TXA Improves Cuagulopathy in Troops Injured in Battle

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The use of Tranexamic Acid (TXA) with blood component-based resuscitation following combat injury results in improved measures of cuagulopathy and survival, a recent study has concluded, leading to the use of the agent in casualty care for U.S. troops.

For the study, U.S. and British military researchers sought to characterize the use of tranexamic acid (TXA) in combat injury and to assess the effect of its administration on total blood-product use, thromboembolic complications and mortality.1

“We think it is fairly significant,” Air Force Col. Todd Rasmussen, deputy commander of the U.S. Army Institute of Surgical Research and the U.S. primary investigator for the study, told U.S. Medicine. “It is the first time that, at least we are aware of, the use of TXA has been looked at in those who are injured in combat. It is also significant because it is one of the first comprehensive collaborations between the U.S. and British military surgical research entities. We feel like it was a true international collaboration with them.”

TXA has been used by the U.K. Defence Medical Service since 2009 as part of a massive transfusion protocol, but the U.S. combat-casualty program was not using it.  The British started using TXA after a study, the CRASH-2 trial, was published in 2010 demonstrating that the antifibrinolytic agent TXA resulted in reduced mortality following civilian trauma.

Rasmussen explained that the U.S. Combat Casualty Care program deferred at the time on using the agent for combat injuries, largely because there still was debate “about the applicability of CRASH-2 findings to those wounded in combat.”

Although the U.S. was not using TXA, their British counterparts in theater were having success with it, which led to further studies.

The thinking was “if we were not going to use it, we better study its effectiveness in the best way we know,” Rasmussen recounted.

For the study, researchers conducted a retrospective observational study comparing TXA administration with no TXA in patients receiving at least 1 unit of packed red blood cells. The researchers also examined a subgroup of patients receiving massive transfusion. The study participants included a total of 896 consecutive patient admissions with combat injury, of which 293 received TXA. The patients were identified from prospectively collected U.K. and U.S. trauma registries.

Researchers found that the TXA group had lower unadjusted mortality than the no-TXA group, despite being more severely injured. This benefit was greatest in the group of patients who received massive transfusion (14.4% vs 28.1%, respectively; P = .004), where TXA also was independently associated with survival (odds ratio = 7.228; 95% CI, 3.016-17.322) and less coagulopathy (P = .003).

The researchers concluded that the use of TXA with blood component-based resuscitation following combat injury “results in improved measures of coagulopathy and survival, a benefit that is most prominent in patients requiring massive transfusion.” The researchers wrote that treatment with TXA, “should be implemented into clinical practice as part of a resuscitation strategy following severe wartime injury and hemorrhage.”

“I think the main takeaway is that the use of this medication as an adjunct to resuscitation in [patients who are] severely injured does result in a survival benefit,” Rasmussen said. “I think it is important to note that this study has some limitations; it is a retrospective study. So, I think the other takeaway is that, like many studies of this type, they really put out a call for additional research to confirm or refute or refine the findings of this retrospective study.”

Rasmussen said that, because the study was published online, the U.S. has begun using TXA in combat-casualty care, though research continues.

“We are currently monitoring its use currently through the Joint Trauma System and the Joint Trauma Registry. If a patient now gets this medication downrange, their clinical course is charted and their outcomes are followed, just like a multitude of strategies that are implemented in casualty care,” he said.

1: Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012 Feb;147(2):113-9. Epub 2011 Oct 17. PubMed PMID: 22006852.

Best AntiCoagulation Clinics Share Some Characteristics

A recent VA study sought to compare the organization and management of top-performing anticoagulation clinics (ACCs) with that of bottom-performing ACCs.1

For the study, three high outlier and three low outlier ACCs were studied at VA. The researchers conducted site visits with qualitative data collection and analysis.

“We conducted semi-structured interviews with ACC staff regarding work flow, staffing, organization and quality-assurance efforts. We also observed ACC operations and collected documents, such as the clinic protocol. We used grounded thematic analysis to examine site-level factors associated with high and low outlier status,” the authors wrote.

The study found that the high outlier sites were characterized by six characteristics: (1) adequate (pharmacist) staffing and effective use of (nonpharmacist) support personnel; (2) innovation to standardize clinical practice around evidence-based guidelines; (3) the presence of a quality champion for the ACC; (4) higher staff qualifications; (5) a climate of ongoing group learning; and (6) internal efforts to measure performance.

“Although high outliers had all of these features, no low outlier had more than two of them,” the authors wrote.

Researchers concluded that the top-performing ACCs in the VA system “shared six relatively recognizable characteristics. Efforts to improve performance should focus on these domains.”

1: Rose AJ, Petrakis BA, Callahan P, Mambourg S, Patel D, Hylek EM, Bokhour BG. Organizational Characteristics of High- and Low-Performing Anticoagulation Clinics in the Veterans Health Administration. Health Serv Res. 2012 Feb 2. doi: 10.1111/j.1475-6773.2011.01377.x. [Epub ahead of print] PubMed PMID: 22299722.

Small Study Finds MRDH Is Effective in Controlling Bleeding

A recent study examined 30 consecutive uses of the modified rapid deployment hemostat (MRDH) during combat operations in Iraq. 1

“Topical hemostatic agents have generated intense research interest in recent years, prompted in part by the demands of wartime medicine. Numerous animal studies demonstrate variable degrees of efficacy of a variety of agents; however, little clinical data are available in severely traumatized patients,” researchers wrote.

For the study, investigators looked at patients presenting to a combat support hospital or a forward surgical team with difficult-to-control hemorrhage and who had the MRDH applied to their wounds. They recorded basic demographics, wounding mechanism, wound characteristics, circumstance and efficacy, as well as the presence of a clinical coagulopathy.

A total of 30 hemostatic bandages applied to 19 patients — all but one in the operating room — where conventional interventions had failed to stop bleeding. Hemostasis was achieved in 16 of 19 wounds, with re-bleeding occurring upon removal in three cases.

This is the single largest description of the clinical efficacy of the MRDH and the first description during combat operations,” the researchers wrote. “The MRDH bandage was an effective hemostat for temporarily controlling hemorrhage in difficult circumstances. Caution should be exercised when removing the dressing, as re-bleeding may occur.”

1: King DR. Thirty consecutive uses of a hemostatic bandage at a US Army combat
support hospital and forward surgical team in Operation Iraqi Freedom. J Trauma.
2011 Dec;71(6):1775-8. PubMed PMID: 22182888.

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