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Radoeshki A.1, Shosholcheva M.2, Kostadinovska Jordanoska B.1, Nikolikj A.1, Stefanovski I.1, Bedzeti F.1
1Acibadem Sistina Hospital, Department of Cardiac Surgery, Skopje, N. Macedonia
2Faculty of Medicine, Department of Anaesthesia and Intensive Care, “Ss. Cyril and Methodius” University – Skopje
| Shosholcheva Mirjana | https://orcid.org/0000-0003-1677-7482 |
| Nikolkj Aleksandar | https://orcid.org/0009-0008-7481-7669 |
Abstract
Introduction: Postoperative bleeding is a frequent and clinically significant complication after cardiac surgery due to its invasive nature, cardiopulmonary bypass, and perioperative anticoagulation. Excessive bleeding is associated with re-exploration, prolonged intensive care unit stay, increased morbidity, and increased mortality. Antifibrinolytic therapy, particularly tranexamic acid (TXA), is strongly recommended to reduce bleeding and transfusion requirements, yet the optimal dosing strategy remains uncertain.
Aim: To assess the influence of three different doses of TXA on early and total postoperative bleeding in non-anaemic patients undergoing on-pump cardiac surgery.
Material and Methods: Prospective, randomized, single-center study of 180 non-anaemic patients, randomized in three TXA dosing groups: low-dose 20mg/kg, medium-dose 35mg/kg, and high-dose 50mg/kg. The following outcomes were monitored: postoperative bleeding at 4, 12, and 24 hours, total postoperative bleeding, and surgical revision due to bleeding or cardiac tamponade.
Results: Bleeding volumes did not differ significantly between TXA dosing groups at any predefined postoperative interval (0–4 hours, p = 0.470; 4–12 hours, p = 0.853; 12–24 hours, p = 0.199), nor did the cumulative bleeding volumes differ within 24 hours (p = 0.647) or the total postoperative bleeding volumes (p = 0.758). In multivariable models, the TXA dose was not an independent predictor of early postoperative bleeding, neither there are significant differences for low-dose (B = 0.136, p = 0.214) nor for medium-dose TXA (B = 0.182, p = 0.087) compared with the high-dose group. Similarly, the TXA dose was not associated with total postoperative bleeding (low-dose: B = 0.019, p = 0.785; medium-dose: B = −0.011, p = 0.870). Aortic valve surgery was associated with significantly lower total postoperative bleeding compared with combined procedures (B = −0.393, 95% CI −0.592 to −0.194; p < 0.001).
Conclusion: These findings do not support routine escalation of tranexamic acid dosing.
Key Words: Cardiac surgery; Postoperative bleeding; Tranexamic acid.
References:
1. Karkouti K, Wijeysundera DN, Yau TM et al. The independent association of massive blood loss with mortality in cardiac surgery. Transfusion. 2004;44(10):1453–62,
2. Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Pagano D; Task Force on Patient Blood Management for Adult Cardiac Surgery of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Cardiothoracic Anaesthesiology (EACTA). 2017 EACTS/EACTA guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth. 2018;32(1):88-120. doi:10.1053/j.jvca.2017.06.026.
3. Stover EP, Siegel LC, Parks R et al. Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study. Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology. 1998 Feb;88(2):327-33. doi: 10.1097/00000542-199802000-00009. PMID: 9477051,
4. Guideline on haemoglobin cutoffs to define anaemia in individuals and populations. Geneva: World Health Organization; 2024. Licence: CC BY-NC-SA 3.0 IGO,
5. Menkis AH, Martin J, Cheng DC et al. Drug, devices, technologies, and techniques for blood management in minimally invasive and conventional cardiothoracic surgery: a consensus statement from the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) 2011. Innovations (Phila). 2012 Jul-Aug;7(4):229-41. doi: 10.1097/IMI.0b013e3182747699. PMID: 23123988,
6. Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, et al. Guidelines for perioperative care in cardiac surgery: Enhanced Recovery After Surgery Society recommendations. JAMA Surg. 2019;154(8):755-7jamasurg. 0.1001/jamasurg.2019.1153.
7. Zufferey PJ, Lanoiselée J, Graouch B, Cazenave JP, Billaud P, Durand M, et al. Exposure-response relationship of tranexamic acid in cardiac surgery. Anesthesiology. 2021;134(2):165-178. doi:10.1097/ALN.0000000000003633.
8. Guo, J., Gao, X., Ma, Y. et al. Different dose regimes and administration methods of tranexamic acid in cardiac surgery: a meta-analysis of randomized trials. BMC Anesthesiol 19, 129 (2019). https://doi.org/10.1186/s12871-019-0772-0,
9. Sigaut S, Tremey B, Ouattara A et al. Comparison of two doses of tranexamic acid in adults undergoing cardiac surgery with cardiopulmonary bypass. Anesthesiology. 2014 Mar;120(3):590-600. doi: 10.1097/ALN.0b013e3182a443e8. PMID: 23903022,
10. Rangwala HS, Rangwala BS, Alotaibi M, Bansal A, Patel K, Sharma R, et al. Clinical outcomes with high versus low-dose tranexamic acid infusion in patients undergoing cardiac surgery: a systematic review and meta-analysis. Thorac Cardiovasc Surg. 2025;73(5):346-359. doi:10.1055/s-0044-1791233.
11. Shi J, Zhou C, Pan W, Li H, He Y, Zhang Y, et al. Effect of high- vs low-dose tranexamic acid infusion on need for red blood cell transfusion and adverse events in patients undergoing cardiac surgery: the OPTIMAL randomized clinical trial. JAMA. 2022;328(4):336-347. doi:10.1001/jama.2022.10725.
12. Armellin G, Vinciguerra A, Bonato R et al. Tranexamic acid in primary CABG surgery: high vs low dose. Minerva Anestesiol. 2004 Mar;70(3):97-107. PMID: 14997082,
13. Myles PS, Smith JA, Forbes A, Silbert B, Jayarajah M, Painter T, et al.; ATACAS Investigators of the ANZCA Clinical Trials Network. Tranexamic acid in patients undergoing coronary-artery surgery. N Engl J Med. 2017;376(2):136-148. doi:10.1056/NEJMoa1606424.