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The article focuses on the implications of placenta accreta spectrum (PAS) among patients seeking abortion, highlighting the importance of preprocedural planning to improve outcomes and minimize complications. It discusses the rising incidence of PAS, its associated risk factors, and the critical role of ultrasound in diagnosis, particularly for patients with a history of cesarean delivery and placenta previa.

Pediatric patients who undergo spinal corrective surgery often require multiple blood product transfusions. The use of antifibrinolytics, especially tranexamic acid (TXA), to mitigate intraoperative blood loss has increased in popularity. The goal of this quality improvement project was to evaluate provider compliance with a TXA dosing protocol during pediatric corrective spine procedures. A retrospective chart review was conducted to compare pre- and postimplementation data on cell saver and packed red blood cell (PRBC) administration and dose of antifibrinolytic administered. A total of 486 patients (68% idiopathic and 32% neuromuscular) were evaluated over a 9-year period. Following implementation of the protocol, patients of idiopathic origin experienced a 20% reduction in cell saver administration, a 10% reduction in PRBC administration, and a 37% increase in provider compliance with the dosing protocol. Patients of neuromuscular origin experienced a 53% increase in provider compliance with the recommended TXA dosing protocol; however, this patient population did not experience a statistically significant reduction in transfusion requirements. Implementation of an antifibrinolytic protocol can facilitate compliance with recommended TXA dosing parameters and potentially decrease intraoperative blood loss, reducing blood product transfusion requirements. [ABSTRACT FROM AUTHOR]

Background: Prehospital obstetric events, including out-of-hospital deliveries and their complications, are a rare but high-risk event encountered by emergency medical services (EMS). Understanding the epidemiology of these encounters would help identify strategies to improve prehospital obstetric care. Our objective was to determine the characteristics of out-of-hospital deliveries and high-risk complications treated by EMS clinicians in the U.S. Methods: We conducted a cross-sectional analysis of EMS patient care records in the 2018 and 2019 National EMS Information System Public Release Version 3.4 datasets. We included EMS activations after a 9-1-1 scene response for patients aged 12–50 years with evidence of an out-of-hospital delivery or delivery complication, or where the patient was a newborn aged 0-<6 h. We examined patient, community, emergency response, and clinical characteristics using descriptive statistics. Results: Of the 56,735,977 EMS activations included in the 2018 and 2019 datasets, there were 8,614 out-of-hospital deliveries, 1,712 delivery complications, and 5,749 records for newborns. Most maternal (76%) out-of-hospital deliveries involved patients between the ages of 20–34 years, occurred on a weekday (73%), were treated by an advanced life support crew (85%), and occurred in a home or residence (73%). EMS-assisted field delivery was documented in 3,515 (34%) of all maternal activations but only 2% of activations with a delivery complication. Few patients received an EMS-administered medication (e.g., 0.4% received oxytocin). Supplemental oxygen was administered in 870 (15%) of newborn activations. Activations from counties with the most racial/ethnic diversity were more often treated by a BLS-level unit (16% vs. 12%, p < 0.001), and activations from rural areas had significantly longer transport times (19.7 min [IQR 8.7, 32.8] vs. urban, 13.1 min [IQR 8.7, 19.7], p < 0.001). Conclusion: In this large, national repository of EMS patient care records from across the U.S., most activations for out-of-hospital delivery, delivery complication, or a newborn included only routine EMS care. There were potential disparities in level of care, clinical care provided, and measures of access to definitive care based on maternal and community factors. We also identified gaps in current practice, such as for postpartum hemorrhage, that could be addressed with changes in EMS clinical protocols and regulations. [ABSTRACT FROM AUTHOR]

Objectives: The use of nebulized tranexamic acid (TXA) in massive pulmonary hemorrhage is well-described. Published utilization in post-tonsillectomy bleeding (PTB) is limited to a single case. This study examines whether TXA resulted in change of operative intervention necessity and narcotic utilization. Methods: This was a retrospective cohort study at a single, urban academic medical center in the United States. Chart review was conducted of all patients who presented to the hospital for post-tonsillectomy bleed (PTB) between 3/1/2018 and 7/1/2020. Demographic data, intervention modality, need for control under general anesthesia, and opioid use were collected and analyzed. Results: Twenty-one patients underwent a total of 23 visits for PTB over the study period. Control of hemorrhage without need for operating room intervention for PTB was 100% (6/6) for patients receiving TXA nebulizer and 53% (9/17) for those receiving other treatment modalities. Opioid usage in hospital and on discharge was also lower in patients receiving TXA nebulizers. All results were statistically significant. Conclusions: Our study supports nebulized TXA as an effective, non-invasive mode of hemostasis in patients presenting to the emergency department for post-tonsillectomy hemorrhage. Nebulized TXA may prevent the need for general anesthesia and operative intervention. Otolaryngologists should consider addition of this novel treatment appropriation of TXA to their management options for postoperative tonsillar hemorrhage. [ABSTRACT FROM AUTHOR]

Objective: Currently there is variation in perioperative care of orthognathic surgery patients and limited clinical practice guidelines. The current orthognathic surgery practice patterns among US academic OMFS training centers have not been described. The purpose of this study is to describe the practice patterns among US academic OMFS training centers. Design: The study design is cross-sectional. Data was collected through a survey of the sample. Setting: OMFS programs in the US. Participants: Academic OMFS. 573 surgeons were contacted and 85 responses were received. Main Outcome Measure: Descriptive and bivariate statistics were reported. Results: Respondents were 87% male and worked in full-time academic (80%), part-time academic (19%), or military settings (1%). Thirty-one percent have practiced for 30 years or more and then 29% with 11–20 years, 18% with 21–30 years, 12% with 6–10 years and 11% with 1–5 years. Twenty-six percent of respondents perform 20–40 orthognathic surgeries a year, 22% perform less than 20 surgeries a year, 21% perform 40–60 surgeries per year, and 19% perform more than 100 surgeries per year. Intraoperatively, 48% of surgeons request a mean arterial pressure of 60–64 mmHg, 25% utilize tranexamic acid (TXA), 85% report a blood loss of less than 400 milliliters, and 93% report a blood transfusion rate of <1%. Conclusion: There are variations in orthognathic surgery practice patterns with limited clinical practice guidelines. Only 13 of the 32 survey questions had a single response holding a simple majority. This study demonstrates the need for further research and evidence-based protocols and decision making. [ABSTRACT FROM AUTHOR]

Objective : This study aims to characterize current use, knowledge, and attitude toward ERAS protocols by academic craniofacial surgeons. Design : Craniofacial surgeons were provided with electronic surveys. Setting : Electronic survey; Institutional tertiary surgeons. Participants : 102 cleft palate surgeons surveyed and 31 completed the survey (30.4%). Interventions : None. Main Outcome Measures : Respondents rated their knowledge, use, and willingness to implement perioperative interventions modeled after adult ERAS protocols. Results : Majority (67.7%) rated they were knowledgeable about ERAS. However, 61.3% "never use" a standardized protocol for cleft palate surgery. Only 3 ERAS elements are currently implemented by a majority of cleft surgeons: avoiding prolonged perioperative fasting (67.7%), using hypothermia prevention measures (74.2%), and minimizing use of opioids (62.5%). A large majority of respondents noted they never administer bolus (71.0%) or infusion (80.6%) dosing of tranexamic acid; most of these surgeons also indicated that administering tranexamic acid "would not be a valuable addition" (67.7% and 71.0%, respectively). Short-acting sedatives are used by 12.9% and by 16.1% of surgeons in all patients during extubation and postoperative recovery, respectively. By contrast, 22.6% never use such agents during extubation and 48.4% never use it during postoperative recovery. Overall, 67.7% of respondents replied that they would be willing to implement an ERAS protocol for cleft palate repair. Conclusions : Many respondents report using interventions compatible with an ERAS approach and the majority are willing to implement an ERAS protocol for cleft palate repair. [ABSTRACT FROM AUTHOR]

Background: Melasma is an acquired melanogenesis dysfunction resulting in chronic hyperpigmentation commonly affecting the face and other frequently sun‐exposed areas of the body. Melasma typically presents in women of reproductive age and can significantly impact self‐esteem, negatively affecting one's quality of life. In the United States, melasma is often treated with application of topical agents that interfere with melanin synthesis, lasers, or chemical peels; however, in some East Asian countries, oral tranexamic acid (TXA) is widely administered to alleviate hyperpigmentation during and after childbirth. TXA is currently only FDA‐approved to treat hypermenorrhea and reduce blood loss in surgery but may offer women in the United States an additional therapeutic option to treat melasma. Aims: The aim of this paper is to evaluate the safety and baseline efficacy of oral transmexic acid as a treatment for melasma. Methods: We retrospectively surveyed 42 patients of Fitzpatrick skin types III‐VI that were prescribed 650 mg of TXA ½ tablet to be taken twice daily by mouth. Results: We found majority of patients saw noticeable improvement in their melasma. Of the 42 patients, only seven experienced side effects. The side effects noted were headaches, malaise and nausea, gastrointestinal upset, congestion, numbness in legs, hypomenorrhea, and hypermenorrhea. Patients who experienced unpleasant side effects discontinued taking oral TXA and were relieved of their symptoms. No long‐term side effects were discovered, and the side effects experienced may be due to other confounding factors. Conclusion: From this data, we concluded oral TXA is a safe and effective treatment option for patients with persistent melasma. [ABSTRACT FROM AUTHOR]

Background: The antifibrinolytic drug tranexamic acid (TXA) improves survival in adults with traumatic hemorrhage; however, the drug has not been evaluated in a trial in injured children. We assessed the feasibility of a large‐scale trial evaluating the effects of TXA in children with severe hemorrhagic injuries. Methods: Severely injured children (0 up to 18th birthday) were randomized into a double‐blind randomized trial of (1) TXA 15 mg/kg bolus dose, followed by 2 mg/kg/h infusion over 8 h, (2) TXA 30 mg/kg bolus dose, followed by 4 mg/kg/h infusion over 8 h, or (3) normal saline placebo bolus and infusion. The trial was conducted at four pediatric Level I trauma centers in the United States between June 2018 and March 2020. We enrolled patients under federal exception from informed consent (EFIC) procedures when parents were unable to provide informed consent. Feasibility outcomes included the rate of enrollment, adherence to intervention arms, and ability to measure the primary clinical outcome. Clinical outcomes included global functioning (primary), working memory, total amount of blood products transfused, intracranial hemorrhage progression, and adverse events. The target enrollment rate was at least 1.25 patients per site per month. Results: A total of 31 patients were randomized with a mean age of 10.7 years (standard deviation [SD] 5.0 years) and 22 (71%) patients were male. The mean time from injury to randomization was 2.4 h (SD 0.6 h). Sixteen (52%) patients had isolated brain injuries and 15 (48%) patients had isolated torso injuries. The enrollment rate using EFIC was 1.34 patients per site per month. All eligible enrolled patients received study intervention (nine patients TXA 15 mg/kg bolus dose, 10 patients TXA 30 mg/kg bolus dose, and 12 patients placebo) and had the primary outcome measured. No statistically significant differences in any of the clinical outcomes were identified. Conclusion: Based on enrollment rate, protocol adherence, and measurement of the primary outcome in this pilot trial, we confirmed the feasibility of conducting a large‐scale, randomized trial evaluating the efficacy of TXA in severely injured children with hemorrhagic brain and/or torso injuries using EFIC. [ABSTRACT FROM AUTHOR]

Objectives: Topical vasoconstrictors and intravenous tranexamic acid (IV TXA) are safe and efficacious to decrease bleeding and improve the surgical field during endoscopic sinus surgery (ESS). The purpose of this study was to investigate practice patterns, awareness of clinical evidence, and comfort levels among anesthesia providers regarding these hemostatic agents for ESS. Methods: A total of 767 attending anesthesiologists, residents, and certified registered nurse anesthetists (CRNAs) at 5 United States academic centers were invited to participate in a survey regarding their experience with IV TXA and 3 topical vasoconstrictor medications (oxymetazoline, epinephrine, and cocaine) during ESS. Results: 330 (47%) anesthesia providers responded to the electronic survey. 113 (97%) residents, 92 (83%) CRNAs, and 52 (68%) attendings managed 5 or fewer ESS cases per month. Two-thirds of providers had not reviewed efficacy or safety literature for these hemostatic agents. Oxymetazoline was perceived safest, followed by epinephrine, IV TXA, and cocaine. Respondents considered potential side effects over surgical field visibility when selecting agents. The majority of providers had no formal training on these agents for ESS, but indicated interest in educational opportunities. Conclusion: Many anesthesia providers are unfamiliar with safety and efficacy literature regarding agents used to improve hemostasis for ESS, highlighting a need for development of relevant educational resources. Rhinologic surgeons have an opportunity to communicate with anesthesia colleagues on the use of hemostatic agents to improve the surgical field during ESS. [ABSTRACT FROM AUTHOR]

Background: Traumatic brain injury (TBI) with acute elevation in intracranial pressure (ICP) is a neurologic emergency associated with significant morbidity and mortality. In addition to indicated trauma resuscitation, emergency department (ED) management includes empiric administration of hyperosmolar agents, rapid diagnostic imaging, anticoagulation reversal, and early neurosurgical consultation. Despite optimization of in-hospital care, patient outcomes may be worsened by variation in prehospital management. In this study, we evaluate geographic variation between emergency medical services (EMS) protocols for patients with suspected TBI.Methods: We performed a cross-sectional analysis of statewide EMS protocols in the United States in December 2020 and included all complete protocols published on government websites. Outcome measures were defined to include protocols or orders for the following interventions, given TBI: (1) hyperventilation and end-tidal capnography (EtCO2) goals, (2) administration of hyperosmolar agents, (3) tranexamic acid (TXA) administration for isolated head injury, (4) non-invasive management including head-of-bed elevation, and (5) hemodynamic goals.Results: We identified 32 statewide protocols including Washington, D.C., 4 of which did not include specific guidance for TBI. Of 28 states providing ventilatory guidance, 22/28 (78.6%) recommend hyperventilation, with 17/22 (77.3%) restricting hyperventilation to signs of acute herniation. The remaining 6 states prohibited hyperventilation. Regarding EtCO2 goals among states permitting hyperventilation, 17/22 (77.3%) targeted an EtCO2 of < 35 mmHg, while 5/22 (22.7%) provided no guide EtCO2 for hyperventilation. Rhode Island was the only state identified that included hypertonic saline (3%), and Delaware was the only state that allowed TXA in the setting of isolated TBI with GCS ≤ 12. Only 15/32 (46.9%) identified states recommend head-of-bed elevation. For blood pressure goals, 12/28 (42.9%) of states set minimum systolic blood pressure at 90 mmHg, while 10/28 (35.7%) set other SBP goals. The remaining 6/28 (21.4%) did not provide TBI-specific SBP goals.Conclusions: There is wide variation among civilian prehospital protocols for traumatic brain injury. Prehospital care within the first "golden hour" may dramatically affect patient outcomes. Neurocritical care providers should be mindful of geographic variation in local protocols when designing and evaluating quality improvement interventions and should aim to standardize prehospital care protocols. [ABSTRACT FROM AUTHOR]

Study Objective: Tranexamic Acid (TXA), an antifibrinolytic, has been used in military trauma cases and civilian Emergency Departments for several years. This study aims to evaluate protocols for the administration of TXA across Emergency Medical Services (EMS) regions in the United States. Methods: An anonymous survey was distributed by the National Association of Emergency Medical Technicians (NAEMT) to its members. Results: A total of 264 eligible responses were received. Respondents included paramedics (62.5%), emergency medical technicians (EMTs) (9%), critical care paramedics (11%), and other health care professionals (19%). The majority of protocols included criteria for blood pressure (67%), heart rate (53%), and age (66%). Notable variations included TXA dilution and indications for traumatic brain injury. Conclusion: TXA has been widely implemented in EMS protocols since the CRASH (Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage) trials. However, there remains significant variations in indications and dose concentrations. [ABSTRACT FROM AUTHOR]

Background: Although controversial, early administration of tranexamic acid (TXA) has been shown to reduce mortality in adult patients with major trauma. Tranexamic acid has also been successfully used in elective pediatric surgery, with significant reduction in blood loss and transfusion requirements. There are limited data to guide its use in pediatric trauma patients. We sought to determine the current practices for TXA administration in pediatric trauma patients in the United States. Methods: A survey was conducted of all the American College of Surgeons-verified Level I and II trauma centers in the United States. The survey data underwent quantitative analysis. Results: Of the 363 Level I and II qualifying centers, we received responses from 220 for an overall response rate of 61%. Eighty of 99 verified pediatric trauma centers responded for a pediatric trauma center response rate of 81%. Of all responding centers, 148 (67%) reported they care for pediatric trauma patients, with an average of 513 pediatric trauma patients annually. The pediatric trauma centers report caring for an average of 650 pediatric trauma patients annually. Of all centers caring for pediatric trauma, 52 (35%) report using TXA, with the most common initial dosing being 15 mg/kg (68%). A follow-up infusion was utilized by 45 (87%) of the programs, most commonly dosed at 2 mg/kg/hr × 8 hr utilized by 24 centers (54%). Conclusion: Although the clinical evidence for TXA in pediatric trauma patients is limited, we believe that consideration should be given for use in major trauma with hemodynamic instability or significant risk for ongoing hemorrhage. If available, resuscitation should be guided by thromboelastography to identify candidates who would most benefit from antithrombolytic administration. This represents a low-cost/low-risk and high-yield therapy for pediatric trauma patients. [ABSTRACT FROM AUTHOR]

Teen pregnancies are at high risk of obstetrical complications with an increased rate of adverse maternal and fetal outcomes. Acute care clinicians should be familiar with, and adept at, caring for the common or emergent obstetrical complications that may occur in a pregnant teenager. [ABSTRACT FROM AUTHOR]

Background: Tranexamic acid (TXA) may be a useful adjunct for military patients with severe traumatic brain injury (TBI). These patients are often treated in austere settings without immediate access to neurosurgical intervention. The purpose of this study was to evaluate any association between TXA use and progression of intracranial hemorrhage (ICH), neurologic outcomes, and venous thromboembolism (VTE) in TBI.Methods: This was a retrospective cohort study of military casualties from October 2010 to December 2015 who were transferred to a military treatment facility (MTF) in the United States. Data collected included: demographics, types of injuries, initial and interval head computerized tomography (CT) scans, Glasgow Coma Scores (GCS), and six-month Glasgow Outcome Scores (GOS). Results were stratified based on TXA administration, progression of ICH, and VTE.Results: Of the 687 active duty service members reviewed, 71 patients had ICH (10.3%). Most casualties were injured in a blast (80.3%), with 36 patients (50.7%) sustaining a penetrating TBI. Mean ISS was 28.2 ± 12.3. Nine patients (12.7%) received a massive transfusion within 24 h of injury, and TXA was administered to 14 (19.7%) casualties. Patients that received TXA had lower initial reported GCS (9.2 ± 4.4 vs. 12.5 ± 3.4, p = 0.003), similar discharge GCS (13.3 ± 4.0 vs. 13.8 ± 3.2, p = 0.58), and a larger improvement between initial and discharge GCS (3.7 ± 3.9 vs. 1.3 ± 3.1, p = 0.02). However, there was no difference in mortality (7.1% vs. 7.0%, p = 1.00), progression of ICH (45.5% vs. 14.7%, p = 0.09), frequency of cranial decompression (50.0% vs. 42.1%, p = 0.76), or mean GOS (3.5 ± 0.9 vs. 3.8 ± 1.0, p = 0.13). Patients administered TXA had a higher rate of VTE (35.7% vs. 7.0%, p = 0.01). On multivariate analysis, however, TXA was not independently associated with VTE.Conclusions: Patients that received TXA were associated with an improvement in GCS but not in progression of ICH or GOS. TXA was not independently associated with VTE, although this may be related to a paucity of patients receiving TXA. Decisions about TXA administration in military casualties with ICH should be considered in the context of the availability of neurosurgical intervention as well as severity of extracranial injuries and need for massive transfusion. [ABSTRACT FROM AUTHOR]

In the United States, postpartum hemorrhage (PPH) accounts for 4.6% of all maternal deaths and is responsible for major peripartum medical and surgical morbidity. Therefore, a national health priority is to ensure that women who experience severe PPH receive timely, appropriate, and effective treatment. In this article, we describe our system-wide approach for the planning and delivery of women with suspected placenta accreta spectrum disorder, a condition associated with life-threatening blood loss at the time of delivery. We also highlight current evidence related to transfusion decision making and hemostatic monitoring during active postpartum bleeding. Specifically, we describe how we activate and use the massive transfusion protocol to obtain sufficient volumes and types of blood products. We also describe how we use viscoelastic monitoring (thromboelastography) and standard laboratory tests to assess the maternal coagulation profile. Finally, we review the findings of recent studies examining the potential efficacy of tranexamic acid and fibrinogen concentrate as adjuncts for PPH prevention and treatment. We describe how we have incorporated these drugs into PPH treatment protocols at our institution. [ABSTRACT FROM AUTHOR]

Background: There is limited real-world evidence on hereditary angioedema (HAE) patient characteristics and health-care resource utilization (HCRU); in addition, pediatric patients have been described in small cohorts. Objective: To describe patient characteristics, treatment patterns, and HCRU among adult and pediatric patients treated for HAE in a large U.S. cohort. Methods: This retrospective cohort study used an administrative claims data base (January 2006 to September 2015). Eligible patients with either ⥠pharmacy claim for HAE-indicated therapies (C1 inhibitors, ecallantide, icatibant) or â¥2 medical claims with codes associated with HAE (per medical billing codes), and ⥠claim for androgens, fresh frozen plasma, tranexamic acid, or «-aminocaproic acid formed a Â"treated cohort.Â" Three nonexclusive treated cohorts were assessed: overall, pediatric, and HCRU (â¥2 years of continuous enrollment during 2010-2015). Results: Overall, 1429 patients received treatment (mean±standard deviation [SD] age, 38.8 615.7 years; 62.4% female patients; mean±SD Charlson Comorbidity Index of 1.4±2.4). Common comorbidities were allergy or anaphylaxis (51.4%) and anxiety or depression (35.8%). Diagnoses indicative of HAE attacks included swelling and/or angioedema (78.5%), abdominal pain (55.6%), and asphyxiation (27.2%). Use of HAE-indicated medication rose between 2006 and 2015 to 81.8%, whereas androgen use declined (from 91.5% to 24.9%). Similar trends were observed in the pediatric treated cohort (n = 143). In the HCRU treated cohort (n = 538), HAE-related claims for emergency department and inpatient admissions were observed for 36.6% and 22.3% of patients, respectively. Conclusion: In a large U.S. cohort of adult and pediatric patients who received treatments indicated or used for HAE, common comorbidities and trends in resource use denoted the substantial burden of attacks, which reflected a continued need that recently approved long-term prophylactic treatments may help to address. [ABSTRACT FROM AUTHOR]

Objectives: The CRASH‐2 trial demonstrated that tranexamic acid (TXA) in adults with significant traumatic hemorrhage safely reduces mortality. Given that the CRASH‐2 trial did not include U.S. sites, our objective was to evaluate patient characteristics, TXA dosing strategies, and the incidence of mortality and adverse events in adult trauma patients receiving TXA at a U.S. Level I trauma center in the post–CRASH‐2 era. Methods: We conducted a retrospective study that included patients aged 18 years or older who received TXA after an acute injury from July 2014 to June 2017. We excluded patients who received TXA orally, patients who received TXA for elective surgical procedures or nontrauma indications, patients who received it 8 hours or longer after the time of injury, and patients with cardiac arrest at time of emergency department arrival. Trained abstractors collected data from the trauma registry and hospital electronic medical records. Our primary outcome measures were in‐hospital death and acute thromboembolic events within 28 days from injury. Results: We included 273 patients with a mean (±SD) age of 43.8 (±18.7) years. The mean (±SD) time of administration of TXA from time of injury was 1.55 (±1.2) hours with 229 patients (83.9%) receiving TXA within 3 hours. The overall mortality within 28 days from injury was 12.8% (95% confidence interval [CI] = 8.9% to 16.7%), which was similar compared to that in the CRASH‐2 trial (14.5%, 95% CI = 13.9% to 15.2%). The incidence of acute thromboembolic events was 6.6% (95% CI = 3.7% to 9.5%), which was higher than that in the CRASH‐2 trial (2.0%, 95% CI = 1.73% to 2.27%). Patients in our cohort also received surgery (64.8% vs. 47.9%) and blood transfusions (74.0% vs. 50.4%) more frequently than those in the CRASH‐2 cohort. Conclusions: Adult trauma patients receiving TXA had similar incidences of death but higher incidences of thromboembolic events compared to the CRASH‐2 trial. Variation in patient characteristics, injury severity, TXA dosing, and surgery and transfusion rates could explain these observed differences. Further research is necessary to provide additional insight into the incidence and risk factors of thromboembolic events in TXA use. [ABSTRACT FROM AUTHOR]

Introduction: Tranexamic acid (TXA) use has been associated with thrombotic complications., Objective: We aim to investigate outcomes associated with TXA use in the setting of high- (HP) and low-profile (LP) introducer sheaths for resuscitative endovascular balloon occlusion of the aorta (REBOA)., Participants: The Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery (AORTA) database was queried for patients who underwent REBOA using a low-profile 7 French (LP) or high-profile, 11-14 French (HP) introducer sheaths between 2013 and 2022. Demographics, physiology, and outcomes were examined for patients who survived beyond the index operation., Results: 574 patients underwent REBOA (503 LP, 71 HP); 77% were male, mean age was 44 ± 19 and mean injury severity score (ISS) was 35 ± 16. 212 patients received TXA (181 [36%] LP, 31 [43.7%] HP). There were no significant differences in admission vital signs, GCS, age, ISS, SBP at AO, CPR at AO, and duration of AO among LP and HP patients. Overall, mortality was significantly higher in the HP (67.6%) vs the LP group (54.9%; P = .043). Distal embolism was significantly higher in the HP group (20.4%) vs the LP group (3.9%; P < .001). Logistic regression demonstrated that TXA use was associated with a higher rate of distal embolism in both groups (OR = 2.92; P = .021). 2 LP patients (one who received TXA) required an amputation., Conclusion: Patients who undergo REBOA are profoundly injured and physiologically devastated. Tranexamic acid was associated with a higher rate of distal embolism in those who received REBOA, regardless of access sheath size. For patients receiving TXA, REBOA placement should be accompanied by strict protocols for immediate diagnosis and treatment of thrombotic complications., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The following authors have/had relationships with the following entities: MB Prytime Medical Inc (end 5/2022) LM Frontline Medtech Inc.

The utilization of tranexamic acid (TXA) for the management of bleeding trauma patients has been a subject ofmuch debate on both sides of the Atlantic and in Australia. As a result of the large randomized controlled study called the Clinical Randomization of an Antifibrinolytic in Severe Hemorrhage (CRASH-2), there was an initial enthusiasm for the use of TXA to treat bleeding patients. However, the adoption of TXA in the United States was delayed by concerns of "knowledge and evidence gaps" of the CRASH-2 study and because of a lack of mechanistic rationale that would explain the survival benefit noted in the study. Subsequent nonrandomized controlled trials questioned the liberal use of TXA in trauma patients. This narrative review explores the historical as well as clinical and theoretical grounds for the more measured use of TXA in the United States and proposes a clinical and point-of-care guided utilization of TXA, blood components, and adjunctive hemostatic agents in bleeding trauma patients. [ABSTRACT FROM AUTHOR]

Introduction: Improvised Explosive Devices (IED) are the primary wounding mechanism for casualties in Operation Enduring Freedom. Patients can sustain devastating traumatic amputations, which are unlike injuries seen in the civilian trauma sector. This is a database analysis of the largest patient registry of multiple traumatic amputations.Methods: The Joint Theater Trauma Registry was queried for patients with a traumatic amputation from 2009 to 2012. Data obtained included the Injury Severity Score (ISS), Glasgow Coma Score (GCS), blood products, transfer from theatre, and complications including DVT, PE, infection (Acinetobacter and fungal), acute renal failure, and rhabdomyolysis. Comparisons were made between number of major amputations (1-4) and specific outcomes using χ2 and Pearson's rank test, and multivariable logistic regression was performed for 30-day survival. Significance was considered with p<0.05.Results: We identified 720 military personnel with at least one traumatic amputation: 494 single, 191 double, 32 triple, and 3 quad amputees. Average age was 24.3 years (18-46), median ISS 24 (9-66), and GCS 15 (3-15). Tranexamic acid (TXA) was administered in 164 patients (23%) and tourniquets were used in 575 (80%). Both TXA and tourniquet use increased with increasing number of amputations (p<0.001). Average transfusion requirements (in units) were packed red blood cells (PRBC) 18.6 (0-142), fresh frozen plasma (FFP) 17.3 (0-128), platelets 3.6 (0-26), and cryoprecipitate 5.6 (0-130). Transfusion of all blood products increased with the number of amputations (p<0.001). All complications tested increased with the number of amputations except Acinetobacter infection, coagulopathy, and compartment syndrome. Transfer to higher acuity facilities was achieved in 676 patients (94%).Conclusion: Traumatic amputations from blast injuries require significant blood product transfusion, which increases with the number of amputations. Most complications also increase with the number of amputations. Despite high injury severity, 94% of traumatic amputation patients who are alive upon admission to a role II/III facility will survive to transfer to facilities with higher acuity care. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The United States has one of the highest rates of maternal mortality among developed regions, and postpartum hemorrhage (PPH) accounted for 14% of all pregnancy-related deaths between 2017 and 2019. Several large studies have demonstrated decreased PPH rates with the use of tranexamic acid (TXA). Consensus has not yet been reached on the when to administer use of TXA. Little data exist regarding the prevalence of TXA use in obstetric patients with and without PPH. METHODS: Using a national database, we identified over 1.2 million pregnancies between January 1, 2015, and June 30, 2021. Pregnancy and delivery information was abstracted using ICD-10 codes. The GW Institutional Review Board approved the study protocol and waived the requirement for patient informed consent. RESULTS: Overall, TXA was used 1% of the time (12,394/1,262,574), and there was a fivefold increase in TXA use (0.5–2.5%) during the study period. Patients had similar demographic characteristics. Tranexamic acid use differed by geographic region. The use of TXA increased in both patients with PPH and those without. There was a greater increase in the number of patients who received TXA for prophylaxis of PPH than those who received it as treatment of PPH. CONCLUSION: This is the largest U.S. observational study to examine patterns of TXA use in obstetrics. Tranexamic acid was only administered in approximately 10% (4,586/43,928) of cases of PPH. This represents an opportunity to increase awareness for the role of TXA in management and prevention of PPH. [ABSTRACT FROM AUTHOR]

Postpartum hemorrhage is a significant contributor to maternal mortality worldwide and in the United States. Tranexamic acid (TXA) has been shown to reduce PPH complications although it is not routinely recommended for use as prophylaxis to date. To estimate the cost-effectiveness of alternative risk-dictated strategies utilizing prophylactic tranexamic acid for the prevention of postpartum hemorrhage. We constructed a microsimulation-based Markov decision-analytic model estimating the cost-effectiveness of three alternative risk-dictated strategies for tranexamic acid prophylaxis versus the no prophylaxis in a cohort of 3.8 million pregnant women delivering in the United States. Each strategy differentially modified risk-specific hemorrhage probabilities by preliminary estimates of tranexamic acid's prophylactic efficacy. Outcome measures included incremental costs, quality-adjusted life-years, and outcomes averted. Costs and benefits were considered from the healthcare system and societal perspectives over a lifetime time horizon. All intervention strategies were dominant versus no prophylaxis, implying that they were simultaneously more effective and cost-saving. Prophylaxing delivering women irrespective of hemorrhage risk produced the most favorable results overall, with estimated cost savings greater than $690 million and up to 149,505 PPH cases, 2,933 hysterectomies, and 70 maternal deaths averted, per annual cohort. Threshold analysis suggested that tranexamic acid is likely to be cost-saving for health systems at costs below $190 per gram. Our findings suggest that routine prophylaxis with tranexamic acid would likely result in substantial cost-savings and reductions in adverse maternal outcomes in this context. This study is a cost-effectiveness analysis demonstrating cost-savings and reduction in adverse maternal outcomes with routine tranexamic acid as prophylaxis for post-partum hemorrhage., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Results from the 2017 World Maternal Antifibrinolytic trial found that patients who received tranexamic acid during delivery had significantly lower rates of death and hysterectomy. Several months after the World Maternal Antifibrinolytic trial publication, American College of Obstetricians and Gynecologists endorsed the consideration of tranexamic acid usage when traditional uterotonics fail during postpartum hemorrhage. Since then, tranexamic acid usage has become more mainstream for the treatment of postpartum hemorrhage., Objective: This study aimed to evaluate tranexamic acid trends in obstetrics both temporally and geographically within the United States. Additional outcomes included patient demographics and perinatal outcomes., Study Design: This retrospective cohort study included 19 hospitals divided into East, Central, and West geographic regions within the Universal Health Services, Incorporated network. Rates of tranexamic acid use were compared from July 2019 through June 2021. Patient demographics and perinatal outcomes were analyzed for tranexamic acid recipients., Results: During the two-year study period, 3.2% (1580/50,150) of patients received tranexamic acid during delivery. The western region of the United States demonstrated increased tranexamic acid use over the 2-year study period. Recipients of tranexamic acid were more likely to have a history of postpartum hemorrhage (P<.0001), chronic hypertension (P<.0001), preeclampsia (P<.0001), and/or diabetes (P=.004). Patients who received tranexamic acid did not have an increased likelihood of venous thromboembolism in comparison with those who did not receive tranexamic acid (8 [0.5%] vs 226 [0.5%]; P=.77). Of those who received tranexamic acid, 53.2% (840/1580) had an estimated blood loss <1000 mL., Conclusion: Nationally, a higher percentage of patients received tranexamic acid without a postpartum hemorrhage diagnosis compared with previous studies, and the western region of the United States had an overall increased use of tranexamic acid during delivery compared with previous years. There was no increased risk of venous thromboembolism in those who received tranexamic acid, regardless of postpartum hemorrhage diagnosis., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF., Methods: A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis., Results: A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic., Conclusion: The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Massive transfusion practices have undergone several recent developments. We sought to examine institutional practices guiding hemostatic resuscitation in the setting of massive hemorrhage.Study Design and Methods: A 37-question online survey was sent to American Association for the Surgery of Trauma members.Results: A total of 191 surgeons from 125 institutions completed the survey. Level I and II centers composed 70 and 18% of responding sites, respectively. A total of 123 institutions have a massive transfusion protocol (MTP); 54% report having an MTP for less than 5 years. The number of coolers and units of red blood cells, plasma, and platelets are highly variable. Tranexamic acid is part of the MTP at 64% of centers; 26% continue to use recombinant activated Factor VII. MTP activation occurs more than five times per month at 32% of centers. MTPs are utilized for nontrauma patients in 82% of institutions. Point-of-care prothrombin time, international normalized ratio, and partial thromboplastin time testing is utilized in 37% of institutions. Only 9% routinely utilize thromboelastography or rotational thromboelastometry (TEG/ROTEM) within their MTP. Just 7% use a validated scoring system to guide MTP activation. The incorporation of TEG/ROTEM into the MTP is associated with the use of a scoring system in regression analysis (p = 0.024).Conclusion: Most institutions regularly activate recently implemented MTPs for trauma and nontrauma indications; however, few use validated scoring systems for MTP activation. MTP content is highly variable. Few institutions use TEG, while most have incorporated tranexamic acid into their protocol. The lack of consistent practices underscores the need for outcome-based studies to guide transfusion practices. [ABSTRACT FROM AUTHOR]

This month we focus on current research in global women's health. Drs. Ramsey and Stuart discuss four recent publications, which are concluded with a "bottom line" that is a take-home message. A complete reference for each can be found in on this page along with direct links to abstracts. [ABSTRACT FROM AUTHOR]

Wild and exotic animal attacks are not common in the United States. Animal-related injuries in the United States are usually caused by dog bites, followed by cattle and horse injuries. Exotic animal attacks can occur when the animals are provoked, depressed, or housed improperly by owners. We report the case of a 51-year-old woman who sustained multiple systemic traumatic injuries after she was pinned to a fence by an elephant’s trunk. Upon arrival in the emergency department, she was hypothermic with a temperature of 35.1ºC (95.1ºF), hypotensive to 94/60 mm Hg after 5 L crystalloid, tachycardic at 108 beats/min, and intubated with oxygen saturation of 100%. Tranexamic acid was administered in addition to starting a massive transfusion protocol. Injuries included bilateral multiple rib fractures, left abdominal wall degloving injury, right pneumothorax, right hemothorax, left chest wall puncture wound, grade IV splenic laceration, 3 grade III liver lacerations, retroperitoneal hematoma, and degloving injuries to bilateral posterior thighs requiring more than 30 operations. Why should an emergency physician be aware of this? Several factors need to be considered when evaluating animal-related injuries, including type, age, and sex of the animal. Multisystem traumatic injuries should be assumed when a large animal is involved. Prehospital care and transport time are vital to a patient’s survival in both urban and rural settings. During the initial resuscitation, administering antibiotics tailored to the specific animal can greatly decrease risk of infection and morbidity. Additionally, tetanus immunoglobulin, tetanus toxoid, and rabies immunoglobulin and vaccine may be needed, unless the victim has been previously vaccinated. [ABSTRACT FROM AUTHOR]

Purpose: Tranexamic acid (TXA) is a potent pro-coagulation drug. Pre-operative, preventive TXA administration and TXA use for active bleeding are established treatments in many medical situations; yet, less is known about its use in otolaryngology head and neck surgery practice. The primary study goals were: MATERIALS AND METHODS: This is an international survey exploring TXA administration strategy. The electronic, anonymous, questionnaire was emailed to all registered Israeli and American Otolaryngology Head and Neck Surgery (OHNS) physicians, investigating TXA administration: RESULTS: Overall, 317 otolaryngologists participated in the study. TXA was administered to 40.5 % of the pediatric population and 50 % of the adult patients when needed. Epistaxis was the most common indication for TXA administration (48-55 %). A small number of otolaryngologists, 4-13 %, recommended preventive TXA for various operations. More surgeons include TXA in their practice and adjusted the dose according to renal function in academic compared to non-academic medical centers and among otolaryngologists practicing in Israel compared to the United States., Conclusions: TXA is provided by many otolaryngologists to treat active epistaxis but to a substantially lesser extent as a preventive measure. TXA is given to children and adults, some with substantial comorbidities. Treatment is more common among surgeons working in academic institutes and medical centers in Israel., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background. Tranexamic acid (TXA) is an antifibrinolytic agent that reduces blood loss during surgery, decreases mortality in civilian and military trauma populations, was adopted for prehospital use by the British military, and is now issued to U.S. Special Operations Forces for use on the battlefield. Objective. This study tested whether storage of TXA ampoules at four temperatures (-20°C, 4°C, 22°C, or 50°C) for 1, 2, 4, and 12 weeks would result in chemical degradation and the loss of activity to block streptokinase-induced fibrinolysis in human plasma. Methods. For each temperature and storage duration, normal plasma, plasma plus streptokinase (SK) (50 units/mL), and plasma + SK + TXA (0.2 μg/mL, n = 4) were tested for D-dimer (DD), for fibrin degradation products (FDP), by thromboelastography (to measure the units/mL of SK needed to get 100% fibrinolysis at 60 minutes [LY60]), and by high-performance liquid chromatography (HPLC). The results were similar for all temperatures and storage durations, and were therefore combined. Results. Streptokinase led to a rise in LY60, DD, and FDP that was significantly (p < 0.05) attenuated with TXA. The results in the three test conditions were LY60: 0.00% ± 0.00%, 70.52% ± 4.7%, 0.02% ± 0.01%; DD: 0.23 ± 0.1, 205.05 ± 101.59, 0.31 ± 0.01 mg/L; and FDP: <10, >40, and <10 μg/mL, respectively. The HPLC results showed no chemical breakdown of TXA. All TXA glass ampoules at -20°C were cracked by week 1. Conclusions. Except for the finding that TXA ampoules cracked when frozen, this study indicated that the drug remains effective when stored under conditions likely to be encountered in the prehospital environment and outside the manufacturer's recommended temperature range for at least 12 weeks. [ABSTRACT FROM AUTHOR]

Résumé: Parce qu'ils sont malheureusement pourvoyeurs d'un grand nombre de blessés graves en un temps restreint, les conflits armés procurent un environnement propice aux avancées médicales. En milieu militaire, les capacités logistiques et l'organisation efficace permettent de rapidement diffuser de nouvelles idées, de nouvelles thérapeutiques ou de nouveaux équipements. Les récents conflits irakien ou afghan ne font pas exception : plus d'une trentaine de nouvelles clinical practice guidelines ont été éditées par l'armée américaine en réponse aux observations et aux recherches faites par les médecins militaires et ont eu un impact direct sur la survie des blessés. Nous retraçons ici les changements dans les pratiques médicales au cours des dix dernières années qui ont permis d'améliorer la prise en charge des blessés traumatisés graves. Ils proviennent des leçons tirées de l'expérience des équipes médicales dans la réalisation des transfusions massives, des rapports d'autopsies et des analyses approfondies des dossiers médicaux du Joint Theater Trauma Registry. Ils comprennent notamment l'utilisation de sang total, le nouveau rapport transfusionnel de 1/1/1 et la mise en place de nouveaux matériels ou produits pharmaceutiques afin de lutter contre les hémorragies. Aujourd'hui, les nouvelles stratégies visant à réduire la mortalité sur le champ de bataille se focalisent sur le pré-hospitalier, là où les décès par hémorragie constituent encore un réel challenge. Les recherches actuelles se concentrent donc sur la coagulopathie post-traumatique et sur l'évaluation de nouveaux produits sanguins pouvant être déployés au niveau des unités les plus avancées. [ABSTRACT FROM AUTHOR]

A Nursing Continuing Professional Development (NCPD) from Lippincott Professional Development on tranexamic acid administration for pediatric trauma patients is presented.

Introduction: Tranexamic acid (TXA) has been shown to reduce blood loss and transfusion risk in various orthopedic surgeries including shoulder arthroplasty. However, concerns still exist regarding its use in patients with a history of thrombotic events. Using national claims data, we aimed to study the safety of TXA administration in shoulder arthroplasty patients with a history of thrombotic events., Methods: We used retrospective national claims data (Premier Healthcare) on 71,174 patients who underwent a total or reverse shoulder arthroplasty between 2010 and 2016. TXA use was evaluated specifically within a subgroup of patients with a history of thrombotic events such as myocardial infarction, deep venous thrombosis, pulmonary embolism, transient ischemic attack, or ischemic stroke. Studied outcomes were blood transfusion need, complications (including acute renal failure, new onset myocardial infarction, deep venous thrombosis, pulmonary embolism, transient ischemic attack, or ischemic stroke), and cost and length of hospitalization. Mixed-effects models measured the association between TXA use and outcomes, separately in patients with and without a history of thrombotic events. Odds ratios (OR) or percent change for continuous outcomes with 95% confidence intervals (CI) were reported., Results: Overall, TXA was used in 13.7% (n = 9735) of patients, whereas 10.5% (n = 7475) of patients had a history of a thrombotic event. After adjustment for relevant covariates, TXA use (compared with no TXA use) in patients without a history of thrombotic events was associated with decreased odds of blood transfusions (OR, 0.48; CI, 0.24-0.98; P = .0444), whereas no increased odds for complications were observed (OR, 0.83; CI, 0.40-1.76; P = .6354). Similar results were observed in patients with a history of thrombotic events. Moreover, in this subgroup, TXA use was associated with a slight reduction in hospitalization cost (-8.9% CI: -13.1%; -4.6%; P < .0001; group median $18,830)., Conclusions: Among shoulder arthroplasty patients, TXA use was not associated with increased complication odds, independent of a history of thrombotic events. These findings are in support of wider TXA use., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to measure trends in the use of tranexamic acid (TXA) during delivery in the United States and to evaluate demographic data and morbidity outcomes among these patients., Methods: This retrospective cohort study includes data from 19 hospitals in the Universal Health Services network. We compared rates of TXA use between January 2015 and June 2019 across geographic sectors. We also evaluated associations of demographic variables and perinatal outcomes of women who received TXA., Results: 209 cases of TXA use were found from analysis of 101,564 deliveries. TXA use increased over time and rates were higher in the West than in Central and East; the slope of increase over years did not differ between regions. Women who received TXA were more likely to have a history of postpartum hemorrhage (59 (28.2%) vs. 2290 (2.2%), P < 0.0001) but were not more likely to have a chronic disease, including diabetes mellitus, hypertension and heart disease. Women who received TXA were more likely to have estimated blood loss greater than or equal to 1000 mL (adjusted odds ratio (aOR) 15.3; 95% CI 11.1-21.1; P < 0.0001). Likelihood of venous thromboembolism was not significantly increased in TXA recipients (aOR 2.0; 95% CI 0.3-14.6; P = 0.49)., Conclusion: Increasing national trends of TXA use in the peripartum period was observed, with variable increases by geographic region. Likelihood of venous thromboembolism was not significantly increased among women who received TXA. Increasing TXA use throughout the country suggests that updated hemorrhage guidelines from national obstetrical organizations can shape clinical practice.

Aims: The safety and efficacy of tranexamic acid (TXA) in reducing blood loss after total joint arthroplasty and spinal fusion surgery has been well documented. However, little data exist regarding the effectiveness of intraoperative TXA in children with cerebral palsy (CP). The aim of this double cohort study is to investigate the safety and efficacy of intraoperative TXA in reducing blood loss and transfusion requirements for children with CP undergoing a proximal unilateral or bilateral femoral varus derotational osteotomy (VDRO)., Patients and Methods: A retrospective review was performed of all paediatric theatre lists between May 2012 and January 2019 for all paediatric (< 16 years old) CP patients who underwent unilateral or bilateral VDRO combined with soft tissue release at our institution. Fifty-one patients were included in our study further subdivided into two individual groups, unilateral and bilateral VDRO., Results: No statistically significant differences were found in demographics such as age, weight, ASA, GMFCS and antiepileptic medication between the groups. However, there were significant statistically differences in TBL and transfusion rates between the groups that received TXA and those that did not, both in unilateral [241 ml (TXA) vs. 369 ml (non-TXA)] and bilateral [287 ml (TXA) vs. 467 ml (non-TXA)] operations., Conclusion: TXA successfully reduced TBL (in both TXA subgroups) and the transfusion rates without associated complications. TXA's safety and efficacy should be explored further in adequately powered randomized controlled trials.

Background: The use of Tranexamic Acid (TXA) in trauma patients remains controversial. The CRASH II trial, while randomized and prospective, did not include patients suffering from major bleeding. We wanted to examine our population of patients who underwent a massive transfusion protocol (MTP) (greater than 10 Units of packed red blood cells in the first 24 h of admission) to see if those who were undergoing massive transfusion and received TXA had any benefit in mortality. Our hypothesis was that massively transfused patients who received TXA and those that did not had no difference in mortality., Methods: We performed a single institution retrospective review of our Trauma Registry for all patients who received a massive transfusion between 2010 and 2017. Patients were separated into two cohorts, those who received TXA within the first 24 h of admission and those who did not. The primary outcome of the study was mortality. Secondary outcomes included total blood products transfused, Deep Venous Thrombosis (DVT), Pulmonary Embolus (PE), Myocardial Infarction (MI), and cardiac arrest., Results: 283 patients received MTP between 2010 and 2017. 179 (63%) did not receive TXA and 104 (37%) were treated with TXA. The groups were then propensity matched and yielded 62 patients in each group (124 total) (ISS 36 ± 12 no TXA vs. 37 ± 13 TXA; p = 0.59). There was no significant difference observed in mortality (50% no TXA vs. 39% TXA; p = 0.21), total PRBC's transfused (20 ± 11 no TXA vs. 23 ± 18 TXA; p = 0.45), DVT (8% no TXA vs. 6% TXA; p = 0.99), PE (2% no TXA vs. 3% TXA; p = 0.99), MI (3% no TXA vs. 0% TXA; p = 0.50), or cardiac arrest (26% no TXA vs. 18% TXA; p = 0.28)., Conclusion: There does not appear to be any benefit to TXA administration in Trauma Patients in our institution. This is a single-center retrospective review. More data from other similar centers in the region or the United States is warranted., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The World Maternal Antifibrinolytic trial demonstrated that tranexamic acid administered during postpartum hemorrhage reduces hemorrhage-related mortality and laparotomies. The World Health Organization has thus recommended early use of tranexamic acid in the treatment of postpartum hemorrhage. This recommendation has not been universally adopted in the United States, in part because of concerns about cost-effectiveness.Objective: We aim to demonstrate the cost-effectiveness of routine tranexamic acid administration in the treatment of postpartum hemorrhage in the United States, where the rate of hemorrhage-related mortality is lower than that described in the World Maternal Antifibrinolytic trial.Study Design: We constructed a decision tree comparing 3 strategies in women with a clinical diagnosis of postpartum hemorrhage: no tranexamic acid, tranexamic acid given at any time, and ideal use of tranexamic acid given within 3 hours of delivery. The study was performed from a health care institution perspective with a time horizon of delivery until 6 weeks postpartum. We included interventions that differed by arm in the World Maternal Antifibrinolytic trial (hemorrhage-related mortality, laparotomies, and brace or compression sutures) and incorporated probabilities and costs based on available data for a population of women with postpartum hemorrhage in the United States. In our base case, the rate of postpartum hemorrhage-related mortality was 0.0388%, and the cost of tranexamic acid was $37.80. We assumed that the relative risk reduction in death and laparotomy with tranexamic acid would be similar to the World Maternal Antifibrinolytic trial (19% and 36%, respectively). The primary outcome was incremental cost per hemorrhage-related death averted, and a main secondary outcome was incremental cost per laparotomy avoided under each strategy. Another planned secondary outcome was cost per quality-adjusted life-year. We anticipated that the risk reduction (benefit) because of tranexamic acid in the United States may be less than in the World Maternal Antifibrinolytic trial; thus, we performed 1-way and 2-way sensitivity analyses to explore the parameter uncertainty across a wide range of data-supported estimates. Probabilistic sensitivity analyses with Monte Carlo simulation were performed.Results: Tranexamic acid strategies were dominant (more effective and cost saving) compared with no tranexamic acid for patients with postpartum hemorrhage in the United States. One-way analyses showed that tranexamic acid is cost saving as long as the relative risk reduction of death with tranexamic acid is greater than 4.7%; the model was not sensitive to any other variables. Threshold analyses outside the bounds defined in the model showed that tranexamic acid is cost saving as long as the relative risk reduction of laparotomy with tranexamic acid is greater than 7% or the cost of tranexamic acid is less than $194. A 2-way sensitivity analysis of the risk reduction of death because of tranexamic acid and the baseline risk of postpartum hemorrhage-related death confirmed that tranexamic acid is cost saving across a wide range of plausible estimates. Furthermore, probabilistic sensitivity analysis demonstrated that the tranexamic acid strategies are cost saving in >99.9% of 10,000 Monte Carlo simulations. Despite the initial cost of administration, the annual net cost savings expected from routine use of tranexamic acid for the treatment of postpartum hemorrhage in the United States is $11.3 million, and we estimate that 9 maternal deaths would be averted in 1 year with this strategy. Giving tranexamic acid within 3 hours would almost triple the cost savings and improve maternal outcomes much further.Conclusion: A policy of routine tranexamic acid early in the treatment of postpartum hemorrhage is likely to be cost saving in the United States. This conclusion holds true even when the relative risk reduction with tranexamic acid is significantly less than reported in the World Maternal Antifibrinolytic trial and when tranexamic acid is significantly more expensive than currently reported. [ABSTRACT FROM AUTHOR]

Background: Minimising perioperative bleeding is a key goal of "patient blood management" programs. One component of respective strategies includes preventive inhibition of fibrinolysis using protease inhibitors, such as tranexamic acid (TXA). TXA inhibits plasminogen activation and plasmin-induced fibrin degradation., Objectives: The present article provides an overview of the existing literature and TXA applications in the prophylaxis of perioperative bleeding., Methods: Literature search in PubMed/MEDLINE (U.S. National Library of Medicine®, Bethesda, MD, USA)., Results: TXA reduces perioperative blood loss and transfusion requirements in several randomized controlled trials (RCTs) and meta-analyses in the field of hip and knee arthroplasty for both intravenous and topical use. Moreover, evidence favours use of TXA in complex spine surgery and reconstructive surgery (e. g. craniosynostosis in children). Single RCTs showed benefits of TXA in abdominal hysterectomy, open prostatectomy, liver surgery and actively bleeding trauma patients. For prophylaxis of peripartum haemorrhage (PPH) following vaginal delivery or Caesarean section, TXA cannot be routinely recommended, although evidence points to benefits in actively bleeding patients. A recommendation exists for the treatment of (active) PPH. For prophylactic perioperative administration, different dosage regimens exist for adults. Most often an initial i. v. bolus of 1 g or 10-15 mg/kg body weight with/without repetition after 6 h or continuous infusions over 8 h is administered. Increased rates of thromboembolic events were not noted., Conclusion: Protease inhibitors such as TXA reduce perioperative blood loss and transfusion requirements in selected surgical fields.

Background: Hemoptysis is a major cause of morbidity and mortality in patients with cystic fibrosis (CF). Antifibrinolytic agents have shown efficacy in a broad range of bleeding disorders and conditions., Objectives: The goal of this study was to examine the use of antifibrinolytic agents in managing hemoptysis in CF. We developed a clinical treatment pathway for inpatient and outpatient use, and rates of admission for bleeding prior to and following implementation of the pathway are reported., Methods: All adult patients with CF treated with systemic antifibrinolytic agents over a 54-month period according to the treatment pathway were analyzed. Data collected included demographic characteristics, baseline CF-related characteristics, and bleeding and treatment parameters. Effectiveness of the pathway was evaluated via comparison of annualized hemoptysis admission rates prior to and following pathway enrollment., Results: Seventy-two distinct episodes of hemoptysis treated with antifibrinolytic agents were analyzed in a total of 21 adult patients with CF. Two-thirds of episodes treated involved moderate or massive hemoptysis. Bleeding ceased following a median of 2 days. Outpatient treatment was associated with a 50% reduction in the annualized hemoptysis admission rate following pathway enrollment (2.44 vs 1.23 admissions per year; P = .0024) that was independent of other changes in management. Antifibrinolytic therapy was well tolerated. One central catheter-associated upper extremity DVT was observed in a patient with previous thrombosis in the same vessel., Conclusions: A pathway using systemic antifibrinolytic therapy to treat hemoptysis in patients with CF was associated with a reduction in hospital admissions. No serious adverse events were observed. Additional studies are needed to further define the benefits of systemic antifibrinolytic use in patients with CF., (Copyright © 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: The prevalence of tranexamic acid (TXA) use for trauma and other conditions in children is unknown.Objectives: The objective of this study was to describe the use of TXA in United States (US) children's hospitals for children in general, and specifically for trauma.Methods: We conducted a secondary analysis of a large, administrative database of 36 US children's hospitals. We included children <18 years of age who received TXA (based on pharmacy charge codes) between 2009 and 2013. Patients were grouped into the following diagnostic categories: trauma, congenital heart surgery, scoliosis surgery, craniosynostosis/craniofacial surgery, and other, based on the International Classification of Diseases, Ninth Revision principal procedure and diagnostic codes. TXA administration and dosage, in-hospital clinical variables, and diagnostic and procedure codes were documented.Results: A total of 35,478 pediatric encounters with a TXA charge were included in the study cohort. The proportions of children who received TXA were similar across the years 2009 to 2013. Only 110 encounters (0.31%) were for traumatic conditions. Congenital heart surgery accounted for more than one-half of the encounters (22,863; 64%). Overall, the median estimated weight-based dose of TXA was 22.4 mg/kg (interquartile range, 7.3-84.9 mg/kg).Conclusions: We identified a wide frequency of use and range of doses of TXA for several diagnostic conditions in children. The use of TXA among injured children, however, appears to be rare despite its common use and efficacy among injured adults. Additional work is needed to identify appropriate indications for TXA and provide dosage guidelines among children with a variety of conditions, including trauma. [ABSTRACT FROM AUTHOR]

The article discusses a study conducted by Jashvant Poeran and colleagues which aims to assess the perioperative use of the medication tranexamic acid in total hip and total knee arthroplasties without the need for blood transfusions and risks for thromboembolic and renal problems. Topics discussed include the summary answer and the main result of the study, what the research adds on previous studies on tranexamic acid use, and the methodology of the study.

Hemostatic agents are currently used in the form of special granules or soaked gauze. Their use is particularly advantageous in difficult body location (e.g. on neck, armpit or groin), where other methods of bleeding control are impossible to use or fail. In a tactical environment tranexamic acid received first class recommendation for use in case of severe bleeding in the US Army. Its application should be considered in case of traumatic amputation, penetrating chest and abdominal trauma or hemorrhagic shock. The aim of the implementation of hypotensive resuscitation is to maintain perfusion of vital organs in patient with hypovolemia, without excessive fluid infusion. Modern method of bleeding control in combat condition are compression clamps. The purpose of these devices is to compress blood vessel by external pressure pads, especially in difficult to access arteries and large veins in the pelvis or in the distal abdominal aorta., (© 2015 MEDPRESS.)