1. The use of Tranexamic Acid to reduce blood loss in paediatric burns: Our institute’s experience Dr Steven Cook, Mr Bernard Carney, Dr  Michelle  Lodge, Dr  Amy Jeeves, Mr Darren Molony, Dr  Rebecca  Cooksey, Ms Linda Quinn
Background
Bleeding and the resultant anaemia are well described complications of tangential excision of major burns. The use of Tranexamic acid (TXA) has been proposed as a method to decrease the volume of blood loss during excision of burns.
TXA is an antifibrinolytic that binds to plasminogen and prevents the breakdown of a fibrin clot, thus aiding in the prevention of fibrinolysis that occurs in trauma and large volume blood loss, thus enhancing clot stabilisation.
TXA was first developed in the 1960’s for treatment of menorrhagia, and has been proven to decrease bleeding and the need for transfusion by up to 33% in many surgical procedures, while significantly decreasing mortality rates in severe trauma cases[1,2,3].
While some smaller studies suggest it may be beneficial in decreasing blood loss in tangential excision[4,5], no large scale studies investigating its efficacy in burns surgery have been published.
Our institution has commenced the use of intravenous administration of Tranexamic acid during excision of large burns in a paediatric population, based on an established institution protocol for craniofacial surgery.
Patients received TXA at a pre-operative loading dose of 15mg/kg and then a continuous infusion at a rate of 5mg/kg/hr until wounds were dressed.
Methods
A retrospective analysis was performed of both the small sample of patients treated with TXA and similar cohort of patients not treated with TXA.
A sample of 20 patients with TBSA >/= to 30% spanning 8 years were randomly selected and reviewed for the number of transfusions and mortality rate during their acute debridement and grafting phases of treatment.
The same data was collected for the 3 patients with TBSA > 30% who received Tranexamic acid.
The TXA group were also examined for episodes of Venous Thromboembolism (VTE), Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE) and seizures, which are known complications of TXA when used in other surgical disciplines[1].
Comparisons were made between overall groups as well as comparisons for patients of similar TBSA%
Results
When the average number of packed red cell transfusions was analysed between the groups, the subjects that didn’t receive TXA averaged 12.8 units of packed cells transfused during their treatment, while the TXA group average 7.6 units transfused (40.6% fewer units)
When average units transfused were analysed for comparative TBSA% between the two groups the results were similar at the lower TBSA%, however at a higher TBSA% the TXA group average fewer transfusions.
None of the patients who received TXA developed at venous thrombotic event or experienced seizures.
The mortality rate in both the TXA group and the non-TXA group was zero.
Discussion
The results of this review have to be interrupted with great care due to the extremely small sample size.
Despite the use TXA to reduce blood loss in burn surgery being in it’s infancy at our institution, the preliminary data suggests that it may be effective in decreasing the volume of blood transfusions required by patients.
Data also showed no adverse effects from the use of TXA in this small sample
Our unit plans to continue the use of TXA in an attempt to decrease blood loss during tangential excision of burns with TBSA approximately 30% or greater
We believe that our preliminary result of the use of Tranexamic acid for the reduction of blood loss during tangential excision of large burns in a paediatric cohort warrants further formal investigation.
We plan to undertake expanded cohort study into blood product usage pre and post our implementation of our tranexamic acid protocol with substantially larger treatment and control groups.
References
CRASH-2 Trial Collaborators, Shakur H, Roberts I, Bautista R, Caballero J, Coats T, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010;376:23.
Napolitano LM, Cohen MJ, Cotton BA, Schreiber MA, Moore EE. Tranexamic acid in trauma: how should we use it? J Acute Care Surg 2013;74:1575–86.
Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ 2012;344:e3054.
Jennes SMD, Degrave EMD, Despiegeleer X, Grenez O. Effect of tranexamic acid on blood loss in burn surgery: a preliminary study: 33. J Burn Care Rehabil 2003; 24:S59.
Tang YMJ, Chapman TWL, Brooks P. Use of tranexamic acid to reduce bleeding in burn surgery. J Plast Reconstr Surg 2011;65:684–6.
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