EA21 Newsletter: Session 12D2 Pro-Con debate: Tranexamic acid for all bleeding patients in the perioperative setting

Sunday December 19, 11:00 – 12:00 – Channel 4

The pro stance in this debate will be presented by Beverley Hunt, Professor of Thrombosis & Haemostasis, Kings College London, Consultant at Guy’s and St Thomas’ NHS Foundation Trust, London and Medical Director of Thrombosis UK.

Prof Hunt will say: “Tranexamic acid (TXA) is a wonderful drug for in multiple large randomised controlled trials when used in low dose and for 8 hours or less, it reduced death due to bleeding by about a third in trauma, post-partum haemorrhage and perioperatively without increasing thrombotic risk.”

Moreover, she explains that in bleeding patients it reduces bleeding by about 30%, which means the use of transfusion is cut, and operation times and length of stay will tend to be shorter. “However to say that it should be used in all surgical procedures is a step too far,” she says. “Firstly it only needs to be used when there is a risk of excessive bleeding: the UK’s National Institute for Health and Care Excellence (NICE) suggests it should be used if > 500mls of blood loss is expected and this seems a sensible cut-off. It is not without its side effects, trials of larger doses and/or used for longer periods of time have shown increased fits and some increase in thrombotic risk. It should not be used in those with haematuria or disseminated intravascular coagulation.”

Prof Hunt concludes: “In summary, we are in a good place with TXA, it is excellent at reducing bleeding when used in low dose and is very safe in this setting.”

The con position in the debate will be presented by Professor Marc Maegele, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Germany.

He will discuss how the results from the CRASH-2, CRASH-3 and WOMAN randomized controlled trials (RCTs) have influenced major clinical guidelines for the treatment of acute bleeding in various settings and have also prompted a rather uncritical use of the antifibrinolytic tranexamic acid (TXA) across a range of indications.

He says: “Subsequent studies, mostly retrospective though, could not reproduce these positive findings and two most recent RCTs on the prehospital use of TXA in patients at risk of haemorrhage or moderate to severe TBI could not find a difference in outcomes versus placebo. Vice-versa, a recent single-centre RCT on the effect of early intravenous two and four-gram bolus dosing of TXA versus placebo showed a dose-dependent increase in thromboembolic events. Substantial uncertainties and knowledge gaps in the clinical use of TXA remain.”

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