S001: EFFICACY OF COMBINED TOPICAL AND INTRAVENOUS TRANEXAMIC ACID IN ADULT CARDIAC SURGERY: A SYSTEMATIC REVIEW AND META-ANALYSIS.
Pablo Paredes, MD1; Diana Catalina Alvarez, MD2; Asad Iqbal3
1Clinica Cardiovascular Colsubsidio; 2Instituto Nacional de Cancerología; 3Bacha Khan Medical College
Background: Tranexamic acid (TXA) administration is an effective strategy for reducing bleeding in cardiac surgical patients, with intravenous (IV) administration TXA strongly recommended in current guidelines. Concerns regarding thrombotic and neurological complications have prompted research into its topical use to enhance efficacy while minimizing adverse events. However, results generally favor IV administration, and evidence regarding combined IV and topical TXA use remains limited.
Methods: A systematic search of PubMed, EMBASE, and Cochrane Central through December 2024 identified studies comparing combined IV + topical TXA administration to IV TXA alone in adult cardiac surgical patients. The primary outcome was postoperative bleeding within the first 24 hours. Secondary outcomes included transfusion requirements, coagulation parameters, and postoperative complications, such as reoperation, neurological complications, and mortality. Subgroup analysis assessed differences between randomized controlled trials (RCTs) and observational studies. Statistical analysis was performed using RevMan 5.1.7 and R, with heterogeneity assessed via the I² statistic.
Results: Four studies met the inclusion criteria, with a total enrollment of 1,079 patients. Pooled analysis showed no significant reduction in postoperative blood loss with combined TXA administration compared to IV TXA alone (MD: -46.75 mL, 95% CI: [-132.41 to 38.91], p = 0.12). An observational study suggested a potential benefit (MD: -124.50 mL, 95% CI: [-212.27 to -36.73], p = 0.005), but RCTs did not confirm this effect (MD: -13.18 mL, 95% CI: [-47.59 to 21.24], p = 0.32).
Heterogeneity was moderate (I² = 53%), with significant subgroup differences (p = 0.02, I² = 82.4%). Among secondary outcomes, a small but significant reduction in red blood cell (RBC) transfusion volume was observed with the combined application (MD: -67.14 mL, 95% CI: [-115.80 to -18.48], p < 0.01), with low heterogeneity (I² = 0.0%). No significant differences were found for surgical reinterventions, neurological complications, or mortality.
Conclusions: The combined application of topical and IV TXA does not significantly reduce postoperative blood loss compared to IV administration alone, as reduced bleeding was observed only in the observational study and not confirmed by RCTs. However, a modest but statistically significant reduction in RBC transfusion volume was observed as a pooled result. No increased risk of neurological complications or mortality was associated with the combined TXA strategy. Further studies are needed to confirm the potential benefits of a combined application strategy.
