A randomized prospective analysis of alteration of hemostatic function in patients receiving tranexamic acid and hydroxyethyl starch (130/0.4) undergoing off pump coronary artery bypass surgery

Abstract

Postoperative hemorrhagic complications is still one of the major problems in cardiac surgeries. It may be caused by surgical issues, coagulopathy caused by the side effects of the intravenous fluids administered to produce plasma volume expansion such as hydroxyl ethyl starch (HES). In order to thwart this hemorrhagic issue, few agents are available. Fibrinolytic inhibitors like tranexamic acid (TA) may be effective modes to promote blood conservation; but the possible complications of thrombosis of coronary artery graft, precludes their generous use in coronary artery bypass graft surgery. The issue is a balance between agents that promote coagulation and those which oppose it. Therefore, in this study we have assessed the effects of concomitant use of HES and TA. Thromboelastogram (TEG) was used to assess the effect of the combination of HES and TA. With ethical committee approval and patient's consent, 100 consecutive patients were recruited for the study. Surgical and anesthetic techniques were standardized. Patients fulfilling our inclusion criteria were randomly allocated into 4 groups of 25 each. The patients in group A received 20 ml/kg of HES (130/0.4), 10 mg/kg of T.A over 30 minutes followed by infusion of 1 mg/kg/hr over the next 12 hrs. The patients in group B received Ringer's lactate + TA at same dose. The patients in the Group C received 20 ml/kg of HES. Group D patients received RL. Fluid therapy was goal directed. Total blood loss was assessed. Reaction time (r), α angle, maximum amplitude (MA) values of TEG were assessed at baseline, 12, 36 hrs. The possible perioperative myocardial infraction (MI) was assessed by electrocardiogram (ECG) and troponin T values at the baseline, postoperative day 1. Duration on ventilator, length of stay (LOS) in the intensive care unit (ICU) were also assessed. The demographical profile was similar among the groups. Use of HES increased blood loss significantly (P < 0.05). Concomitant use of TA reduced blood loss when used along with HES. r value was prolonged at 12 hours in all the groups and α angle was reduced at 12 hours in all the groups, where as MA value was reduced at 12 th hour in the HES group compared to the baseline and increased in TA + HES group. These findings were statistically significant. No significant change in Troponin T values/ECG, duration of ventilation and LOS ICU was observed. No adverse events was noticed in any of the four groups. HES (130/0.4) used at a dose of 20 ml/kg seems to produce coagulopathy causing increased blood loss perioperatively. Hemodilution produced by fluid therapy seems to produce Coagulopathy as observed by TEG parameters. Concomitant use of TA with HES appears to reverse these changes without causing any adverse effects in patients undergoing OPCAB surgery.

Major liver resection, systemic fibrinolytic activity, and the impact of tranexamic acid

“…45 Two trials have examined the impact of TXA on TEG markers of fibrinolysis in cardiac surgery, yielding conflicting conclusions. 46,47 To our knowledge, none of the trials identified measured the impact of TXA on PAP complex levels.…”

Tranexamic acid is beneficial for reducing perioperative blood loss in transurethral resection of the prostate

“…experimental group (two doses of TXA) and a control group (normal saline), but the results were not statistically significant. Chakravarthy et al (28) used TEG to compare the influence of TXA and hydroxyethyl starch on extracorporeal circulation blood loss during heart surgeries; however, these results were not statistically significant either. Due to limited funding, TEG could not be used in this study.…”

The safety and efficiency of intravenous administration of tranexamic acid in coronary artery bypass grafting (CABG): A meta-analysis of 28 randomized controlled trials

“…The characteristics of included studies were shown in [12,14,[16][17][18][23][24][25][26]28,[30][31][32]34,36,38,39], off-pump condition in 9 trails [3,10,11,15,27,29,33,35,37] and both condition in 2 trails [4,8].…”

“…14 studies [3,11,12,14,16,[23][24][25][27][28][29][30]35,38] did not provide a satisfactory description of their random processes. Blinding process was at high risk of bias in one study [39] and unclear risk of bias in 7 studies [11,12,[23][24][25]29,35] due to unclear description. 3 studies [16,25,31] had unclear or incomplete descriptions of their outcome data.…”

“…An increasing number of studies that investigated the effectiveness and safety of TXA in CABG surgery have been conducted in recent years with varying results [8,[10][11][12][13][14][15][16][17][18]. Therefore, we conducted a meta-analysis of existing studies to estimate the safety and efficiency of TXA in CABG surgery focusing on the incidence of postoperative cerebrovascular accident, seizures and reoperation for bleeding.…”