Severely Injured Trauma Patients With Admission Hyperfibrinolysis; Is There A Role Of Tranexemic Acid? (Lima)

Khan M, et al. Severely Injured Trauma Patients With Admission Hyperfibrinolysis; Is There A Role Of Tranexemic Acid? Findings From The PROPPR Trial. J Trauma Acute Care Surg. 2018 Feb 5. [Epub ahead of print]

INTRODUCTION: Administration of tranexemic acid (TXA) in coagulopathy-of-trauma (COT) gained popularity after the CRASH-2 trial. The aim of our analysis was to analyze the role of TXA in severely injured trauma patients with admission hyperfibrinolysis.

METHODS: We reviewed the prospectively collected Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) database. We included patients with admission hyperfibrinolysis (Ly30>3%) on thromboelastography. Patients were stratified into two groups (TXA and No-TXA) and were matched in 1:2 ratio using propensity score matching for demographics, admission vitals, and injury severity. Primary outcome measures were 6h, 12h, 24hr, and 30d mortality, 24-hour transfusion requirements, time to achieve hemostasis and re-bleeding after hemostasis requiring intervention. Secondary outcome measures were thrombotic complications.

RESULTS: We analyzed 680 patients. Of those, 118 had admission hyperfibrinolysis, and 93 patients (TXA: 31; No-TXA: 62) were matched. Matched groups were similar in age (p=0.33), gender (p=0.84), race (p=0.81), emergency department (ED) Glasgow coma scale (p=0.34), ED systolic blood pressure (p=0.28), ED heart rate (p=0.43), mechanism of injury (p=0.45), head-AIS (p=0.68), ISS (p=0.56), and blood products ratio (p=0.44). Patients who received TXA had a lower 6-hour mortality rate (34% vs. 13%, p=0.04) and higher 24h transfusion of plasma (15 units vs. 10 units, p=0.03) compared to the No-TXA group. However, there was no difference in 12h (p=0.24), 24h (p=0.25), and 30d mortality (p=0.82). Similarly, there was no difference in 24h transfusion of RBC (p=0.11) or platelets (p=0.13), time to achieve hemostasis (p=0.65), re-bleeding requiring intervention (p=0.13), and thrombotic complications (p=0.98).

CONCLUSION: Tranexamic acid (TXA) was associated with increased 6 hour survival but does not improve long term outcomes in severely injured trauma patients with hemorrhage who develop hyperfibrinolysis. Moreover, TXA administration was not associated with thrombotic complications. Further randomized clinical trials will identify the subset of trauma patients which may benefit from TXA.

LEVEL OF EVIDENCE: Level-III, Therapeutic studies.

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