Post CABG Bleeding Clinical Trial
Official title:
Efficacy in Controlling Bleeding Post-coronary Bypass Surgery Using Combination of Local Application of Tranexamic Acid and Intravenous Tranexamic Compared to Intravenous Tranexamic Acid Alone. A Randomized Controlled Trial
The purpose of this study is to assess the efficacy of IV Tranexamic Acid and topical Tranexamic Acid to control post op bleeding following Coronary Artery Bypass Graft Surgery using Cardiopulmonary Bypass.
Coagulopathy is a common problem after open heart surgery using cardiopulmonary bypass
(CPB). Some bleeding is significant enough to require early re-exploration to control
hemorrhage in 2-4% of patients.(1,2) In adults, excessive post-operative bleeding occurs in
association with repeat operations, emergency procedures, female gender, small body mass
index, older age, peripheral vascular disease, renal insufficiency ( creatinine > 1.8g/dL) ,
poor nutrition ( albumin < 4g/dL) and in patients who have experienced prolonged CPB
durations. (3,4)
Factors that contribute to coagulopathy after coronary artery bypass grafting (CABG) using
CPB include thrombocytopenia, acquired platlet dysfunction, loss of clotting factors, free
heparin and increased fibrinolysis. (5-7). Lemmer and Colleagues (8) found that
extracorporeal circulation results in significant fibrinolysis, as reflected by increased
concentrations of plasmin and fibrin degradation products (FDP), both of which have
deleterious effects on platlet function. Fibrinolysis was found to be responsible for 25-45%
of significant post-bypass bleeding. (9)
Many antifibrinolytic agents have been used to reduce post-bypass bleeding. These include ε-
Aminocaproic Acid (10), Aprotinin (11) and Tranexamic Acid (TA) (12).
TA has been found to bind to lysine binding sites of plasmin and plasminogen. Saturation of
these sites displaces plasminogen from the fibrin surface thus inhibiting fibrinolysis.(13).
TA has been used both systemically and topically.
Due to the natural barrier properties of the pericardium, which prevents the free diffusion
of substances, experimental studies have shown that the local application of different
medications in to the pericardial cavity can lead to desirable therapeutic effects without
significant systemic absorption. (14-16)
There has been a systemic review and meta-analysis study done looking at 8 trials (622
patients) using topical antifibrinolytic agents (aprotinin and tranexamic acid). No adverse
effects were reported following usage of topical antifibrinolytics.(17)
Topical TA has also been successfully used in controlling bleeding in bladder,
gynaecological, oral, & oropharyngeal surgeries. (18-20)
There has been no authors thus far who have compared application of intravenous TA to
combination of application of intravenous TA and topical TA.
This study is based on a hypothesis that the combination of intravenous (IV) TA and topical
TA administration will significantly reduce the amount of post-op bleeding significantly
following CABG using CPB.
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Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Caregiver, Outcomes Assessor), Primary Purpose: Treatment