Tranexamic acid for treatment and prophylaxis of bleeding and hyperfibrinolysis

Ingrid Pabinger, Dietmar Fries, Herbert Schöchl, Werner Streif, Wolfgang Toller, Ingrid Pabinger, Dietmar Fries, Herbert Schöchl, Werner Streif, Wolfgang Toller

Abstract

Uncontrolled massive bleeding with subsequent derangement of the coagulation system is a major challenge in the management of both surgical and seriously injured patients. Under physiological conditions activators and inhibitors of coagulation regulate the sensitive balance between clot formation and fibrinolysis. In some cases, excessive and diffuse bleeding is caused by systemic activation of fibrinolysis, i. e. hyperfibrinolysis (HF). Uncontrolled HF is associated with a high mortality. Polytrauma patients and those undergoing surgical procedures involving organs rich in plasminogen proactivators (e. g. liver, kidney, pancreas, uterus and prostate gland) are at a high risk for HF. Antifibrinolytics, such as tranexamic acid (TXA) are used for prophylaxis and treatment of bleeding caused by a local or generalized HF as well as other hemorrhagic conditions. TXA is a synthetic lysine analogue that has been available in Austria since 1966. TXA is of utmost importance in the prevention and treatment of traumatic and perioperative bleeding due to the resulting reduction in perioperative blood loss and blood transfusion requirements. The following article presents the different fields of application of TXA with particular respect to indications and dosages, based on a literature search and on current guidelines.

Keywords: Bleeding; Hyperfibrinolysis; Surgery; Tranexamic acid; Trauma.

Conflict of interest statement

W. Toller declares that he has no competing interests. I. Pabinger: payment for lectures and Advisory Board Meetings of Bayer, Boehringer, Biotest, CSL Behring, Pfizer companies. D. Fries: Astra Zeneca, AOP Orphan, Baxter, Bayer, BBraun, Biotest, CSL Behring, Delta Select, Dade Behring, Edwards, Fresenius, Glaxo, Haemoscope, Hemogem, Lilly, LFB, Mitsubishi Pharma, NovoNordisk, Octapharm, Pfizer, Tem-Innovation. H. Schöchl: study grants from CSL Behring and Tem International and speaker fees CSL Behring, Baxter, Baxalta, Bayer, Pfizer and Tem International. W. Streif: payment for lectures and counselling of Bayer, Baxalta, Biotest, CSL-Behring, Octapharma, Orphan Medical, Pfizer companies.

Figures

Fig. 1
Fig. 1
Mortality rate by percent fibrinolysis. Rate of amplitude reduction 30 minutes after the maximum amplitude (LY30) is reached and its correlation to mortality. HF was defined as more than 7.5% amplitude reduction 30 minutes after maximal amplitude (LY30). At an LY30 of 3% or less, 30-day mortality was 9%. However, once the LY30 extended to more than 3%, mortality increased to 20%. Large increases in mortality were also seen at LY30’s of greater than 4% (35%), greater than 5% (58%), and greater than 15% (81%). Reproduced with permission from [6]
Fig. 2
Fig. 2
Cumulative survival of military TXA administration in the overall cohort and in patients with massive transfusion from the Trauma Emergency Resuscitation (MATTERs) Study. (Data from Morrison et al. [12])

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