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Published on: April 19, 2022
Prophylactic administration of tranexamic acid combined with thromboelastography-guided hemostatic algorithm reduces
Ting Zhang1, Hua Feng1, Wei Xiao1
1Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China.
Insights
This study shows that combining tranexamic acid (TXA) with thromboelastography (TEG)-guided management significantly reduces the need for allogeneic transfusions in pediatric epilepsy surgery. This multimodal approach improves patient safety by minimizing transfusion risks.
Area of Science:
- Anesthesiology and Perioperative Medicine
- Pediatric Surgery
- Hematology
Background:
- Intraoperative bleeding and allogeneic transfusions are significant concerns in pediatric epilepsy surgery.
- Tranexamic acid (TXA) is a proven antifibrinolytic agent, and thromboelastography (TEG) guides hemostatic management.
- A multimodal approach combining TXA with TEG may reduce transfusion risks in this patient population.
Purpose of the Study:
- To validate the efficacy of a multimodal coagulation therapy using continuous TXA infusion and a TEG-guided algorithm.
- To assess the reduction in allogeneic transfusion exposure risk during pediatric resective epilepsy surgery.
Main Methods:
- Eighty-three children undergoing resective epilepsy surgery were randomized into two groups: treatment (TXA + TEG-guided) and control (conventional management).
- The treatment group received prophylactic TXA (10 mg/kg loading dose, then 5 mg/kg/h infusion).
- Primary outcome was the intraoperative allogeneic transfusion rate; secondary outcomes included blood loss, seizures, and thromboembolic events.
Main Results:
- The multimodal therapy significantly reduced the intraoperative allogeneic transfusion rate by 34.7% (19.0% vs. 53.7%, p=0.001), primarily due to a 44.1% decrease in plasma transfusions.
- While RBC transfusion rates were lower in the treatment group, the difference was not statistically significant (14.3% vs. 29.3%, p=0.098).
- Fibrinogen concentrates were administered more frequently in the TXA+TEG group (45.2% vs. 2.4%), guided by TEG data. No significant differences in blood loss or postoperative seizures were observed, and no thromboembolic events occurred.
Conclusions:
- Prophylactic tranexamic acid combined with a TEG-guided hemostatic algorithm is an effective multimodal strategy.
- This approach significantly reduces the need for allogeneic transfusions in pediatric resective epilepsy surgery.
- The combination therapy offers a safe and effective method for managing coagulation and minimizing transfusion requirements.
Abstract:
Background: Intraoperative bleeding and allogeneic transfusion remain common problems in pediatric resective epilepsy surgery. Tranexamic acid (TXA) is a widely recommended antifibrinolytic drug that reduces blood loss and transfusion requirements for bleeding patients. Thromboelastography (TEG)-guided hemostatic algorithm is commonly used in bleeding management. This trial was designed to validate the efficacy of a multimodal coagulation therapy involving continuous TXA infusion with TEG-guided hemostatic algorithm in reducing allogeneic exposure risk in pediatric resective epilepsy surgery. Methods: Eighty-three children undergoing resective epilepsy surgery were randomized into a treatment group (Group T; n = 42) and a control group (Group C; n = 41). Group T received prophylactic TXA (10 mg/kg followed by 5 mg/kg/h) with TEG-guided hemostatic algorithm, whereas Group C received conventional coagulation management. The primary outcome was allogeneic transfusion rate during surgery, and the secondary outcomes were intraoperative blood loss, incidence of postoperative seizures, and thromboembolic events during hospitalization. Results: The incidence of intraoperative allogeneic transfusion reduced by 34.7% with the use of a multimodal coagulation therapy (19.0% in Group T vs. 53.7% in Group C; RR 0.355, 95% CI 0.179-0.704; p = 0.001). This was mainly triggered by a significant reduction (44.1%) in intraoperative plasma transfusion (7.1% in Group T vs. 51.2% in Group C; RR 0.139, 95% CI 0.045-0.432; p = 0.000). The risk of intraoperative RBC transfusion was lower in Group T than in Group C, but the difference was not statistically significant (14.3% in Group T vs. 29.3% in Group C; RR 0.488, 95% CI 0.202-1.177; p = 0.098). No platelets were transfused in both groups. Further, 19 (45.2%) patients in Group T received fibrinogen concentrates guided by TEG data, whereas 1 (2.4%) patient in Group C received fibrinogen concentrates empirically. There were no significant differences in estimated blood loss and postoperative seizures between the two groups, and no thromboembolic events were observed after surgery. Conclusion: Prophylactic administration of TXA combined with TEG-guided hemostatic algorithm can be an effective multimodal coagulation strategy for reducing allogeneic transfusion requirements during pediatric resective epilepsy surgery. Clinical Trial Registration: www.chictr.org.cn/index.aspx, identifier ChiCTR1800016188.
