Tranexamic Acid Makes Noncardiac Surgery Safer

A hospital policy of giving high transfusion-risk patients tranexamic acid for noncardiac surgery reduced blood transfusions without increasing thromboembolic risk, the TRACTION randomized trial showed.

Hospitals giving tranexamic acid saw 27% fewer red-cell transfusions during hospitalization of these patients compared with placebo (7.4% vs 9.8%, relative risk [RR] 0.73, 95% CI 0.61-0.86), Ryan Zarychanski, MD, of the University of Manitoba in Winnipeg, and colleagues reported in the New England Journal of Medicine.

The rate of venous thromboembolism within 90 days was 2.1% in both groups (RR 0.96, 95% CI 0.65-1.38), which met the criterion for noninferiority, the researchers also reported at the Critical Care Reviews meeting in Belfast, Ireland.

“This concern about thrombosis is one of the main barriers to the use of tranexamic acid and is the reason that the data from the TRACTION trial now reported … are so welcome,” wrote Michael F. Murphy, MBBS, MD, of the University of Oxford in England, and Ian Roberts, MBBCh, PhD, of the London School of Hygiene and Tropical Medicine, in an accompanying editorial.

The data “should encourage its more widespread use,” they wrote. “It may also stimulate consideration of following the lead of the United Kingdom in extending the use of tranexamic acid to surgeries even with a low likelihood of major blood loss or red-cell transfusion.”

Implementation into clinical practice will be key, the editorial argued, noting that even after the U.K. National Institute for Health and Care Excellence made the use of tranexamic acid in adult surgery expected to result in “moderate (>500 ml) blood loss” a quality standard in 2016, about one-third of eligible surgical patients still don’t receive it.

“Strategies based on an understanding of clinical behavior are needed to increase its use and improve patient outcomes,” Murphy and Roberts concluded.

Those might include opinion leadership, training, clinical decision support, and performance feedback as well as adding its use to the World Health Organization’s Safe Surgical Checklist, they suggested.

Findings of the study were first presented last year at the American Society of Hematology annual meeting.

TRACTION included 10 Canadian hospitals that were randomized in 4-week intervals to a hospital-wide policy of intraoperative tranexamic acid or placebo. Outcomes were assessed using linked clinical administrative data for 8,273 adults age 18 and older undergoing inpatient, noncardiac surgeries who were at high (≥5%) risk for transfusion; “such surgeries broadly included open surgeries or laparoscopic surgeries with an estimated duration of at least 3 hours,” the researchers noted.

Exclusions included active thromboembolic disease, pregnancy, and surgeries for which tranexamic acid is routine (cardiac, hip, or knee surgery).

Notably, 5,002 patients were undergoing oncologic surgery — a group often excluded or underrepresented in tranexamic acid trials but which has high risk and limited use of antifibrinolytic agents owing to concerns about prothrombotic risk.

In this subgroup, 90-day venous thromboembolism risk “was low and not increased among those receiving tranexamic acid,” the researchers noted, at 2.4% versus 2.6% in the placebo group (RR 0.92, 95% CI 0.68-1.48), “which provides reassurance that tranexamic acid can be safely administered to patients with cancer undergoing major noncardiac surgery.”

However, the trial included “only a small proportion of patients undergoing vascular surgery, in which use of tranexamic acid is low,” the editorialists added.