Rahman GHAFARI, Narges SHARIFI, Mahmoud NOURAEI, Afshin BARADARI GHOLIPOUR, Mohammad Reza HABIBI2, Amir ZEYDI EMAMI

Decreasing blood loss and the need for transfusion after CABG surgery: a double-blind randomized clinical trial of topical tranexamic acid

Reopening sternotomy to control bleeding after coronary artery bypass grafting surgery (CABG) has been reported in 2%-7% of cases. Platelet dysfunction and activation of fibrinolytic cascade are the common causes of bleeding after on-pump CABG. Different antifibrinolytic drugs have been used to reduce bleeding. In this study, we aimed to investigate the efficacy of topical tranexamic acid in reducing postoperative mediastinal bleeding after CABG. Materials and methods: This was a double-blind placebo-controlled randomized clinical trial on 40 patients as the control and another 40 patients as the study group. On completion of CABG before sternotomy wound closure, tranexamic acid (2 g/20 mL) or placebo (20 mL of saline) was diluted in 500 mL of warm saline (37 °C), poured into the pericardial cavity, and left for 5 min. Results: There was no significant difference in baseline demographic data and laboratory results between the 2 groups (P > 0.05). Mediastinal bleeding and packed red cell transfusion requirements were significantly lower in the study group (P =< 0.01). There were no complications related to topical tranexamic such as mortality, myocardial infarction, cerebrovascular accident, seizure, or renal failure. Conclusion: Topical tranexamic acid can reduce mediastinal bleeding and packed red cell transfusion requirements after CABG.

Anahtar Kelimeler:

Key words: Bypass surgery, coronary artery, tranexamic acid, postoperative hemorrhage

Decreasing blood loss and the need for transfusion after CABG surgery: a double-blind randomized clinical trial of topical tranexamic acid

Keywords:

Key words: Bypass surgery, coronary artery, tranexamic acid, postoperative hemorrhage,

PDF

___

Bostan M, Şatıroğlu Ö, Uydu HA, Çiçek Y, Çanga A, Karadağ Z et al. Distribution of coronary artery risk factors: a regional analysis. Turk J Med Sci 2011; 41: 317–24.
Nalysnyk L, Fahrbach K, Reynolds MW, Zhao SZ, Ross S. Adverse events in coronary artery bypass graft (CABG) trials: a systemic review and analysis. Heart 2003; 89: 767–72.
Santos AT, Kalil RA, Bauemann C, Pereira JB, Nesralla IA. A randomized double-blind and placebo-controlled study with tranexamic acid of bleeding and fibrinolytic activity after primary coronary bypass grafting. Braz J Med Biol Res 2006; 39: 63–9.
Pleym H, Stenseth R, Wahba A, Bjella L, Karevold A, Dale O. Single dose tranexamic acid reduces post-operative bleeding after coronary surgery in patients treated with aspirin until surgery. Anesth Analg 2003; 96: 923–8.
Andreasen J, Nielson C. Prophylactic tranexamic acid in elective, primary coronary artery bypasses surgery using cardiopulmonary bypass. Eur J Cardiothorac Surg 2004; 26: 311–
Snyder-Ramos SA, Mohnle P, Weng YS, Bottiger BW, Kulier A, Levin J et al. The ongoing variability in blood transfusion practices in cardiac surgery. Transfusion 2008; 48: 1284–99.
Fawzy H, Elmistekawy E, Bonneau D, Latter D, Errett L. Can local application of tranexamic acid reduce postcoronary bypass surgery blood loss? A randomized controlled trial. J Cardiothorac Surg 2009; 4: 25.
Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth 2010; 105: 401–16.
Ünlü Y, Tekin SB, Koçak H. Levels of protein c and protein s, tissue-plasminogen activator, and fibrinogen during cardiopulmonary bypass. Turk J Med Sci 2007; 37: 345–50.
Hertfelder HJ, Bos M, Weber D, Winkler K, Hanfland P, Preusse CJ. Perioperative monitoring of primary and secondary hemostasis in coronary artery bypass grafting. Semin Thromb Hemost 2005; 31: 426–40.
Engoren MC, Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ. Effect of blood transfusion on long-term survival after cardiac operation. Ann Thorac Surg 2002; 74: 1180–6.
Jimenez Rivera JJ, Iribarren JL, Raya JM, Nassar I, Lorente L, Perez R et al. Factors associated with excessive bleeding in cardiopulmonary bypass patients: a nested case-control study. J Cardiothorac Surg 2007; 2: 17.
Jakobsen CJ, Ryhammer PK, Tang M, Andreasen JJ, Mortensen PE. Transfusion of blood during cardiac surgery is associated with higher long-term mortality in low-risk patients. European J Cardiothorac Surg 2012; 42: 114–20.
Paone G, Brewer R, Theurer PF, Bell GF, Cogan CM, Prager R et al. Preoperative predicted risk does not fully explain the association between red blood cell transfusion and mortality in coronary artery bypass grafting. J Thorac Cardiovasc Surg 2012; 143: 178–85.
Christensen MC, Krapf S, Kempel A, Heymann CV. Costs of excessive postoperative hemorrhage in cardiac surgery. J Thorac Cardiovasc Surg 2009; 138: 687–93.
Mehr-Aein A, Davoodi S, Madani Givi M. Comparison of effects of auto transfusion and tranexamic acid on post cardiopulmonary bypass bleeding. Tehran Univ Med J 2003; 61: 450–6.
Ipema HJ. Use of topical tranexamic acid or aminocaproic acid to prevent bleeding after major surgical procedures. Ann Pharmacother 2012; 46: 97–107.
Zuffery P, Merquiol F. Do antifibrinolytics reduce allogeneic transfusion in orthopedic surgery? Anesthesiology 2006; 105: 1034–46.
Samama CM. Aprotinin and major orthopedic surgery. Eur Spine J 2004; 13: S1–6.
Clark AD, Gordon WC, Walker ID, Tait RC. ‘Last-ditch’ use of recombinant factor VIIa in patients with massive haemorrhage is ineffective. Vox Sang 2004; 86: 120–4.
Erstad BL. What is the evidence for using hemostatic agents in surgery? Eur Spine J 2004; 13: S1–28.
Abrishami A, Chung F, Wong J. Topical application of antifibrinolytic drugs for on-pump cardiac surgery: a systemic review and meta-analysis. Can J Anaesth 2009; 56: 202–12.
Mehr-Aein A, Sadeghi M, Madani-civi M. Does tranexamic acid reduce blood loss in off-pump coronary artery bypass? Asian Cardiovasc Thorac Ann 2007; 15: 285–9.
Adler Ma SC, Brindle W, Burton G, Gallacher S, Hong FC, Manelius I et al. Tranexamic acid is associated with less blood transfusion in off-pump coronary artery bypass graft surgery: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth 2011; 25: 26–35.
Dryden PJ, O’Connor JP, Jamieson WR, Reid I, Ansley D, Sadeghi H et al. Tranexamic acid reduces blood loss and transfusion in reoperative cardiac surgery. Can J Anaesth 1997: 44: 913–7.
De Bonis M, Cavaliere F, Alessandrini F, Lapenna E, Santarelli F, Moscato U et al. Topical use of tranexamic acid in coronary artery bypass operation: a double-blind, prospective, randomized, placebo-controlled study. J Thorac Cardiovascular Surg 2000; 119: 575–80.
Abdul-Azm A, Abdullah KM. Effect of topical tranexamic acid in open heart surgery. Eur J Anaesthesiol 2006; 23: 380–4.
Ghaffari Nejad MH, Baharestani B, Esfandiari R, Hashemi J, Panahipoor A. Evaluation and comparison of using lowdose aprotinin and tranexamic acid in CABG: a double blind randomized clinical trial. J Teh Univ Heart Ctr 2012; 7: 15–8.
Spegar J, Vanek T, Snircova J, Fajt R, Straka Z, Pazderkova P et al. Local and systemic application of tranexamic acid in heart valve surgery: a prospective, randomized, double blind LOST study. J Thromb Thrombolysis 2011; 32: 303–10.
Baric D, Biocina B, Unic D, Sutlic Z, Rudez I, Vrca VB et al. Topical use of antifibrinolytic agents reduces postoperative bleeding: a double-blind, prospective, randomized study. Eur J Cardiothorac Surg 2007; 31: 366–71.
Bell D, Marasco S, Almeida A, Rowland M. Tranexamic acid in cardiac surgery and postoperative seizures: a case report series. Heart Surg Forum 2010; 13: E257–9.
Murkin JM, Falter F, Granton J, Young B, Burt C, Chu M. Highdose tranexamic acid is associated with nonischemic clinical seizures in cardiac surgical patients. Anesth Analg 2010; 110: 350–
Montes FR, Pardo DF, Carreño M, Arciniegas C, Dennis RJ, Umaña JP. Risk factors associated with postoperative seizures in patients undergoing cardiac surgery who received tranexamic acid: a case-control study. Ann Card Anaesth 2012; 15: 6–12.
Manji RA, Grocott HP, Leake J, Ariano RE, Manji JS, Menkis AH et al. Seizures following cardiac surgery: the impact of tranexamic acid and other risk factors. Can J Anaesth 2012; 59: 6–13.