TXA in patients with angina undergoing non-cardiac surgery... yay or nay?

[woopedazz]

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Emergency lumbar decompression of hospital-avoidant octogenarian.

Previous strokes + MI documented in GP letter from 10years ago.
Last presented to hospital with hypertensive crisis and active NSTEMI 3 years back; self-DC from ED with no follow-up once pain settled with GTN infusion.
Baseline exercise tolerance: Walking to bathroom = SOB and chest pain. Cannot lie flat due to paroxysmal nocturnal dyspnea.
No allergies/reg meds.

BP 200/100. ECG = q-waves, TWI and RBBB - no baseline ECG to compare it to.
Bibasal creps. No murmurs. Cardiomegaly on CXR; no obvious APO/other.
Bloods: GFR ~ 30, everything else okay. Hb 135.

Acute Cauda Equina - surgeon waiting in theatre.
Ignoring the other issues here. My question is this: The surgeon requests TXA.

Thoughts on TXA in this patient?

 

[Planktonmd]

Tranexamic Acid Is Safe in Patients with a History of Coronary Artery Disease Undergoing Total Joint Arthroplasty - PubMed

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

pubmed.ncbi.nlm.nih.gov

 

[woopedazz]

It's a good paper and one that I use to guide my practice in patients with historical coronary artery stenting/stable disease. However, the elective arthroplasties in that study were not performed on patients with active/unoptimized disease.

In an emergent setting, in a significantly high risk patient, for a surgery with minimal blood loss expected... is TXA a suitably low-risk drug?

EDIT: I'd argue that it isn't a great idea. But then the patient did bleed a bit, so maybe I'm being too cautious here.

 

[Beeftenderloin]

Have read the cited paper, that’s in medically optimized total joint patients with stable CAD walking in from home, not generalizable to the patient in front of you. You’re operating in an evidence free zone.

Why do they have cauda equina? Spontaneous hematoma? Maybe an argument to be made there. Acute disk or other non-bleeding pathology, I’d skip it. Patient shouldn’t bleed much for a lumbar decompression, unless this surgeon is a blood-letter, which it sounds like they might be. Either way, I’d take a few hundred mls of EBL over a peri-op MI any day of the week.

 

[woopedazz]

Why do they have cauda equina? .... Acute disk .... Either way, I’d take a few hundred mls of EBL over a peri-op MI any day of the week.

Yeah, that was my thinking.

That said... POISE-3 is another "TXA is okay" paper that's coming out soon. But similar to all the other publications it excludes recent/active cardiac disease.

I do wonder if I'm being too risk averse withholding TXA in this patient population?

 

[PainDrain]

The question you should be asking yourself isn’t whether to use TXA or not, the question is how you are going to treat this man’s ischemia intraop?

 

[Hork Bajir]

In the cardiac surgical world, most patients get TXA or Amicar (including those with very active and unstable CAD). Some will start the anti-fibrinolytic at the start of the case, and some will make an argument that you should wait to start it until you’re heparinized (at least for various flavors of CAD, LM disease, etc). Last I checked there was no evidence to support the practice of waiting for heparin… That patient population (pre-bypass CABG getting TXA before heparin) is more akin to the patient you’re dealing with here than any of the papers cited above. However, arguably the benefit of anti-fibrinolytics is also much greater for a pump case than for a lumbar lami.

Personally for cardiac cases, even with severe CAD and unstable angina, I feel comfortable starting the TXA pre-incision (before heparin bolus) but generally only do so if there is some particularly high bleeding risk (redo chest, planned circ arrest, etc)

 

[IMGASMD]

I looked at FDA approved indication for TXA recently.
I was very very surprised.

 

[abolt18]

I looked at FDA approved indication for TXA recently.
I was very very surprised.

Hemophilia and dental extraction as the only approved indication for IV TXA, and heavy menstrual bleeding is the only approved indication for PO TXA. Is this what you're finding as well?

 

[GassYous]

Just don't inject it intrathecal and you're good

 

[IMGASMD]

Just don't inject it intrathecal and you're good

Yes sirreee.

 

[MirrorTodd]

Hemophilia and dental extraction as the only approved indication for IV TXA, and heavy menstrual bleeding is the only approved indication for PO TXA. Is this what you're finding as well?

That's just what the government WANTS you to think.

 

[lakersbaby]

bleeding is much better than clotting. that being said we use TXA for almost everyone except recent stroke/mi patients.

 

[DrOwnage]

Then again we give TXA like candy. I think its overused especially in joints that have minimal bleeding to start with. Some of my surgeons take 45 minutes to do a total hip or knee. I give the TXA pre-incision, then they want another during closure. I usually say no, mostly for the fact that the first dose is still marinating and probably good for another 3 hours.

 

[IMGASMD]

Then again we give TXA like candy. I think its overused especially in joints that have minimal bleeding to start with. Some of my surgeons take 45 minutes to do a total hip or knee. I give the TXA pre-incision, then they want another during closure. I usually say no, mostly for the fact that the first dose is still marinating and probably good for another 3 hours.

We do.
I have a surgeon who ask to dose pre-incision, post closure AND he injects intra-articular as well.
One of these days…….

 

[GassYous]

Then again we give TXA like candy. I think its overused especially in joints that have minimal bleeding to start with. Some of my surgeons take 45 minutes to do a total hip or knee. I give the TXA pre-incision, then they want another during closure. I usually say no, mostly for the fact that the first dose is still marinating and probably good for another 3 hours.

I do it because it's their patient and they want it. Don't want to get blamed if the patient bleeds later. We have a decent amount of literature now that says txa is pretty safe so I don't mind.

 

[DrOwnage]

I do it because it's their patient and they want it. Don't want to get blamed if the patient bleeds later. We have a decent amount of literature now that says txa is pretty safe so I don't mind.

Not for every patient. Yeah if their renal function is good and their weight is considerable. I'm not blasting low weight old people with CKD 2-3 with 2g of TXA within an hour to save 5ccs of blood loss. Especially when the surgery is done under tourniquet. I'm more talking about how most just give it without much thought involved.

 

[GassYous]

Not for every patient. Yeah if their renal function is good and their weight is considerable. I'm not blasting low weight old people with CKD 2-3 with 2g of TXA within an hour to save 5ccs of blood loss. Especially when the surgery is done under tourniquet. I'm more talking about how most just give it without much thought involved.

Can bleed in pacu even despite tourniquet

 

[DrOwnage]

Can bleed in pacu even despite tourniquet

I mean they achieve hemostasis after tourniquet is deflated and patient is closed. These patients don’t get drains and the chance of a post op bleed is very rare. Maybe if it’s a big arthrotomy the patient can get a post op effusion. Plus my first dose of TXA is still working given patient selection.