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The Effect of Prophylactic Use of Antifibrinolytics During Pediatric Non-Cardiac Surgeries on Bleeding and
Katherine Schertz Hickey1, Morgan Smith2, Oliver Karam3
1Department of Pediatric Critical Care, Mount Sinai Kravis Children's Hospital, New York, New York, USA.
Insights
Intraoperative tranexamic acid, aminocaproic acid, and aprotinin reduce bleeding in pediatric surgery. Tranexamic acid is most effective for scoliosis surgery, while tranexamic acid and aprotinin reduce transfusions in craniofacial procedures.
Area of Science:
- Pediatric Surgery
- Anesthesiology
- Pharmacology
Background:
- Minimizing blood loss and transfusion needs is critical in pediatric surgery.
- Antifibrinolytic agents are increasingly used to manage bleeding during surgical procedures.
- Evidence on the comparative efficacy of different antifibrinolytics in pediatric populations is evolving.
Purpose of the Study:
- To conduct a meta-analysis evaluating the impact of intraoperative tranexamic acid, aminocaproic acid, and aprotinin on bleeding in pediatric surgery.
- To compare the effectiveness of these agents in reducing intraoperative blood loss and transfusion requirements.
- To assess the efficacy of antifibrinolytics across various pediatric surgical subspecialties.
Main Methods:
- Systematic literature search of Ovid MEDLINE, Ovid EMBASE, and The Cochrane Library from inception to April 2023.
- Inclusion of studies involving patients under 18 years undergoing non-cardiac surgery with antifibrinolytic administration.
- Statistical analysis using forest plots to determine primary outcomes of intraoperative blood loss and transfusions.
Main Results:
- Tranexamic acid significantly reduced blood loss in scoliosis (-410.0 mL), craniofacial (-14.0 mL/kg), and tonsillectomy/adenoidectomy (-21.0 mL) surgeries compared to control.
- Aminocaproic acid also reduced blood loss in scoliosis surgery (-464.0 mL).
- Tranexamic acid demonstrated greater efficacy than aminocaproic acid in scoliosis surgery (-391.0 mL).
- Tranexamic acid and aprotinin reduced blood transfusions in craniosynostosis surgery (-7 mL/kg and -20.0 mL/kg, respectively).
- No statistically significant findings for VRO/VDRO and hip reconstruction surgeries.
Conclusions:
- Prophylactic tranexamic acid effectively lowers blood loss in craniofacial, scoliosis, and tonsillectomy/adenoidectomy pediatric surgeries.
- Tranexamic acid and aprotinin are beneficial in reducing transfusions during craniofacial surgery.
- Tranexamic acid shows superior efficacy over aminocaproic acid for scoliosis surgery.
- Further research is needed for VRO/VDRO and hip reconstruction, and optimal dosing regimens.
Objectives:
The objective of this meta-analysis is to determine the effect of intraoperative tranexamic acid, aminocaproic acid, and aprotinin on bleeding in pediatric surgery.
Study Design:
A literature search was performed for the meta-analysis and systematic review in the following databases from inception until April 2023: Ovid MEDLINE, Ovid EMBASE, and The Cochrane Library. Studies included patients under 18 years of age, non-cardiac surgery, and administration of antifibrinolytics. Forest plots were used for statistical analysis. Primary outcomes were intraoperative blood loss and intraoperative blood transfusions.
Results:
One hundred thirty articles met inclusion. Tranexamic acid compared to control resulted in an estimated blood loss of -410.0 mL p-value = < 0.001 for scoliosis surgery, -14.0 mL/kg p-value = < 0.001 for craniofacial surgery, and -21.0 mL p-value < 0.001 for tonsillectomy/adenoidectomy surgery. Aminocaproic acid compared to control resulted in an estimated blood loss of -464.0 mL p-value < 0.001 for scoliosis surgery. Tranexamic acid compared to aminocaproic acid resulted in an estimated blood loss of -391.0 mL p-value < 0.001 for scoliosis surgery. For blood transfusion during craniosynostosis surgery, tranexamic acid compared to control resulted in a mean decrease of -7 mL/kg p-value = 0.010 and aprotinin compared to control resulted in a mean decrease of -20.0 mL/kg p-value < 0.001. The analysis for VRO/VDRO and hip reconstruction did not reach statistical significance.
Conclusions:
In craniofacial, scoliosis, and tonsillectomy/adenoidectomy surgery, prophylactic administration of tranexamic acid results in lower estimated blood loss. Tranexamic acid and aprotinin are effective for reducing transfusion in craniofacial surgery. For scoliosis surgery, tranexamic acid is more efficacious than aminocaproic acid. More literature is needed to assess the efficacy of tranexamic acid in VRDO/VRO and hip reconstruction surgery and the efficacy of different dosing regimens.
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