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

2017 ◽  
Vol 25 (2) ◽  
pp. 118-122 ◽  
Author(s):  
Jigar Patel ◽  
Mrugesh Prajapati ◽  
Hardik Patel ◽  
Hemang Gandhi ◽  
Shilpa Deodhar ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Blood Loss ◽  
Tranexamic Acid ◽  
Low Dose ◽  
Blood Product ◽  
Sternal Closure ◽  
Topical Tranexamic Acid ◽  
Ventilator Time

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−1 intravenously after sternotomy and 20 mg kg−1 after heparin reversal. Group B patients were given tranexamic acid 50 mg kg−1 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−1 intravenously after sternotomy and 50 mg kg−1 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.

Comparison of Two Doses of Tranexamic Acid in Adults Undergoing Cardiac Surgery with Cardiopulmonary Bypass

2014 ◽  
Vol 120 (3) ◽  
pp. 590-600 ◽  
Author(s):  
Stéphanie Sigaut ◽  
Benjamin Tremey ◽  
Alexandre Ouattara ◽  
Roland Couturier ◽  
Christian Taberlet ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Blood Loss ◽  
Tranexamic Acid ◽  
Primary Endpoint ◽  
Low Dose ◽  
Blood Product ◽  
High Dose ◽  
Blood Product Transfusion ◽  
Repeat Surgery ◽  
Frozen Plasma

Abstract Background: The optimal dose of tranexamic acid (TA) is still an issue. The authors compared two doses of TA during cardiac surgery in a multicenter, double-blinded, randomized study. Methods: Patients were stratified according to transfusion risk, then randomized to two TA doses: 10 mg/kg bolus followed by 1 mg·kg−1·h−1 infusion (low dose) until the end of surgery or 30 mg/kg bolus followed by 16 mg·kg−1·h−1 infusion (high dose). The primary endpoint was the incidence of blood product transfusion up to day 7. Secondary ones were incidences of transfusion for each type of blood product and amounts transfused, blood loss, repeat surgery, TA-related adverse events, and mortality. Results: The low-dose group comprised 284 patients and the high-dose one 285. The primary endpoint was not significantly different between TA doses (63% for low dose vs. 60% for high dose; P = 0.3). With the high dose, a lower incidence of frozen plasma (18 vs. 26%; P = 0.03) and platelet concentrate (15 vs. 23%; P = 0.02) transfusions, lower amounts of blood products (2.5 ± 0.38 vs. 4.1 ± 0.39; P = 0.02), fresh frozen plasma (0.49 ± 0.14 vs.1.07 ± 0.14; P = 0.02), and platelet concentrates transfused (0.50 ± 0.15 vs. 1.13 ± 0.15; P = 0.02), lower blood loss (590 ± 50.4 vs. 820 ± 50.7; P = 0.01), and less repeat surgery (2.5 vs. 6%; P = 0.01) were observed. These results are more marked in patients with a high risk for transfusion. Conclusions: A high dose of TA does not reduce incidence of blood product transfusion up to day 7, but is more effective than a low dose to decrease transfusion needs, blood loss, and repeat surgery.

Comparison of Blood-conservation Strategies in Cardiac Surgery Patients at High Risk for Bleeding

2000 ◽  
Vol 92 (3) ◽  
pp. 674-682 ◽  
Author(s):  
Gregory A. Nuttall ◽  
William C. Oliver ◽  
Mark H. Ereth ◽  
Paula J. Santrach ◽  
Sandra C. Bryant ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Cardiopulmonary Bypass ◽  
Tranexamic Acid ◽  
Combined Therapy ◽  
Autologous Blood ◽  
Blood Collection ◽  
Transfusion Requirements ◽  
Risk For Bleeding

Background Aprotinin and tranexamic acid are routinely used to reduce bleeding in cardiac surgery. There is a large difference in agent price and perhaps in efficacy. Methods In a prospective, randomized, partially blinded study, 168 cardiac surgery patients at high risk for bleeding received either a full-dose aprotinin infusion, tranexamic acid (10-mg/kg load, 1-mg x kg(-1) x h(-1) infusion), tranexamic acid with pre-cardiopulmonary bypass autologous whole-blood collection (12.5% blood volume) and reinfusion after cardiopulmonary bypass (combined therapy), or saline infusion (placebo group). Results There were complete data in 160 patients. The aprotinin (n = 40) and combined therapy (n = 32) groups (data are median [range]) had similar reductions in blood loss in the first 4 h in the intensive care unit (225 [40-761] and 163 [25-760] ml, respectively; P = 0.014), erythrocyte transfusion requirements in the first 24 h in the intensive care unit (0 [0-3] and 0 [0-3] U, respectively; P = 0.004), and durations of time from end of cardiopulmonary bypass to discharge from the operating room (92 [57-215] and 94 [37, 186] min, respectively; P = 0.01) compared with the placebo group (n = 43). Ten patients in the combined therapy group (30.3%) required transfusion of the autologous blood during cardiopulmonary bypass for anemia. Conclusions The combination therapy of tranexamic acid and intraoperative autologous blood collection provided similar reduction in blood loss and transfusion requirements as aprotinin. Cost analyses revealed that combined therapy and tranexamic acid therapy were the least costly therapies.

Abstract 19663: Failed Delayed Sternal Closure Following Neonatal Cardiac Surgery Predicted by High Mean Airway Pressure and Associated with Increased Post-operative Mortality

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Dashiell Massey ◽  
Kathryn A Williams ◽  
Ravi R Thiagarajan ◽  
Frank Pigula ◽  
Catherine K Allan
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Cardiopulmonary Bypass ◽  
Categorical Variables ◽  
Sternal Closure ◽  
Increased Risk ◽  
Significant Difference ◽  
Delayed Sternal Closure ◽  
Neonatal Cardiac Surgery

Background: Myocardial edema, increased lung water, and anasarca are common following neonatal cardiac surgery with cardiopulmonary bypass and amplify the risk of hemodynamic instability and inadequate ventilation following sternal closure. Delayed sternal closure (DSC) in the intensive care unit one or more days following surgery is a common strategy to mitigate this risk, but has been associated with increased risk of infection. In addition, failed DSC has previously been identified as a risk factor for mortality. This study sought to identify predictor variables and determine impact of failed DSC. Methods: Records of all neonates undergoing DSC in the cardiac intensive care unit (CICU) following surgery with cardiopulmonary bypass between January 2008 and May 2013 were reviewed. Pre-operative, intra-operative and post-operative variables were compared for those patients who failed DSC versus those who did not. Continuous variables were compared utilizing Wilcoxon’s test and categorical variables using Fisher’s exact test. Results: Of 256 neonates undergoing DSC in the CICU, 22 failed first attempt at DSC. No significant difference between the two groups was appreciated in age, weight, or bypass (cross clamp, circulatory arrest, and total) times. Comparing DSC failures to successes, significantly more failures: followed Stage I palliation (63% vs. 31%); occurred later (post-operative day 4.7 vs. 2.8, p = 0.009); and were proceeded by higher mean airway pressures (9 vs. 8 cm H2O, p = 0.04), peak inspiratory pressure (27 vs. 24, p = 0.002), and inotrope score (12.1 vs. 9.6, p = 0.06). There was no association with systolic blood pressure or lactate prior to DSC. Failed DSC was associated with increased duration of mechanical ventilation (41.6 vs 7.4 days, p < 0.001), length of ICU stay (44.3 vs 12.0 days, p < 0.001), and mortality (38 vs 3%, p < 0.001). Conclusions: Mortality for patients who fail the first ICU attempt at delayed sternal closure is significantly higher than for those with successful sternal closure. Ventilatory pressures but not hemodynamic variables prior to DSC differed significantly between the two groups. First attempt at DSC was later in those who failed, suggesting that clinicians had a priori identified these patients as higher risk.

Safety, Efficacy, and Timeliness of Intravenous Potassium Chloride Replacement Protocols in a Pediatric Cardiothoracic Intensive Care Unit

2018 ◽  
Vol 35 (4) ◽  
pp. 371-377
Author(s):  
Rambod Amirnovin ◽  
Phuong Lieu ◽  
Flerida Imperial-Perez ◽  
Carol Taketomo ◽  
Barry P. Markovitz ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Potassium Chloride ◽  
Low Dose ◽  
Pediatric Patients ◽  
Univariate Analysis ◽  
Lower Percentage ◽  
High Dose ◽  
Increased Risk

Objective: Hypokalemia in children following cardiac surgery occurs frequently, placing them at risk of life-threatening arrhythmias. However, renal insufficiency after cardiopulmonary bypass warrants careful administration of potassium (K+). Two different nurse-driven protocols (high dose and tiered dosing) were implemented to identify an optimal K+ replacement regimen, compared to an historical low-dose protocol. Our objective was to evaluate the safety, efficacy, and timeliness of these protocols. Design: A retrospective cohort review of pediatric patients placed on intravenous K+ replacement protocols over 1 year was used to determine efficacy and safety of the protocols. A prospective single-blinded review of K+ repletion was used to determine timeliness. Patients: Pediatric patients with congenital or acquired cardiac disease. Setting: Twenty-four-bed cardiothoracic intensive care unit in a tertiary children’s hospital. Interventions: Efficacy was defined as fewer supplemental potassium chloride (KCl) doses, as well as a higher protocol to total doses ratio per patient. Safety was defined as a lower percentage of serum K+ levels ≥4.8 mEq/L after a dose of KCl. Between-group differences were assessed by nonparametric univariate analysis. Results: There were 138 patients with a median age of 3.0 (interquartile range: 0.23-10.0) months. The incidence of K+ levels ≥4.8 mEq/L after a protocol dose was higher in the high-dose protocol versus the tiered-dosing protocol but not different between the low-dose and tiered-dosing protocols (high dose = 2.2% vs tiered dosing = 0.5%, P = .05). The ratio of protocol doses to total doses per patient was lower in the low-dose protocol compared to the tiered-dosing protocol ( P < .05). Protocol doses were administered 45 minutes faster ( P < .001). Conclusion: The tiered-dosed, nurse-driven K+ replacement protocol was associated with decreased supplemental K+ doses without increased risk of hyperkalemia, administering doses faster than individually ordered doses; the protocol was effective, safe, and timely in the treatment of hypokalemia in pediatric patients after cardiac surgery.

Topical Application of Tranexamic Acid to Reduce Post-Operative Bleeding in Coronary Artery Bypass Surgery

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 3432-3432
Author(s):  
Oksana Prokopchuk-Gauk ◽  
Mark Rosin ◽  
Taras Mycyk ◽  
Hyun Lim ◽  
Kelsey Brose
Keyword(s):  
Cardiac Surgery ◽  
Blood Loss ◽  
Tranexamic Acid ◽  
Topical Application ◽  
Chest Tube ◽  
Artery Bypass ◽  
Acid Group ◽  
P Value ◽  
Tube Removal ◽  
Topical Tranexamic Acid

Abstract Abstract 3432 Patients who undergo on-pump coronary artery bypass graft surgery (CABG) are at an increased risk of bleeding due physiologic, mechanical and pharmacologic disruption of hemostasis. The use of topically applied antifibrinolytic agents has been explored as a blood-conservation adjunct to reduce post-operative bleeding in cardiac surgery. Analysis of pooled results in a meta-analysis published by Abrishami et al. in 2009 showed that a significant reduction in blood loss could be achieved utilizing topical tranexamic acid in the absence of concurrent intravenous antifibrinolytic agents. However, current blood conservation clinical practice guidelines recommend the use of intravenous lysine analogues to limit peri-operative blood loss. Presently, there is no published prospective data evaluating blood loss in CABG patients who have received intravenous tranexamic acid, plus topical tranexamic acid versus placebo. Our study was designed to determine whether combined intravenous and topical application of tranexamic acid would reduce post-CABG blood loss in low-risk bypass surgery candidates. A sample calculation based on pilot study data analysis concluded that a minimum total of 74 patients was required, allowing 80% power to detect a 200mL difference in total blood loss (Type I error = 0.05) between groups. In our prospective, double-blind, randomized controlled trial, patients enrolled were randomly assigned to receive an intra-operative cardiac bath of either normal saline or tranexamic acid solution prior to sternotomy closure. All participants received intravenous tranexamic acid prior to the initiation of circulatory bypass. Research subject participation ended upon transfer out of the intensive care unit. Primary outcomes included the total volume of chest tube blood loss and number of transfusions administered following CABG. Secondary outcomes included chest tube loss volumes at 6 hours and 12 hours. Between December 1, 2011 and April 30, 2012, a total of 41 patients who underwent randomization were included in final data analysis. Baseline characteristics of patients enrolled in both groups were similar. Post-CABG losses at chest tube removal were found to be significantly reduced in the patients who received topical tranexamic acid. Mean chest tube loss in the placebo group (n=18) was 789mL versus 632mL in the topical tranexamic acid group (n=23), with a difference of 157mL (Figure 1, p value of student t-test 0.0493). A significantly greater proportion of patients in the placebo group were found to bleed more than 700mL at chest tube removal, in comparison with the topical tranexamic acid group (72.2% versus 30.4%, p value of chi-squared test 0.0079). Chest tubes remained in situ for a mean duration of 20 hours and 19 hours, respectively. None of the patients received post-operative red cell transfusions. One patient, randomized to the topical tranexamic acid group, received a single dose each of platelets and cryoprecipitate post-operatively. The application of topical tranexamic acid did not significantly reduce blood loss at 6 hours and 12 hours, with a difference of 76mL (p=0.1876) and 106mL (p=0.0930) respectively. The application of topical tranexamic acid reduces post-operative blood loss in patients undergoing on-pump CABG who have received intravenous tranexamic acid. There was no difference in blood product use between groups. Further studies must be carried out to investigate long-term outcomes of this practice and its applicability in high-risk cardiac surgery patients. (ClinicalTrials.gov number, NCT01519245.) Disclosures: Off Label Use: Intravenous and topical application of tranexamic acid in cardiac surgery.

Sign in / Sign up

Export Citation Format

Share Document