Patient Blood Management Guidelines: Module 1

Critical Bleeding Massive Transfusion

| Clinical practice guidance based on evidence or consensus |

4.9 Effect of tranexamic acid

The systematic review did not assess the effect of antifibrinolytic therapy in critically bleeding patients requiring massive transfusion. However, a recently published RCT has demonstrated improved survival in trauma patients who received tranexamic acid.7 (See Appendix 5 of Volume 1 of the technical report.2) In this international, multicentre RCT of more than 20 000 patients, tranexamic acid (loading dose 1 g over 10 minutes, followed by infusion of 1 g over 8 hours) demonstrated a significant reduction in:

  • all-cause mortality at 4 weeks after injury (14.5% vs. 16.0%; relative risk [RR] = 0.91, 95%CI: 0.85, 0.97; p = 0.0035)
  • risk of death from bleeding (4.9% vs. 5.7%, RR = 0.85; 95%CI: 0.76, 0.96; p = 0.0077).

The study population was beyond the scope of this module (i.e. it was not restricted to those with critical bleeding requiring massive transfusion), and the study was published after the deadline for this review. Nevertheless, the CRG considers the results to be noteworthy and suggests that tranexamic acid should be considered in trauma patients with, or at risk of, significant haemorrhage. Tranexamic acid should be considered as an adjunct in these patients, not as a ‘magic bullet’. It should be administered as part of a locally adapted MTP in the setting of overall patient management, including strict attention to the control of bleeding, physiological and metabolic parameters, coagulation status and temperature maintenance.

The effect of antifibrinolytic therapy will be covered in other modules of these guidelines.

In trauma patients with, or at risk of, significant haemorrhage, tranexamic acid (loading dose 1 g over 10 minutes, followed by infusion of 1 g over 8 hours) should be considered.

The CRASH 2 trial7 was published on 14 June 2010 after the cut-off date of the systematic review. No systematic review was conducted on tranexamic acid in critical bleeding/massive transfusion. The study population was not restricted to critical bleeding requiring massive transfusion.