Routine use of prophylactic tranexamic acid for c-sections

[pgg]

In Oct of 2013, the American Journal of OB & Gyn published an article "Evidence-based surgery for cesarean delivery: an updated systematic review" in which they stated, among other things

Tranexamic acid (10 mg/kg intravenously prior to incision) is an antifibrinolytic and hemostatic agent, and 3 new RCTs have evaluated its use in decreasing blood loss in CD.48,56,57 In these trials, tranexamic acid significantly decreased intraoperative and postpartum blood loss (100-200 mL). In one trial, the EBL of greater than 1000 mL and the need for additional uterotonics was significantly lower in the tranexamic acid group (2.1% vs 5.8%; RR, 2.7; 95% CI, 1.1e6.3; and 8.5% vs 14.5%; RR, 1.7; 95% CI, 1.1e2.6, respectively)48 (recommendation: B; level of certainty: moderate; Table 1; new).

Recommendation B =

The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial

And "moderate" level of certainty =

The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as:
- The number, size, or quality of individual studies.
- Inconsistency of findings across individual studies.
- Limited generalizability of findings to routine primary care practice.
- Lack of coherence in the chain of evidence.
As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.

TXA is cheap, appears to be safe. We used gallons of it for trauma patients in Afghanistan without thrombotic complications. Pregnancy's a different thrombosis risk than trauma but the c-section studies they reference seem to support safety.

So, what are you all doing? Is TXA hanging next to the cefazolin prior to every c-section you do? Should it?

I haven't read the articles this one references, but my initial thought is that a statistically significant difference in blood loss makes for a publishable article, but whether or not that difference in blood loss is clinically significant is another issue. Less need for a 2nd utertonic? So what? I suspect that if there was a difference in actual morbidity, ie emergency hysterectomy rate, or transfusion rate, they'd have mentioned that.

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[seinfeld]

Routinely we have less than a 600ml blood loss, doubt it would help in our practice. Besides shouldn't the goal be to decrease or eliminate transfusions, emergency embolizations and hysterectomies? Seems silly to base the use of a drug to merely decrease blood loss if in the end the blood loss rarely results in transfusions.

 

[pgg]

Routinely we have less than a 600ml blood loss, doubt it would help in our practice. Besides shouldn't the goal be to decrease or eliminate transfusions, emergency embolizations and hysterectomies? Seems silly to base the use of a drug to merely decrease blood loss if in the end the blood loss rarely results in transfusions.

I totally agree. Women are built to bleed (some) during delivery. Treasuring every drop of blood to the point of giving non-zero-risk antifibrinolytic therapy to all comers is quite a leap from a p-value related to EBL.

 

[sevoflurane]

I'd use it for a Jehovah's witness. Outside of that... probably not.

 

[BLADEMDA]

Have you evaluated the risk of increased DVTs? Are you having to transfuse a lot of Mommys after their C sections? We rarely ever transfuse any postpartum patient.
If your OB is an assassin in disguise then perhaps TXA may help. Better yet they can learn to operate and skip the TXA.

 

[BLADEMDA]

Contraindications for TXA use

Previous History of DVT

Sensitivity to Tranexamic acid

Visual problems colour disturbances

Poor renal function.

____________________________________

COMMON SIDE EFFECTS:

Nausea Vomiting and Diarrhoea

Dizziness

Hypotension

Rash (allergic reaction)

Over dosage rare.

 

[sevoflurane]

I honestly find that TXA is a very safe drug.
I've never seen any serious reactions.
Some centers use it routinely for total joints, especially TKAs.

The one place I really think twice about giving antifibrinolytics is DIC or h/o DVT.

 

[sevoflurane]

I've always found the treatment of DIC interesting as often you give products, heparin and antifribinolytics as well as treating the underlying culprit.

 

[fakin' the funk]

Routinely we have less than a 600ml blood loss, doubt it would help in our practice. Besides shouldn't the goal be to decrease or eliminate transfusions, emergency embolizations and hysterectomies? Seems silly to base the use of a drug to merely decrease blood loss if in the end the blood loss rarely results in transfusions.

Agree w/ Seinfeld again.

A 100-200ml reduction in EBL by using TXA routinely may be statistically significant but it isn't clinically meaningful.

You could imagine though that if it was used in patients at high risk of needing transfusion you could show a reduction in # of units transfused or somesuch.

 

[sethco]

Does anybody know why color vision disturbances are a contraindications to the use of TXA? I have honestly never heard this before and I never ask my patients about this preoperatively. Yet, at my institution, we give it to everybody undergoing a pump run.

 

[BLADEMDA]

Remember most patients having C sections are awake under SAB. Hence, TXA may cause Nausea and Vomiting which is something we like to avoid. In addition, A rapid bolus (over 60 seconds) may also result in hypotension.

 

[Random Anesthesiologist]

Does anybody know why color vision disturbances are a contraindications to the use of TXA? I have honestly never heard this before and I never ask my patients about this preoperatively. Yet, at my institution, we give it to everybody undergoing a pump run.

I thought I read once that some acquired color blindness is vascular in nature and that's why it's contraindicated. I can't give you a source, sorry.

 

[GABAergic]

I thought I read once that some acquired color blindness is vascular in nature and that's why it's contraindicated. I can't give you a source, sorry.

I read that it's because preexisting color disturbance makes it difficult/impossible to monitor for TXA toxicity as it causes visual disturbances. Probably not that important for people who aren't going to be on TXA for an extended period of time. The mechanism I read about was related to degeneration of the retinal epithelium, but I couldn't find anything more in depth.

 

[Random Anesthesiologist]

I read that it's because preexisting color disturbance makes it difficult/impossible to monitor for TXA toxicity as it causes visual disturbances. Probably not that important for people who aren't going to be on TXA for an extended period of time. The mechanism I read about was related to degeneration of the retinal epithelium, but I couldn't find anything more in depth.

Thanks. Yeah I couldn't find much either.

 

[Noyac]

My take on TXA is that it is a good tool to have in your back pocket. I would consider giving it in those c/s that I perceive to have the potential to be a bloodfest. Those would be uterine rupture, esp'ly with a slow or poor OB. Possibly in a case with twin gestation (stretched uterus with potential for poor contraction) again with a poor OB. And any other case when I see badness coming. The problem is, you must see the badness coming. I don't think it will buy us a whole lot in the heat of the moment like in war injuries. By the time we are into all the bleeding we should be getting control of it shortly afterwards unlike in the field. But with that said, I wouldn't hesitate to give it if I saw the need.

So in summary, I think it is a good option. Use your experience.

 

[Noyac]

My question is, would you give it to a AFE pt?

 

[sevoflurane]

For small AFE that are not hemodynamically unstable, I'd likely let it ride and provide supportive strategies so long as coags are not out of whack.
AFE progressing to DIC is dicey. With active/accelerated hyperfirinolysis as evidenced by a TEG, it can be used. The problem is, most places don't have a TEG. So figuring out which side of the equation is winning-clotting vs bleeding- can be a challenge. If I have a mottled looking extremity, I certainly would hold off on amicar/txa. Good question BTW.

 

[sevoflurane]

A couple years back I was speaking to a senior OB attending at one of the U of Utah conferences. I was discussing this exact topic with her (I had a case of DIC in the setting of D&C). She brought up TEG and my rebuttal was that most places don't have them. She then proceeded to explain to me the poor mans TEG. Put 10 ccs of whole blood in a syringe. IF it clots, then you probably don't need txa/amicar. I'm not so sure how valid this is, but interesting hearing it from her. Either way, one must exercise caution as it is implicated as aggravating clot formation in the setting of DIC with predominance of clots. (coronary thrombosis, stroke, portal vein thrombosis, etc.)

 

[Noyac]

Did she give you a time frame for which the syringe must clot? I would expect 10 minutes. If it hasn't clotted by 20, what's the consensus?

 

[Noyac]

For small AFE that are not hemodynamically unstable, I'd likely let it ride and provide supportive strategies so long as coags are not out of whack.
AFE progressing to DIC is dicey. With active/accelerated hyperfirinolysis as evidenced by a TEG, it can be used. The problem is, most places don't have a TEG. So figuring out which side of the equation is winning-clotting vs bleeding- can be a challenge. If I have a mottled looking extremity, I certainly would hold off on amicar/txa. Good question BTW.

So you have a smallish AFE, do you wait for evidence of coagulopathy or do you give TXA? Personally, I would give it in hopes of heading off the coagulopathy.

 

[sevoflurane]

Did she give you a time frame for which the syringe must clot? I would expect 10 minutes. If it hasn't clotted by 20, what's the consensus?

Yep. Somewhere btw/ 5-20 minutes. Def. not an exact science. It may be worth doing if you suspect AFE and you see oozing @ IV sites. That is how my patient presented. PIV/CVL oozing and severe persistent bleeding from D&C- she had DIC with predominance of bleeding/inability to for form an effective platelet plug.

So if the blood clots after 3-5 minutes , it may steer you away from giving TXA/amicar. If it hasn’t started to congeal after 30-45min. you might interpret this as accelerated fibrinolysis. This crude method of assessing coagulation needs to be placed into context, but may help steer your decision making towards antifibrinolytics if they start getting cool-aid humors.

 

[sevoflurane]

So you have a smallish AFE, do you wait for evidence of coagulopathy or do you give TXA? Personally, I would give it in hopes of heading off the coagulopathy.

If a straight forward C/S develops sudden br0nchospasm after placental mobilization/removal, but is otherwise fine, I'd probably skip it (AFE in my differential). If it does progress and develop into the diffuse clotting type, antifibrinolytics may not be indicated. I usually like to see some evidence of DIC before giving antifibrinolytics.

If it's a twin gestation with placenta per/accreta with a starting hgb of 8.9... i'd have a dedicated fatty line just for amicar/txa/other products ready for deployment.

 

[Noyac]

Yep. Somewhere btw/ 5-20 minutes. Def. not an exact science. It may be worth doing if you suspect AFE and you see oozing @ IV sites. That is how my patient presented. PIV/CVL oozing and severe persistent bleeding from D&C- she had DIC with predominance of bleeding/inability to for form an effective platelet plug.

So if the blood clots after 3-5 minutes , it may steer you away from giving TXA/amicar. If it hasn’t started to congeal after 30-45min. you might interpret this as accelerated fibrinolysis. This crude method of assessing coagulation needs to be placed into context, but may help steer your decision making towards antifibrinolytics if they start getting cool-aid humors.

So the way I see it is this, I think there is very little risk to giving TXA that I am aware of. If the pt is clotting like you say but I highly suspect AFE I would lean towards giving it to help prevent the coagulopathy. We give it preemptively in other cases like total joints and cardiac.

As far as the time to clot in the syringe goes, just think how fast that syringe clots when you aspirate blood while locating an IJ or SC for CVP placement. You set that syringe aside and before your done threading the catheter, suturing and dressing it, it's started to clot in that syringe. And all this takes me a full 2 minutes ( because I still don't use US).

 

[sevoflurane]

....And all this takes me a full 2 minutes ( because I still don't use US).

 

[sevoflurane]

...except in those cases of absent RIJ....

Just busting your balls Noy... I've personally witnessed Noy perform ninja fast regional w/o USD. Breath of fresh air to see no reliance on it.

That being said, I still pick up the sonosite for 85% of my regional blocks even though I was trained both ways. Total time is usually 1 minute 59 seconds.

 

[Noyac]

...except in those cases of absent RIJ....

Just busting your balls Noy... I've personally witnessed Noy perform ninja fast regional w/o USD. Breath of fresh air to see no reliance on it.

That being said, I still pick up the sonosite for 85% of my regional blocks even though I was trained both ways. Total time is usually 1 minute 59 seconds.

Damn, you got me beat by a second. I'm gonna need to revise my approach.