We plastic surgeons are a little late to the game here on TXA. (Not terribly late- the publications on the reduction of bleeding with TXA started to be published in late 2017.) But at my national Plastic Surgery Meeting 2020, TXA is out there and being widely used.
What is TXA? TXA is Tranexamic acid. It is an “antifibrinolytic,” which is a fancy way of saying it stops the activation of fibrinolysis. Fibrinolysis is what causes the bleeding. It is a synthetic lysine analog and has been around since 1966. (If you want to get into the weeds about it, TXA prevents conversion of plasminogen to plasmin and inhibits plasmin activity directly. It also blocks inflammatory reactions.)
TXA can be used orally or by IV. It can cross the placenta. It is short lived, with a half life of around 2.3 hours. So far there have been no reports showing serious side efects, not even with high doses or long term use. It is recommended to lower the dose in those with impaired renal clearance.
How was its use started? One of the biggest issues for trauma and surgery is blood loss. When you have uncontrolled massive bleeding, it can trigger a reaction in your body which disrupts the coagulation system in your body. In English, the coagulation system is what helps your blood clot, so you stop bleeding. If this system gets disrupted, you can’t clot your blood. That is a big problem.
When there is massive bleeding and your body’s blood clotting goes awry, it is an independent predictor of mortality. With bleeding around childbirth, this coagulation issue can lead to maternal death. What you really don’t want is what they call the “lethal triad”- coagulation disruption (called hyperfibrinolysis), hypothermia, and acidosis.
A form of this was used in the past, but was removed from the market due to massive side effects. You can also imagine something which helps you clot is good if you are bleeding, but if you are not, you would worry it would increase blood clots- DVT and pulmonary emboli- which are also a huge surgical risk.
What can it be used for? The journal article listed HERE goes into detail.
- Severe trauma. One study showed it can significantly increase the rate of survival. The WHO added it to the list of “essential medicines.” The more pronounced the shock in trauma patients, the more disrupted their coagulation is.
- Postpartum hemorrhage. TXA has been shown to decrease the amount of bleeding, time to stop bleeding, and need for transfusion.
- Menometrorrhagia (Yup. fancy name for heavy periods). Some people have blood disorders which prevent them from clotting so they have SUPER heavy periods, and can become anemic. Von Willebrand disease, platelet dysfunction, and other issues.
- GI bleeding. People with ulcers in their GI tract can bleed.
FOR SURGERY: TXA has been used for longer in orthopedic surgery. Think of total knee or hip replacement, where there is a fair amount of blood loss and frequent need for blood transfusions.
- Perioperative blood loss. For large surgeries which required transfusion, the TXA use and resulting decline in blood loss has reduced the need for transfusing blood.
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- In one orthopedic study on knee replacements, the TXA group had zero blood transfusions, while the placebo group had a 32% rate of transfusion. There was no increase seen in blood clots (DVT/PE) in most patients.
- A hip study showed there were some patients who should not use TXA- pre existing history of blood clots, hip fracture or cancer surgery, age over 60, and women.)
- Cardiac bypass surgery.
- Liver transplant surgery.
- Prostate surgery
- Gyne oncology surgery
- Pediatric surgery *though it has not been fully established for the entire range of indications.
- Nose bleeds
- Tonsillectomy
- Neurosurgery and subarachnoid bleeds. (When they had an aneurysm bleed, it reduced the mortality risk due to early rebleeding by 80%!)
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CONTRAINDICATIONS TO TXA:
- Renal failure
- Epilepsy
- Benign gynecological surgery
- Fibrinolysis without significant bleeding
My thoughts?
At my recent Plastic Surgery meeting, TXA is being widely used. In the past people were fearful- we do many surgeries which we worry about blood clots- DVT and pulmonary emboli. And to be honest, big real bleeds in my practice are super rare. I can count the number of patients I have had to transfuse on one hand in my 25 year career and thousands of surgeries.
But what plastic surgeons are saying is they see less blood loss and less bruising. This translates to faster recoveries, less swelling, and less pain.
I’m in.