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Haemorrhage is a leading cause of trauma morbidity and mortality, with many deaths potentially preventable. Hyperfibrinolysis is a central characteristic of trauma-induced coagulopathy (TIC) which develops rapidly and is associated with poor outcomes. Tranexamic acid (TXA) improves survival in trauma haemorrhage but its uptake worldwide remains variable, in part because its effects on the coagulation system during trauma haemorrhage have not been described. Further uncertainty regarding patient selection for TXA therapy has emerged following the description of an early viscoelastic haemostatic assay (VHA) diagnosed hypofibrinolytic phenotype in whom TXA may potentiate thrombotic complications. The patient characteristics and mechanisms leading to this apparent hypofibrinolytic phenotype are poorly understood. Over 900 trauma patients prospectively recruited to a multicentre observational cohort study had blood drawn within 2-hours of injury for VHA and fibrinolysis plasma protein analysis. Patients were categorised according to VHA maximum lysis (ML) and D-dimer (DD) levels. Patients with MLLOW exhibited heterogeneity in clinical and injury characteristics and outcomes. Those who died were severely injured, with a high incidence of traumatic brain injury and a 7-fold higher D-dimer. Patients with MLLOW+DDHIGH had a hyperfibrinolytic biomarker profile, with the fibrinolytic mediator S100A10 identified as a potential driver of fibrinolysis, which can ex-vivo artificially reduce ML. Empiric TXA could benefit this occult hyperfibrinolytic phenotype. Over two subsequent observational studies, the effects of TXA on the coagulation system during trauma haemorrhage and the effect of TXA infusion and timing of treatment on thrombotic events were investigated. Early empiric TXA avoided VHA-hyperfibrinolysis and provided a degree of protection from TIC. Whilst univariate analysis suggested increased thromboses with later TXA treatment in patients receiving TXA bolus+infusion, neither the TXA infusion nor time to bolus were associated with thrombotic events after multivariate analysis. A single TXA bolus may provide a lower effective therapeutic dose with reduced complications.

Infection after trauma complicates the patients clinical course. Infection leads to longer critical care and hospital stays, has been associated with increased mortality rates and places considerable cost pressures on health economies. The predictors of infection after severe injury are not known, and the effects on outcomes other than mortality are under-reported. The overall objective of this research was to characterise factors predictive of infection in severely injured patients admitted to critical care. A prospective cohort study of 271 patients investigated admission factors predictive of the development of infection. A second study of 280 patients evaluated post-injury immune cell changes and the association with infection. Thirdly the relationship between early coagulopathy and infections was investigated in 158 patients. Finally a study of 385 patients examined the use of Tranexamic Acid (TXA) and its association with infection and other outcomes. Infection was a significant burden for severely injured patients. Admission hypoperfusion was the only early characteristic associated with the development of infection, and a dose dependent relationship was observed between severity of shock and increased percentage of infection (p<0.01). Lymphopenia prolonged to day four post injury was strongly predictive infection (OR 0.10, CI 0.02-0.48, p<0.01). At 24 hours, the anticoagulant Protein C was lower in those with infection (Infection: 70.2 iu/dL vs. No infection: 83.3 iu/dL p=0.02), and increased fibrinolysis was also associated with infectious complications (Infection: 6156 μg/L vs. No infection: 3324 μg/L p=0.03). There was a trend to a beneficial relationship between TXA and infection, and it was independently associated with reduced organ failure (OR 0.27, CI: 0.10 – 0.73, p=0.01) and mortality (OR 0.16 CI 0.03 - 0.86, p=0.03). In severely injured patients, admission shock, prolonged lymphopenia and early coagulation dysfunction post severe injury were independent predictors of infection. Timely modulation of these responses after trauma may help to reduce the burden of infection.

This retrospective chart review examined female patients (N=25) who had a postpartum hemorrhage. Electronic medical records from Regional One Health were queried for ICD-10 072 related codes from January 1, 2021-October 31, 2023. Of those, a maximum of 25 charts were identified and the information was deidentified. All data was de-identified, coded, encrypted, housed, and locked securely. Selected records that met the above criteria were then queried for the following: Baseline demographics, gravida, para, amount of blood loss, pharmacological and non-pharmacological interventions, and timing of tranexamic acid (TXA) administration. Data was imported into MS Excel and statistical analysis was conducted using Intellectus Statistical Software. Continuous variables were reported as mean, median, and categorical variables as frequency (%).

Enhanced Recovery After Surgery (ERAS) guidelines are multimodal perioperative carepathways based on evidence-based practice to promote faster recovery after surgical procedures.For cardiac surgery ERAS, one intervention that is strongly recommended based on high levelsof evidence is the use of antifibrinolytic medications, such as Tranexamic acid (TXA) andepsilon aminocaproic acid (EACA) which are synthetic antifibrinolytics and analogs of lysine,both known for exerting procoagulant effects by competitively inhibiting activation ofplasminogen to plasmin. Antifibrinolytic medications have been shown to decrease blood loss aswell as the need for blood transfusions and reoperation.There is strong evidence from the literature for best practices and well-establishedinternational standard ERAS guidelines for cardiac surgery. Reports from key stakeholders inthe pharmacy and anesthesia departments at the project site revealed that the routine use ofantifibrinolytic administration is varied within the cardiac surgical setting. The project teamconducted a chart audit that revealed over a three-month period, only 61% (n= 22/36) of cardiacsurgery patients received an antifibrinolytic. Upon further investigation of the patients that didnot receive an antifibrinolytic, 50% (7/14) of those patients required on pump cardiac surgeryand should have received an antifibrinolytic. A review of the anesthesia records also revealedvariations in dosing among the 22 patients that did receive an antifibrinolytic. 36% (8/22) ofthese patients received 10g of EACA, 59% (13/22) received 20g of EACA, and 4% (1/22)received 10mg of TXA. As a result of the chart audit findings, a clinical practice guideline wasdeveloped for TXA and EACA using the Clinical Guidance Recommendation template at theinstitution. The guideline was shared with the Surgery/Anesthesia CPIT Committee for possiblefuture implementation.Co-Author: Lawson, Katonya

BACKGROUND: Tranexamic acid (TXA) has become highly utilized in total joint arthroplasties for its anti-fibrinolytic effect. Recently, intra-articular application of TXA has become popular for its avoidance of systemic distribution within the body. With a more direct application to the surgical site, there is interest to see if topical application will provide hemostasis without increasing rates of venous or arterial thrombotic events and infections. In particular, there is lack of published data describing the safety of TXA in patients who have a significant disposition towards thromboembolic events. METHODS: This study was a retrospective chart-review (RCR) to assess the safety and efficacy of intra-articular TXA (IA-TXA) in total knee and hip arthroplasty patients. IA-TXA 2g/50mL NS was administered to patients who were contraindicated for IV-TXA usage based on our hospital’s guidelines (history of VTE events, mitral or aortic valve replacement with additional risk factors for stroke, active cancer, genetic or acquired thrombophilia, significant cardiac disease, serum creatinine > 2.8 mg/dL). Primary efficacy outcomes were total blood loss on post-operative day 1 (POD1), overall perioperative blood loss, and changes in hemoglobin/hematocrit values over the hospital stay. Primary safety outcomes were the incidence of arterial or venous thrombosis and wound infections. The study compared patients who received IA-TXA (study group) to patients who did not receive TXA (control group). The study included TKA patients=156 (Control=72 Study=83), anterior THA patients=57 (Control=20 Study=37), and posterior THA patients=59 (Control=27 Study=32). RESULTS: TKA patients administered IA-TXA showed a significant decrease in POD1 blood loss compared to the control group [305.84 mL, p = 0.004]. Additionally, the control patients showed significantly lower levels of overall hematocrit than those who had received IA-TXA [0.9 units, p = 0.041]. However, IA-TXA did not cause a reduction in blood loss in either the anterior or posterior THA patients. No statistically significant differences existed between treatment and control groups for transfusion rates or post-operative complications (VTE events and infections). CONCLUSION: IA-TXA 2g/50mL is effective in reducing blood loss in TKA patients; however, further research is needed regarding IA-TXA use in THA patients. The lack of efficacy in THA may have been related to the dosage used, the volume instilled, the timing of administration, or technique of administration.

Background: Institutional data from the Mayo Clinic in Rochester Minnesota shows that the blood transfusion rate is twice the national average, and is implemented in a non-standardized fashion. Blood transfusions pose many risks to critically ill patients. The aim of this quality improvement project was to answer the research question: What are the effects of utilizing Lean Six Sigma (LSS) methodology and evidence-based interventions to standardize the blood transfusion practices, and decrease blood transfusion rates, for women undergoing cytoreduction surgery for ovarian and endometrial cancer at a large academic hospital? Methods: The Define, Measure, Analyze, Improve, and Control framework, adopted from LSS quality improvement methods, was applied in this study. A root cause analysis conducted in the study setting, identified reasons why patients were over-transfused. A literature review was conducted to identify evidence-based interventions. Education was provided to the department of gynecology oncology surgery, anesthesia and nursing staff in the study setting. The multidisciplinary team implemented the following interventions; follow updated institution wide transfusion guidelines, communicate between the anesthesia provider and surgeon every 500 mL of fluid in the suction canister, utilize the hemostasis checklist, and administer a Tranexamic acid (TA) 15mg/kg one time dose in the operating room (OR), prior to incision for patients who met criteria. Results: A total of 184 cases in the pre-implementation group identified in a retrospective chart audit, and 89 cases in the post-implementation group that met the study criteria, were investigated. Overall, the blood transfusion rate in the post-implementation group was decreased by 56.4% (p7g/dl. Data Sources: PubMed, Embase, and CINAHL were utilized for the literature review. Keywords: blood transfusion guidelines, Tranexamic acid, cytoreduction surgery, ovarian carcinoma, blood transfusions, process improvement, Lean Six Sigma