From the Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery (M.K., F.J., T.O., B.J.), College of Medicine, University of Arizona, Tucson, Arizona; Division of Trauma and Critical Care, Department of Surgery (E.M.B.), School of Medicine, University of Washington, Seattle, Washington; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (J.B.H., C.E.W.), Medical School, University of Texas Health Science Center, Houston, Texas; and Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery (M.A.S.), School of Medicine, Oregon Health & Science University, Portland, Oregon.
J Trauma Acute Care Surg. 2018 Nov;85(5):851-857. doi: 10.1097/TA.0000000000002022.
Administration of tranexamic acid (TXA) in coagulopathy of trauma 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.
We reviewed the prospectively collected Pragmatic, Randomized Optimal Platelet and Plasma Ratios 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 6-, 12-, and 24-hour and 30-day mortality; 24-hour transfusion requirements; time to achieve hemostasis; and rebleeding after hemostasis requiring intervention. Secondary outcome measures were thrombotic complications.
We analyzed 680 patients. Of those, 118 had admission hyperfibrinolysis, and 93 patients (TXA: 31 patients; No-TXA: 62 patients) 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 Abbreviated Injury Scale score (p = 0.68), injury severity score (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 24-hour transfusion of plasma (15 vs. 10 units, p = 0.03) compared with the No-TXA group. However, there was no difference in 12-hour (p = 0.24), 24-hour (p = 0.25), and 30-day mortality (p = 0.82). Similarly, there was no difference in 24-hour transfusion of RBC (p = 0.11) or platelets (p = 0.13), time to achieve hemostasis (p = 0.65), rebleeding requiring intervention (p = 0.13), and thrombotic complications (p = 0.98).
Tranexamic acid 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 who may benefit from TXA.
Therapeutic study, level III.
在 CRASH-2 试验后，氨甲环酸（TXA）在创伤性凝血病中的应用得到了广泛关注。我们分析的目的是分析 TXA 在入院时存在纤溶亢进的严重创伤患者中的作用。
我们回顾了前瞻性收集的实用、随机最佳血小板和血浆比例数据库。我们纳入了入院时纤溶亢进（Ly30＞3%）的血栓弹性描记术患者。患者分为两组（TXA 组和非-TXA 组），并使用倾向评分匹配进行 1：2 匹配，匹配因素包括人口统计学、入院生命体征和损伤严重程度。主要观察指标为 6、12 和 24 小时及 30 天死亡率；24 小时输血需求；达到止血的时间；止血后需要干预的再出血。次要观察指标为血栓并发症。
我们分析了 680 名患者。其中 118 例入院时存在纤溶亢进，93 例（TXA 组：31 例；非-TXA 组：62 例）进行了匹配。匹配组在年龄（p=0.33）、性别（p=0.84）、种族（p=0.81）、急诊室（ED）格拉斯哥昏迷量表（p=0.34）、ED 收缩压（p=0.28）、ED 心率（p=0.43）、损伤机制（p=0.45）、头部损伤严重程度评分（p=0.68）、损伤严重程度评分（p=0.56）和血液制品比例（p=0.44）方面相似。与非-TXA 组相比，接受 TXA 治疗的患者 6 小时死亡率较低（34% vs. 13%，p=0.04），24 小时血浆输血量较高（15 单位 vs. 10 单位，p=0.03）。然而，12 小时（p=0.24）、24 小时（p=0.25）和 30 天死亡率无差异（p=0.82）。同样，24 小时红细胞（p=0.11）或血小板（p=0.13）输血、达到止血的时间（p=0.65）、需要干预的再出血（p=0.13）和血栓并发症（p=0.98）无差异。
氨甲环酸可增加 6 小时生存率，但不能改善发生纤溶亢进的严重创伤性出血患者的长期预后。此外，TXA 给药与血栓并发症无关。进一步的随机临床试验将确定可能从 TXA 中获益的创伤患者亚组。
治疗性研究，III 级。
