Tranexamic acid

[rock_shoes]

We just had one of our Orthopods (whose patients are almost always heavy bleeders, go figure...) start it in his post-op regimen. We're giving it IV for total knees (that's the only one I've seen it with so far) about 4 hours after they come up from PACU. Pretty interesting stuff! Nobody's had a bad reaction to it so far. I still had to reinforce damn near all those dressings though... so.... we'll see lol.

It's like the data on ketamine... everyone says yeah, it's fantastic! It's amazing! And my personal experience with it in our setting has been "holy shit! It turned my patient into a fruit loop and now they're on constant observation! That's expensive!"

Pretty cool idea!

Wendy

CO EMT-B

RN-ADN

What type of emergence protocol does your unit use? Patient's coming off of ketamine need a quiet, relaxed, dark environment with as little external stimulus as possible. Failing that some benzo's usually help tremendously.

[Eydawn]

We usually have concurrent benzos. We do a continuous infusion with a PCA pump and I've seen folks hop off the deep end within 2-4 hours of starting the infusion.

Wendy

CO EMT-B

RN-ADN

[emt399]

Just took in a seminar about this very subject. Was very interesting. Apparently, Tulsa Ok and Oklahoma city are now using txa prehospital. Here is the powerpooint presentation

http://www.kemsa.org/sites/default/files/users/2/TXATRAUMALECTURE.pdf

[island emt]

Thanks for sharing that 399

[rock_shoes]

We usually have concurrent benzos. We do a continuous infusion with a PCA pump and I've seen folks hop off the deep end within 2-4 hours of starting the infusion.

Wendy

CO EMT-B

RN-ADN

Without seeing your step down environment my best guess would be that your post-procedure monitoring area provides too much stimulation. As you've seen emergence is a very real issue requiring careful management to avoid. Think of the type of environment people who suffer from migraines sequester themselves in during an episode. That's the perfect emergence environment for a patient coming off of ketamine. If your facility can't provide that type of environment for whatever reason a different agent would likely serve them better.

[Eydawn]

See, I've seen it used as a more continuous infusion for pain control, either for refractory post surgical pain or as the intended treatment for chronic regional pain syndrome. You're right- the environment isn't great, it's a busy post surgical floor. Lots of noise, lots of stimulation... and because they're on a continuous infusion, there's frequent vitals and assessments which causes more stimuli. They're fine once we stop the infusion and it wears off, it's during the infusion that we've seen problems. Oddly, I haven't seen one for a few months now, so maybe they decided my floor wasn't the best environment for ketamine infusions...

One can only hope, anyway! I think we need a lot more education on it before they use it again in our particular setting. Fortunately I was never directly responsible for a patient on it...

Wendy

CO EMT-B

RN-ADN

[HarryM]

We've just had a memo out from our clinical research team which has said that at the moment the evidence is against prehospital use of TXA, but that we will be taking part in trials ourselves and make a final decision from there. The rationale was that while studies did show TXA decreased mortality from trauma, the studies were conducted in countries that had much higher levels of trauma deaths than New Zealand. They applied the study results to NZ and found that as the rate of death from trauma was much lower here then TXA would have a lower efficacy and with a lower efficacy, the risks of pathological clotting are significantly increased which outweighs the possible benefits.

[Eydawn]

I wonder really at the rationale for using tranexamic acid in postoperative patients.... while concurrently starting them on coumadin, lovenox or xarelto. I wonder if the pharmacologic active life of tranexamic acid is really short enough to just be enough to help with surgical site bleeding, with subsequent anticoagulation to prevent DVT's or other issues... I s'pose I should go look it up. ;-)

Seems kind of counter-intuitive, though.

Wendy

CO EMT-B

RN-ADN

[Just Plain Ruff]

We've just had a memo out from our clinical research team which has said that at the moment the evidence is against prehospital use of TXA, but that we will be taking part in trials ourselves and make a final decision from there. The rationale was that while studies did show TXA decreased mortality from trauma, the studies were conducted in countries that had much higher levels of trauma deaths than New Zealand. They applied the study results to NZ and found that as the rate of death from trauma was much lower here then TXA would have a lower efficacy and with a lower efficacy, the risks of pathological clotting are significantly increased which outweighs the possible benefits.

That doesn't sound like a good thing.

[rock_shoes]

We've just had a memo out from our clinical research team which has said that at the moment the evidence is against prehospital use of TXA, but that we will be taking part in trials ourselves and make a final decision from there. The rationale was that while studies did show TXA decreased mortality from trauma, the studies were conducted in countries that had much higher levels of trauma deaths than New Zealand. They applied the study results to NZ and found that as the rate of death from trauma was much lower here then TXA would have a lower efficacy and with a lower efficacy, the risks of pathological clotting are significantly increased which outweighs the possible benefits.

My interpretation of that evidence is a little different. What that evidence tells me is that the indications for use need to be tailored such that only sufficiently high risk trauma patients are treated with it. The evidence with regard to benefit is crystal clear in that the sooner a high risk trauma patient receives TXA the lower their risk of bleeding related death.

The current evidence screams that pre-hospital is exactly the place for TXA provided it's being administered to the correct patient population.