Tranexamic acid leads to paradoxical coagulation changes during cardiac surgery: a pilot rotational thromboelastometry study

Sharma, Rajiv, Letson, Hayley L., Smith, Samuel, and Dobson, Geoffrey P. (2017) Tranexamic acid leads to paradoxical coagulation changes during cardiac surgery: a pilot rotational thromboelastometry study. Journal of Surgical Research, 217. pp. 100-112.

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Abstract

Background: Tranexamic acid (TXA) is increasingly used during major surgery with the goal to reduce excessive bleeding, transfusion requirements, and reexploration. Our aim was to examine the effect of TXA on coagulation at different times during cardiac surgery using rotational thromboelastometry.

Materials and Methods: Nineteen adult males (EuroSCORE 4-5) were recruited consecutively for first-time cardiopulmonary bypass (CPB) surgery. Ten patients received TXA at anesthesia and nine received no TXA. Rotational thromboelastometry analysis occurred before anesthesia (baseline), after sternotomy, after CPB-heparinization and surgery, and after protamine administration-sternal closure.

Results: A median sternotomy had no effect on clot time (CT), formation, amplitude, or lysis in non-TXA patients. In contrast, TXA patients had twofold prolonged clotting time (all-tests) and ∼30% reduced FIBTEM (A5-30) and maximum clot firmness, indicating reduced thrombin generation and lower clot fibrinogen. After CPB, CTs in both groups were prolonged, possibly linked to overheparinization. In addition, TXA patients had significantly decreased EXTEM (A5-30), suggesting lower clot strength. After protamine-sternal closure, clotting time remained prolonged in both groups, and TXA patients had a persistently 25%-33% lower FIBTEM (A5-30) and maximum clot firmness. TXA patients also had significantly reduced platelet numbers (37% from baseline), which continued Days 1 and 2. Maximum clot lysis was <10% indicating little or no hyperfibrinolysis during cardiac surgery.

Conclusions: In this nonrandomized, nonblinded, observational trial, patients in the TXA group displayed prolonged CTs and clot fibrinogen (FIBTEM A5-30) after sternotomy, decreased clot strength (EXTEM) after CPB/surgery, and acute thrombocytopenia after protamine-sternal closure. There was no significant decrease in clot lysis, questioning the need for TXA in this medium-risk group.

Item ID: 50172
Item Type: Article (Research - C1)
ISSN: 1095-8673
Keywords: antifibrinolytic; cardiac surgery; cardiopulmonary bypass; TXA; trauma; coagulation
Funders: Mater Hospital, Australian Institute of Tropical Health and Medicine (AITHM)
Date Deposited: 12 Sep 2017 22:46
FoR Codes: 11 MEDICAL AND HEALTH SCIENCES > 1102 Cardiovascular Medicine and Haematology > 110299 Cardiovascular Medicine and Haematology not elsewhere classified @ 65%
11 MEDICAL AND HEALTH SCIENCES > 1103 Clinical Sciences > 110323 Surgery @ 35%
SEO Codes: 92 HEALTH > 9201 Clinical Health (Organs, Diseases and Abnormal Conditions) > 920103 Cardiovascular System and Diseases @ 60%
92 HEALTH > 9201 Clinical Health (Organs, Diseases and Abnormal Conditions) > 920118 Surgical Methods and Procedures @ 40%
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