TXA

[nimbus]

Some good news.

Anesthesiology

pubs.asahq.org

edit: link to full text PDF

https://watermark.silverchair.com/aln.0000000000003772.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAvowggL2BgkqhkiG9w0BBwagggLnMIIC4wIBADCCAtwGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMX9qt97VocUanrJLHAgEQgIICrRP1Me2O82IfEOOekxYT-5WeDet3g3qCD3Bdu5x1LT9f5WpvWgpHOqMzPfhj0Crwe9wuOlifV-SF-Pn5HohB84cweOj_n7jjHo0AyzFeN4t7R5EKHWeG1oT0o00fO_NMdqewNb8n2Vt9XaoOgvae5SOxUPcVwoUc3cFHoktPaBuMlh8dfu404N-EEGLtBoQxsXNDS9VWOrt1vzzc7lXXlW9r4b3nCCaJYWmEbT2Q5SHwvFxL-OUGDomDcAE6kYLva39MZlvQ7V5VywkBdjtNUUHmxifQLysAXD_StmihGmya5JxRIv3nxlq4mnWpwsz41cCX4Z21bvnWiFoPlS_vIgBg6ttAjR_j2J0tS-wtr4RrrzbCdc4Ckow36IuYyxwZGWk8AzJ8r5B0wk_VQTrNtxqmlqRql7NP_9zgSoaPrDjJfXRslluJ2c1SLtKPwRDnOEQ2pPyYVCVlSETS9ASEW9o5IfWhebGLSBw2KbHtXIh-FiK0FT7sKZiuQP-KTT79FJ3CuqgLCDsv4hk7p-TgY370DdMPde3Ru5Q5kPPMux5Bj2EuEkwjJV7RMCPrMg1gXoghYRcY4_r69RN-MbQf2iBW1skrhF2yjwwVyZEnCbE3Mm7Ha8OBhtjDfuPVSdRs1SreJoW9qADHFS7HsBFiD5xO1Qwf909zzAYkNhEpIZp0hbLMHkNLVFB4wMNqRzvAdi3P7-2jwUjQ9OmMHyDtqrkTXJv3okCXt1FU_JyD7ZSxIkpCPoNTE5fI2k_H4RkiON_vyAdXQdjjwKPqLyu1SKkJ5Ds-DxvSckEXEhI0SeIloNmevSxvOy7vaO5q6wIGHuohYNF8vFS1rrNeTXYzx6QzAYHhdspfwNSuehJg3doFwzJj05rZHO7doBnndbGmhe0090duAqU1eMOmENY

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[1halfMVsquared]

Did most of the patients in their study receive TXA bolus or bolus with infusion? I'm particularly curious about the group they deemed to be "high risk".

 

[GassYous]

Thanks for sharing I didn't see this yet. We give txa routinely in joints and some spine and I've been a little concerned in people with stents. Didn't think that it would cause an issue but I really don't want an in stent thrombosis or something like that.

 

[nimbus]

Did most of the patients in their study receive TXA bolus or bolus with infusion? I'm particularly curious about the group they deemed to be "high risk".

Most of the doses were 1-2gm so I would guess they were boluses.

 

[nimbus]

Thanks for sharing I didn't see this yet. We give txa routinely in joints and some spine and I've been a little concerned in people with stents. Didn't think that it would cause an issue but I really don't want an in stent thrombosis or something like that.

I think we all shared similar concerns so I’m glad this paper came out.

 

[dchz]

Several critiques:

- Not randomized
- Not prospective
- Single healthcare payer (Premier Healthcare claims)
- Not mortality end point.

But this is one step towards the giving me confidence for a drug that I give at the ortho's medical direction.

 

[zizzer]

That's reassuring. I try to use it whenever possible. They swear they can tell a difference in the blood when it's given and when it's not. It can usually be justified to as a risk vs benefit estimation, as bleeding in a patient with anemia + CAD can also be harmful.

In a patient with seizure history, would you use aminocaproic acid instead?

 

[GassYous]

I think that the risk of seizure is low even for those that a predisposed. So as long as you're not injecting it in the intrathecal space...

 

[zizzer]

I understand that you could probably give it without a seizure, but aren't we in the business of minimizing risk? What is the reasoning for using TXA, a known contributor to decreasing the seizure threshold, over aminocaproic acid?

 

[MirrorTodd]

I understand that you could probably give it without a seizure, but aren't we in the business of minimizing risk? What is the reasoning for using TXA, a known contributor to decreasing the seizure threshold, over aminocaproic acid?

TXA is way easier to say.

 

[nimbus]

I understand that you could probably give it without a seizure, but aren't we in the business of minimizing risk? What is the reasoning for using TXA, a known contributor to decreasing the seizure threshold, over aminocaproic acid?

We switched to TXA when there was a shortage of EACA a few years ago.

 

[GassYous]

I understand that you could probably give it without a seizure, but aren't we in the business of minimizing risk? What is the reasoning for using TXA, a known contributor to decreasing the seizure threshold, over aminocaproic acid?

How many times have you seen it cause a seizure? I've used it hundreds of times and not once. I feel like it is similar to the whole lengthening qtc thing with droperidol.

 

[dchz]

How many times have you seen it cause a seizure? I've used it hundreds of times and not once. I feel like it is similar to the whole lengthening qtc thing with droperidol.

Selection bias alert.

Most of the time you see your patient they have been administered 1 or more anti seizure medicine.

 

[zizzer]

How many times have you seen it cause a seizure? I've used it hundreds of times and not once. I feel like it is similar to the whole lengthening qtc thing with droperidol.

I'm talking about patients with a lower seizure threshold. You've given it to hundreds of patients with epilepsy?

 

[GaseousClay]

Latest orthopedic society guidelines state there are essentially ZERO contradictions to giving TXA for joints. Even someone with existing dvt or ischemic stroke in last year. I refused someone who is actively on anticoag for dvt and they flipped.

 

[GassYous]

I'm talking about patients with a lower seizure threshold. You've given it to hundreds of patients with epilepsy?

Have you seen it cause seizure in any patient?

 

[zizzer]

Have you seen it cause seizure in any patient?

No, but I've been careful to avoid it in patients with seizure history. What's so bad about using EACA instead?

 

[GassYous]

Well now you don't need to avoid it in people with seizure history! Can you push amicar? And it can be hard to use when there's a national shortage of it.

 

[deleted697127]

I understand that you could probably give it without a seizure, but aren't we in the business of minimizing risk? What is the reasoning for using TXA, a known contributor to decreasing the seizure threshold, over aminocaproic acid?

Unfortunately, don’t have access to the full article but this appears to specifically address your concern. Are you concerned with the seizure risk using opiates or local? No -because they have obvious benefit, much like TXA for joints.

Tranexamic acid administration during total joint arthroplasty surgery is not associated with an increased risk of perioperative seizures: a national database analysis | Regional Anesthesia & Pain Medicine

Tranexamic acid administration during total joint arthroplasty surgery is not associated with an increased risk of perioperative seizures: a national database analysis(6 May, 2020)
Meghan A Kirksey, Lauren A Wilson, Megan Fiasconaro, JashvantPoeran, Jiabin Liu, Stavros G Memtsoudis

Abstract
Background Tranexamic acid (TXA) has been used extensively to minimize blood loss in cardiac surgery and more recently in orthopedic surgery. Despite a generally good safety profile, an increased risk of seizures has been observed in patients with cardiac disease. However, this issue has not been adequately addressed in the orthopedic literature.
Methods After institutional review board approval, we queried a large national database to identify patients who had undergone total hip and total knee arthroplasties (2012–2016). Patients were divided based on their exposure to TXA and history of seizures. The main outcome of interest was a perioperative seizure. We conducted univariable comparisons and a multivariable regression analysis to elucidate a potential independent association between TXA administration and seizures in the perioperative period (with or without a history of seizures).
Results TXA was used overall in 45.9% (n=4 21 890) of joint arthroplasty recipients (n=9 18 918), with more frequent use over time. Utilization rates did not differ between those with and without a history of seizures; 42.2% (3487/8252) of patients with a seizure history received TXA. Rates of perioperative seizure were low and did not differ between those who did and did not receive TXA (0.01% vs 0.02%, p=0.11); when subgrouping patients by history of seizures, we found no difference in incidence of perioperative seizures between groups (0.06% vs 0.02%, p=0.39). Our adjusted analysis further confirmed these results.
Conclusion Despite increasing TXA utilization in total joint arthroplasty, we found an overall low seizure incidence. TXA use was not associated with elevated odds of perioperative seizure, even in patients with history of seizure.

 

[vector2]

Well now you don't need to avoid it in people with seizure history! Can you push amicar? And it can be hard to use when there's a national shortage of it.

I've pushed 5g of amicar hundreds of times pre and postbypass

 

[GassYous]

I've pushed 5g of amicar hundreds of times pre and postbypass

Damn. It was a real question because i've never pushed it so good to know. But there have been multiple shortages in the last few years.

 

[zizzer]

Thanks for sharing that study, Dr. SnapperRocks.

 

[Hork Bajir]

Hot off the presses:

Anesthesiology

pubs.asahq.org

Punchline: in cardiac surgery, TXA is effective at decreasing blood loss, but with higher doses (> 20 mg/kg) there are minimal additional gains in hemostasis despite significant increase in seizure risk

 

[anbuitachi]

here we have some non ortho surgeons request txa to decrease bleeding. not even big cases. with the safety of txa, it's hard to say no...
gyn likes it for their cases. have had plastics ask for txa too. however when the expected ebl is <100ml, how much of a use is txa... but i usually give it anyway since contraindications are so few

 

[GassYous]

here we have some non ortho surgeons request txa to decrease bleeding. not even big cases. with the safety of txa, it's hard to say no...
gyn likes it for their cases. have had plastics ask for txa too. however when the expected ebl is <100ml, how much of a use is txa... but i usually give it anyway since contraindications are so few

Which is weird because the woman trial was a negative trial but somehow they decided that txa is some nectar of the gods.

 

[Drangue]

I've pushed 5g of amicar hundreds of times pre and postbypass

We're taught to put it on a 10 minute infusion. I have never read that it does anything if pushed vs infusion. I am pretty sure 10 minutes was entirely an arbitrary number that my attendings chose.

 

[deleted697127]

here we have some non ortho surgeons request txa to decrease bleeding. not even big cases. with the safety of txa, it's hard to say no...
gyn likes it for their cases. have had plastics ask for txa too. however when the expected ebl is <100ml, how much of a use is txa... but i usually give it anyway since contraindications are so few

urology has started asking for it for prostates here

 

[Beeftenderloin]

One of the outside places we go to do hearts in my residency the CT anesthesia folks there routinely give 1g TXA IV push through a central vein at the start of the case. Have been doing it that way for years. Granted these patient are all under GA and have received somewhere between 5 and 20mg of Midaz by that point.

 

[deleted697127]

One of the outside places we go to do hearts in my residency the CT anesthesia folks there routinely give 1g TXA IV push through a central vein at the start of the case. Have been doing it that way for years. Granted these patient are all under GA and have received somewhere between 5 and 20mg of Midaz by that point.

lol nothing like 20mg of midazolam to establish a posts credibility.

 

[GassYous]

lol nothing like 20mg of midazolam to establish a posts credibility.

Maybe he meant 2 😉

 

[Beeftenderloin]

lol nothing like 20mg of midazolam to establish a posts credibility.

Lol, unfortunately not joking. There are some serious old timers there doing cardiac. Very, uh, “old school” approach.

 

[nimbus]

Lol, unfortunately not joking. There are some serious old timers there doing cardiac. Very, uh, “old school” approach.

Curious what the rest of the anesthetic looks like. Is it straight outta 1990?

 

[Guillemot]

It is my understanding that TXA is infused over 10 mins as an instant bolus can cause hypotension.

 

[deleted162650]

It is my understanding that TXA is infused over 10 mins as an instant bolus can cause hypotension.

I’ve never seen it bolusing 1gm for joints.

 

[GassYous]

It is my understanding that TXA is infused over 10 mins as an instant bolus can cause hypotension.

Nah

 

[Guillemot]

I’ve never seen it bolusing 1gm for joints.

This may be due to a different patient population or different dose. For example, per the cardiac TXA study linked in this thread, the high dose TXA regimens gave doses potentially > 10x the amount you are bolusing.

I don't know where or when it was determined that TXA can cause hypotension, and I am not going to try to conduct a search to try to find out because that would take too much time and effort on my part. Maybe someone who reads this thread can comment on this matter.

 

[Beeftenderloin]

Curious what the rest of the anesthetic looks like. Is it straight outta 1990?

Relatively limited echo skills. Can get all the views and know what they’re looking at, but they’re not getting gradients, doing 3D or anything like that. Lean heavily on narcs. Some vapor if the patient tolerates. Lots of deference to surgeon preference when it comes to drips and coming off pump.

These folks are becoming the minority though. Lots of recent hires less than 5 years out of big name fellowships.

 

[Beeftenderloin]

TCCC recently updated their trauma guidelines to include TXA 2 grams slow IV push in the field followed by infusion once patient gets to definitive care.

 

[ChiDO]

Recent ortho study shows no contradictions to give txa IV in all joints patients even those with stents, history of dvt, stroke history, etc.

 

[AnesthAnon]

Push 2g TXA all the time at the beginning of a cardiac case all the time. No issues.