Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland.
Surgical Critical Care Initiative, Bethesda, Maryland.
JAMA Surg. 2018 Feb 1;153(2):169-175. doi: 10.1001/jamasurg.2017.3821.
Since publication of the CRASH-2 and MATTERs studies, the US military has included tranexamic acid (TXA) in clinical practice guidelines. While TXA was shown to decrease mortality in trauma patients requiring massive transfusion, improper administration and increased risk of venous thromboembolism remain a concern.
To determine the appropriateness of TXA administration by US military medical personnel based on current Joint Trauma System clinical practice guidelines and to determine if TXA administration is associated with venous thromboembolism.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study of US military casualties in US military combat support hospitals in Afghanistan and a single US-based tertiary military treatment facility within the continental United States was conducted from 2011 to 2015, with follow-up through initial hospitalization and readmissions.
Data collected for all patients included demographic information as well as Injury Severity Score; receipt of blood products, TXA, and/or a massive transfusion; and admission hemodynamics.
Variance from guidelines in TXA administration and venous thromboembolism. Tranexamic acid overuse was defined as a hemodynamically stable patient receiving TXA but not a massive transfusion, underuse was defined as a patient receiving a massive transfusion but not TXA, and TXA administration was considered delayed when given more than 3 hours after injury.
Of the 455 identified patients, 443 (97.4%) were male, and the mean (SD) age was 25.3 (4.8) years. A total of 173 patients (38.0%) received a massive transfusion, and 139 (30.5%) received TXA in theater. Overuse occurred in 18 of 282 patients (6.4%) and underuse in 46 of 173 (26.6%) receiving massive transfusions, and delayed administration was found in 6 of 145 patients (4.3%) receiving TXA. Overuse increased at 3.3% per quarter (95% CI, 4.0-9.9; P < .001; R2 = 0.340) and underuse decreased at -4.4% per quarter (95% CI, -4.5 to -3.6; P < .001; R2 = 0.410). Tranexamic acid administration was an independent risk factor for venous thromboembolism (odds ratio, 2.58; 95% CI, 1.20-5.56; P = .02).
Military medical personnel decreased missed opportunities to appropriately use TXA but also increased overuse. In addition, TXA administration was an independent risk factor for venous thromboembolism. A reevaluation of the use of TXA in combat casualties should be undertaken.
自 CRASH-2 和 MATTERs 研究发表以来，美国军方已将氨甲环酸（TXA）纳入临床实践指南。虽然 TXA 已被证明可降低需要大量输血的创伤患者的死亡率，但给药不当和静脉血栓栓塞风险增加仍然令人担忧。
根据当前的联合创伤系统临床实践指南，确定美国军方医务人员使用 TXA 的适当性，并确定 TXA 的使用是否与静脉血栓栓塞有关。
设计、地点和参与者：这是一项对 2011 年至 2015 年期间在阿富汗的美国军事作战支援医院和美国大陆上的一家单一的美国三级军事治疗机构的美国军事伤员的队列研究，随访至首次住院和再次入院。
为所有患者收集的数据包括人口统计学信息以及损伤严重程度评分；接受血液制品、TXA 和/或大量输血；以及入院时的血液动力学。
TXA 给药和静脉血栓栓塞的指南偏差。血流动力学稳定的患者接受 TXA 但未接受大量输血定义为过度使用，接受大量输血但未接受 TXA 定义为使用不足，TXA 给药超过受伤后 3 小时被认为是延迟。
在确定的 455 名患者中，443 名（97.4%）为男性，平均（SD）年龄为 25.3（4.8）岁。共有 173 名患者（38.0%）接受了大量输血，139 名（30.5%）在现场接受了 TXA。过度使用发生在 282 名患者中的 18 名（6.4%），在接受大量输血的 173 名患者中的 46 名（26.6%）中出现了不足，在接受 TXA 的 145 名患者中的 6 名（4.3%）中出现了延迟。每季度过度使用率增加 3.3%（95%CI，4.0-9.9；P<0.001；R2=0.340），每季度使用率减少 4.4%（95%CI，-4.5 至-3.6；P<0.001；R2=0.410）。TXA 给药是静脉血栓栓塞的独立危险因素（比值比，2.58；95%CI，1.20-5.56；P=0.02）。
军事医务人员减少了适当使用 TXA 的机会，但也增加了过度使用的机会。此外，TXA 给药是静脉血栓栓塞的独立危险因素。应该对 TXA 在战斗伤员中的使用进行重新评估。
