, exposure of the injured endothelium initiates platelet adhesion. The glycoprotein-Ia platelet receptors adhere to the damaged vessel wall with von Willebrand factor serving as a bridge. Platelet degranulation, which follows adhesion, liberates substances which in turn further augment platelet aggregation and vessel vasoconstriction. The third phase of haemostasis is the contact phase of coagulation, which includes the intrinsic and extrinsic coagulation cascades. The consequence of the third phase is fibrin clot formation and activation of the fibrinolytic system. Fibrinolysis, the fourth stage of haemostasis, results in dissolution of fibrin clots mediated by plasmin. Evidence suggests that plasmin also inhibits haemostasis at other levels, including inhibition of platelet aggregation through cleavage of the glycoprotein-Ia receptors on platelets and inactivation of fibrinogen [7]. Thus, a patient who develops a relative excess of fibrinolysis will be more likely to experience considerable blood loss during surgery.A relative increase in fibrinolysis occurs in cardiac surgery primarily owing to the use of the cardiopulmonary Abstract Patients who undergo major spinal surgery often require multiple blood transfusions. The antifibrinolytics are medications that can reduce blood-transfusion requirements in cardiac surgery and total knee arthroplasty. The present role of synthetic antifibrinolytics, especially tranexamic acid, in reducing perioperative blood-transfusion requirements in spine surgery is still unclear. The majority of studies exploring the role of these drugs in spine surgery have limited patient enrolment and report mixed results. The goal of the present review is to discuss the pharmacology of tranexamic acid briefly. A brief synopsis of the studies using the synthetic antifibrinolytics for spine surgery is presented. Finally, the potential risks and the benefits of antifibrinolytics are discussed.

Influence of curve magnitude and other variables on operative time, blood loss and transfusion requirements in adolescent idiopathic scoliosis

“…These techniques are varied and include intraoperative controlled hypotension (directly reducing the volume of blood lost) and acute normovolaemic haemodilution which reduces the proportion of red cells lost intraoperatively [18,31,32]. Infusion of antifibrinolytic drugs such as tranexamic acid can also decrease the need for allogeneic blood transfusion by competitive inhibition of the activation of plasminogen to plasmin [22,33]. The evidence for the clinical benefit and cost-effectiveness of intraoperative blood salvage is more variable, with many studies showing a decreased need for transfusion with its use [18].…”

Comparison of aprotinin and tranexamic acid in adult scoliosis correction surgery

“…Concerns had been raised about the safety of aprotinin after an association between increased renal dysfunction [12,13,15,16], myocardial infarction, encephalopathy, stroke [16] and mortality [12,14,16] was shown in retrospective observational studies. The risk of acute renal failure is higher in women over the age of 60 [13].…”

“…An increase in all-cause mortality with aprotinin relative to tranexamic acid or epsilon-aminocaproic acid was seen in a pre-planned periodic analysis of the large Blood conservation using Antifibrinolytics in a Randomized Trial study. The latter finding resulted in the trial being halted, and aprotinin has subsequently been withdrawn from the market pending detailed analysis of efficacy and safety results from the study [12].…”

“…To compare the safety of the agents, complications including renal failure, myocardial infarction, stroke and post-operative serum creatinine and urea and were identified as the secondary outcome measures. This was based on previously reported complications with the use of aprotinin in cardiac surgery [12][13][14][15][16].…”

Tranexamic acid reduces blood loss in simultaneous bilateral total knee arthroplasty: a randomized control trial

“…One such modality is pharmacological manipulation of coagulation cascade by antifibrinolytics (i.e., e-aminocaproic acid [EACA], aprotinin, tranexamic acid [TXA]), and was first described for cardiac surgery [5]. It has reported benefits in orthopedics surgery as well as reported by other authors [1,6].…”