High- versus low-dose tranexamic acid as part of a Patient Blood Management strategy for reducing blood loss in patients undergoing surgery for adolescent idiopathic scoliosis
Abstract:Purpose:
The administration of tranexamic acid (TXA) has been shown to be beneficial in reducing blood loss during surgery for adolescent idiopathic scoliosis (AIS), but optimal dosing has yet to be defined. This retrospective study compared high versus low dose TXA as part of a Patient Blood Management strategy for reducing blood loss in patients undergoing posterior spine fusion surgery.
Methods:
Clinical records were reviewed for 223 patients with AIS who underwent p… Show more
“…Included studies were either retrospective cohort reviews (n = 14), double blinded RCTs (n = 8), or case series (n = 1), published between 2005 and 2021, with sample sizes ranging from 22 to 318 total participants (Table 1). Of the 23 studies, 1 was a case series of HD interventions, 20 1 compared various HD regimens to each other, 7 4 compared HD and LD cohorts, 9,21-23 15 compared HD to placebo controls, and 2 compared HD to other anti-fibrolytics. 24,25 Funnel plot analysis was performed using VTE as the outcome of interest, the funnel plot showed some asymmetry with a moderate risk of publication bias (Appendix 3).…”
Section: Resultsmentioning
confidence: 99%
“…Analysis on perioperative transfusion events showed significant results favoring HD over NHD (2 studies, 505 patients, P = .043) (Figure 6) while there was a present but insignificant difference for intraoperative transfusion events (2 studies, 339 patients, OR = .244 [95% CI, .053 to 1.115]; P = .069; I 2 = 88%). Lastly, 3 studies were included in the meta-analysis for surgical duration, 9,21,22 which demonstrated no correlation with TXA dose ( P = .904) (Appendix 4). Figure 6.Meta analysis with a random effects model comparing perioperative RBC transfusion events between high-dose (HD) and low-dose (LD) cohorts across all age groups.…”
Section: Resultsmentioning
confidence: 99%
“…42 Higher concentrations (126-152 µg/mL) have the potential to further inhibit fibrinolysis and enhance hemostasis by increasing thrombin formation, improving platelet function. 9,13,14,43 There may be an anti-inflammatory effect as well through its action on cytokine production. 39…”
Section: Discussionmentioning
confidence: 99%
“…44 Notably, the effect size was greatest in studies with the largest blood loss. 9,10 For example, Tumber et al reviewed 223 patients with AIS, with an average EBL per vertebral body fused (EBL/VB) of 160 and 104 mL in the LD and HD cohorts, respectively. 9 They found a statistically significant 48% reduction in pRBC transfusion rate (67% LD vs 19% HD, P < .001).…”
Section: Discussionmentioning
confidence: 99%
“…9,10 For example, Tumber et al reviewed 223 patients with AIS, with an average EBL per vertebral body fused (EBL/VB) of 160 and 104 mL in the LD and HD cohorts, respectively. 9 They found a statistically significant 48% reduction in pRBC transfusion rate (67% LD vs 19% HD, P < .001). On the other hand, Johnson et al also examined 116 AIS patients, reporting an average EBL/VB of 87 and 63, respectively.…”
Study Design Literature review and meta-analysis. Objectives Single-center series may be underpowered to detect whether high-dose (HD) tranexamic acid (TXA) confers a higher risk of complications. We sought to determine the safety and efficacy of HD TXA as compared to low-dose (LD) or placebo. Methods A systematic literature review was performed to find studies where spine surgery patients were given HD TXA (loading dose ≥30 mg/kg). Complication rates were pooled, and meta-analyses performed on outcomes of interest. Articles were evaluated for risk of bias and a strength of evidence assessment was given for each conclusion. Results Twenty three studies (n = 2331) were included. The pooled medical complication rate was 3.2% in pediatric patients, 8.2% in adults. Using lower dose TXA or placebo as the reference, meta-analysis showed no difference in medical complications (n = 1,723, OR 1.22 [95% CI, .78 to 1.22]; P = .388; I2 = 0%) or thrombotic events (n = 1158 patients, OR 1.27 [95% CI, .71 to 2.63]; P = .528; I2 = 0%). Compared to LD, HD TXA was associated with less intraoperative blood loss (823 patients, WMD = −285 [95% CI, −564 to −5.90]; P = .0454; I2 = 86%), fewer perioperative transfusions (n = 505, OR .28 [95% CI, .082 to .96]; P = .043; I2 = 76%) and lower perioperative transfusion volumes (n = 434, WMD −227.7 mL [95% CI, −377.3 to −78.02]; P = .0029; I2 = 0%). Conclusion Compared to LD TXA or placebo, there is moderate evidence that HD is not associated with an increased risk of medical complications. Compared to LD, there is moderate evidence that HD reduces transfusion requirements. High-Dose TXA can be safely utilized in healthy patients undergoing major spine surgery.
“…Included studies were either retrospective cohort reviews (n = 14), double blinded RCTs (n = 8), or case series (n = 1), published between 2005 and 2021, with sample sizes ranging from 22 to 318 total participants (Table 1). Of the 23 studies, 1 was a case series of HD interventions, 20 1 compared various HD regimens to each other, 7 4 compared HD and LD cohorts, 9,21-23 15 compared HD to placebo controls, and 2 compared HD to other anti-fibrolytics. 24,25 Funnel plot analysis was performed using VTE as the outcome of interest, the funnel plot showed some asymmetry with a moderate risk of publication bias (Appendix 3).…”
Section: Resultsmentioning
confidence: 99%
“…Analysis on perioperative transfusion events showed significant results favoring HD over NHD (2 studies, 505 patients, P = .043) (Figure 6) while there was a present but insignificant difference for intraoperative transfusion events (2 studies, 339 patients, OR = .244 [95% CI, .053 to 1.115]; P = .069; I 2 = 88%). Lastly, 3 studies were included in the meta-analysis for surgical duration, 9,21,22 which demonstrated no correlation with TXA dose ( P = .904) (Appendix 4). Figure 6.Meta analysis with a random effects model comparing perioperative RBC transfusion events between high-dose (HD) and low-dose (LD) cohorts across all age groups.…”
Section: Resultsmentioning
confidence: 99%
“…42 Higher concentrations (126-152 µg/mL) have the potential to further inhibit fibrinolysis and enhance hemostasis by increasing thrombin formation, improving platelet function. 9,13,14,43 There may be an anti-inflammatory effect as well through its action on cytokine production. 39…”
Section: Discussionmentioning
confidence: 99%
“…44 Notably, the effect size was greatest in studies with the largest blood loss. 9,10 For example, Tumber et al reviewed 223 patients with AIS, with an average EBL per vertebral body fused (EBL/VB) of 160 and 104 mL in the LD and HD cohorts, respectively. 9 They found a statistically significant 48% reduction in pRBC transfusion rate (67% LD vs 19% HD, P < .001).…”
Section: Discussionmentioning
confidence: 99%
“…9,10 For example, Tumber et al reviewed 223 patients with AIS, with an average EBL per vertebral body fused (EBL/VB) of 160 and 104 mL in the LD and HD cohorts, respectively. 9 They found a statistically significant 48% reduction in pRBC transfusion rate (67% LD vs 19% HD, P < .001). On the other hand, Johnson et al also examined 116 AIS patients, reporting an average EBL/VB of 87 and 63, respectively.…”
Study Design Literature review and meta-analysis. Objectives Single-center series may be underpowered to detect whether high-dose (HD) tranexamic acid (TXA) confers a higher risk of complications. We sought to determine the safety and efficacy of HD TXA as compared to low-dose (LD) or placebo. Methods A systematic literature review was performed to find studies where spine surgery patients were given HD TXA (loading dose ≥30 mg/kg). Complication rates were pooled, and meta-analyses performed on outcomes of interest. Articles were evaluated for risk of bias and a strength of evidence assessment was given for each conclusion. Results Twenty three studies (n = 2331) were included. The pooled medical complication rate was 3.2% in pediatric patients, 8.2% in adults. Using lower dose TXA or placebo as the reference, meta-analysis showed no difference in medical complications (n = 1,723, OR 1.22 [95% CI, .78 to 1.22]; P = .388; I2 = 0%) or thrombotic events (n = 1158 patients, OR 1.27 [95% CI, .71 to 2.63]; P = .528; I2 = 0%). Compared to LD, HD TXA was associated with less intraoperative blood loss (823 patients, WMD = −285 [95% CI, −564 to −5.90]; P = .0454; I2 = 86%), fewer perioperative transfusions (n = 505, OR .28 [95% CI, .082 to .96]; P = .043; I2 = 76%) and lower perioperative transfusion volumes (n = 434, WMD −227.7 mL [95% CI, −377.3 to −78.02]; P = .0029; I2 = 0%). Conclusion Compared to LD TXA or placebo, there is moderate evidence that HD is not associated with an increased risk of medical complications. Compared to LD, there is moderate evidence that HD reduces transfusion requirements. High-Dose TXA can be safely utilized in healthy patients undergoing major spine surgery.
BackgroundAdolescent Idiopathic Scoliosis (AIS) affects 2%–4% of the general pediatric population. While surgical correction remains one of the most common orthopedic procedures performed in pediatrics, limited consensus exists on the perioperative anesthetic management.AimsTo examine the current state of anesthetic management of typical AIS spine fusions at institutions which have a dedicated pediatric orthopedic spine surgeon.MethodsA web‐based survey was sent to all members of the North American Pediatric Spine Anesthesiologists (NAPSA) Collaborative. This group included 34 anesthesiologists at 19 different institutions, each of whom has a Harms Study Group surgeon performing spine fusions at their hospital.ResultsThirty‐one of 34 (91.2%) anesthesiologists completed the survey, with a missing response rate from 0% to 16.1% depending on the question. Most anesthesia practices (77.4%; 95% confidence interval [CI], 67.7–93.4) do not have patients come for a preoperative visit prior to the day of surgery. Intravenous induction was the preferred method (74.2%; 95% CI 61.3–89.9), with the majority utilizing two peripheral IVs (93.5%; 95% CI 90.3–100) and an arterial line (100%; 95% CI 88.8–100). Paralytic administration for intubation and/or exposure was divided (51.6% rocuronium/vecuronium, 45.2% no paralytic, and 3.2% succinylcholine) amongst respondents. While tranexamic acid was consistently utilized for reducing blood loss, dosing regimens varied. When faced with neuromonitoring signal issues, 67.7% employ a formal protocol. Most anesthesiologists (93.5%; 95% CI 78.6–99.2) extubate immediately postoperatively with patients admitted to an inpatient floor bed (77.4%; 95% CI 67.7–93.3).ConclusionMost anesthesiologists (87.1%; 95% CI 80.6–99.9) report the use of some form of an anesthesia‐based protocol for AIS fusions, but our survey results show there is considerable variation in all aspects of perioperative care. Areas of agreement on management comprise the typical vascular access required, utilization of tranexamic acid, immediate extubation, and disposition to a floor bed. By recognizing the diversity of anesthetic care, we can develop areas of research and improve the perioperative management of AIS.
The objective of this study was to conduct a systematic literature review to evaluate the impact of perioperative blood loss reduction and blood transfusion rate in patients undergoing adolescent idiopathic scoliosis correction surgery and to correlate these results with the different doses of tranexamic acid used in the literature. Ten databases (BVS, COCHRANE, EBSCOHOST, EMBASE, EPISTEMONIKOS, PROQUEST, PUBMED PMC, PUBMED, SCOPUS, WEB OF SCIENCE) were searched to find studies on the effectiveness of tranexamic acid in idiopathic scoliosis surgery. The mean differences in bleeding and transfusions were combined using a random-effects meta-analysis. A total of 17 studies with 1608 patients were included in the evaluation, demonstrating an Odds Ratio of 2.8 (95% CI: 0.8-4.3) as a measure of association for the risk of bleeding and transfusion in the control group (non-users of tranexamic acid), efficiency in reducing bleeding (p=0.03). Additionally, a mean reduction in bleeding of approximately 700 ml was observed. There was no statistical difference between the doses used. The systematic review showed that tranexamic acid effectively reduces bleeding and the need for transfusions, but there were no significant differences in the results between different doses of tranexamic acid. Level of Evidence II; Systematic Review.
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