Association of Tranexamic Acid Administration With Mortality and Thromboembolic Events in Patients With Traumatic Injury

Abstract

IMPORTANCETranexamic acid is widely available and used off-label in patients with bleeding traumatic injury, although the literature does not consistently agree on its efficacy and safety. OBJECTIVE To examine the association of tranexamic acid administration with mortality and thromboembolic events compared with no treatment or with placebo in patients with traumatic injury in the literature. DATA SOURCES On March 23, 2021, PubMed, Embase, and the Cochrane Library were searched for eligible studies published between 1986 and 2021. STUDY SELECTION Randomized clinical trials and observational studies investigating tranexamic acid administration compared with no treatment or placebo among patients with traumatic injury and traumatic brain injury who were 15 years or older were included. Included studies were published in English or German. The electronic search yielded 1546 records, of which 71 were considered for full-text screening. The selection process was performed independently by 2 reviewers. DATA EXTRACTION AND SYNTHESIS The study followed the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted by 2 independent reviewers and pooled using the inverse-variance random-effects model. MAIN OUTCOMES AND MEASURESOutcomes were formulated before data collection and included mortality at 24 hours and 28 and 30 days (1 month) as well as the incidence of thromboembolic events and the amount of blood products administered. Owing to missing data, overall mortality was added and the amount of blood products administered was discarded. RESULTSThirty-one studies with a total of 43 473 patients were included in the systematic review.The meta-analysis demonstrated that administration of tranexamic acid was associated with a significant decrease in 1-month mortality compared with the control cohort (risk ratio, 0.83 [95% CI, 0.71-0.97]; I 2 = 35%). The results of meta-analyses for 24-hour and overall mortality and thromboembolic events were heterogeneous and could not be pooled. Further investigations on clinical heterogeneity showed that populations with trauma and trial conditions differed markedly. CONCLUSIONS AND RELEVANCEThese findings suggest that tranexamic acid may be beneficial in various patient populations with trauma. However, reasonable concerns about potential thromboembolic events with tranexamic acid remain.

Prehospital tranexamic acid is associated with a dose-dependent decrease in syndecan-1 after trauma: A secondary analysis of a prospective randomized trial

“…Tranexamic acid (TXA) in particular has emerged as a useful therapeutic agent to promote hemostasis and to prevent blood loss in injured patients. Prior to its application to trauma, TXA was routinely used in orthopedic, obstetrics and gynecology, and cardiothoracic patients in hospital and surgical settings 5–7 . Most recently, in the Study of Tranexamic Acid During Air and Ground Prehospital Transport (STAAMP) Trial, prehospital TXA was associated with lower mortality in specific subgroups of injured trauma patients who received TXA close to the time of their injuries 3,8,9 .…”

Postoperative clinical outcomes with and without short-term intravenous tranexamic acid after posterior lumbar interbody fusion: A prospective cohort study

“…[39] Although it may help reduce surgical blood loss, administering TXA to unsuitable patients or at inappropriate doses may increase the risk of thrombosis. [40][41][42][43] However, most studies have reported that TXA use before and during lumbar fusion surgery does not increase the risk of postoperative thrombosis. Surgeons should be cautious when identifying patients at a high risk of thrombosis before using TXA.…”

Administration of TXA Is Not Associated with Increased Risk of Thromboembolism, Even in Patients Considered High Risk

“…As a result, many orthopaedic surgery patients with notable comorbidities do not receive perioperative TXA even though they might derive the most benefit from its use. Evidence supporting the concern that TXA may lead to a higher risk of pulmonary embolism can only be found in studies of complex trauma patients receiving high doses of the drug (2 to 4 g intravenously) 2,3 . This concern is not supported in the orthopaedic literature.…”