Highlights
- •We conducted a systematic review and meta-analysis on studies that compared standard dose with high dose IV TXA, defined as ≥2g or ≥30mg/kg as a single bolus, in adults (≥ 16 years of age) with hemorrhage.
- •When compared to standard dose, high dose IV TXA probably reduces transfusion requirements (OR, 0.86; 95% CI, 0.76-0.97; p = 0.01) with an uncertain effect on thromboembolic events and mortality.
- •Despite an uncertain effect on mortality, high dose TXA may be able to play an integral role in survival, particularly when the risk of exsanguination is high.
Abstract
Background
Standard dose (≤ 1g) tranexamic acid (TXA) has established mortality benefit in trauma
patients. The role of high dose IV TXA (≥2g or ≥30mg/kg as a single bolus) has been
evaluated in the surgical setting, however, it has not been studied in trauma. We
reviewed the available evidence of high dose IV TXA in any setting with the goal of
informing its use in the adult trauma population.
Methods
We searched MEDLINE, EMBASE and unpublished sources from inception until July 27,
2022 for studies that compared standard dose with high dose IV TXA in adults (≥ 16
years of age) with hemorrhage. Screening and data abstraction was done independently
and in duplicate. We pooled trial data using a random effects model and considered
randomized controlled trials (RCTs) and observational cohort studies separately. We
assessed the individual study risk of bias using the Cochrane Risk of Bias for RCTs
and the Newcastle-Ottawa Scale for observational cohort studies. The overall certainty
of evidence was assessed using the GRADE approach (Grading of Recommendations Assessment,
Development and Evaluation).
Results
We included 20 studies with a combined total of 12,523 patients. Based on pooled RCT
data, and as compared to standard dose TXA, high dose IV TXA probably decreases transfusion
requirements (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.76 to 0.97, moderate
certainty) but with possibly no effect on blood loss (mean difference [MD] 43.31 ml
less, 95% CI 135.53 to 48.90ml less, low certainty), and an uncertain effect on thromboembolic
events (OR 1.33, 95% CI 0.86 to 2.04, very low certainty) and mortality (OR 0.70,
95% CI 0.37 to 1.32, very low certainty).
Conclusion
When compared to standard dose, high dose IV TXA probably reduces transfusion requirements
with an uncertain effect on thromboembolic events and mortality.
Level of Evidence
Systematic review and meta-analysis, level IV.
Key words
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Article info
Publication history
Accepted:
December 29,
2022
Received in revised form:
December 23,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2023 Elsevier Ltd. All rights reserved.
