Effectiveness of intravenous tranexamic acid administration in managing perioperative blood loss in patients undergoing spine surgery: a systematic review

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Abstract

Background

Perioperative blood loss during and after spine surgery is a common problem that is encountered and can result in devastating patient outcomes if not controlled. The drug tranexamic acid is often used to minimize blood loss. A meta-analysis published in 2008 was undertaken to determine if antifibrinolytic agents reduced blood transfusions in spine surgery in pediatric patients and if one agent had a greater effect than another. Since that meta-analysis was published, one of the antifibrinolytics is no longer available for administration due to safety issues. Also, since 2008, several randomized controlled clinical trials have evaluated the effect of intravenous tranexamic acid on perioperative blood loss. The purpose of this systematic review was to determine if the intravenous administration of tranexamic acid was effective in managing perioperative blood loss in patients of any age undergoing spine surgery.

Objectives

The objective of this review was to identify the effectiveness of intravenous tranexamic acid administration in managing perioperative blood loss in all patients undergoing spine surgery.

Inclusion criteria

Types of participants

Inclusion criteria

This review considered studies that included patients irrespective of the presence or severity of comorbidities undergoing any type of spine surgery. Patients presenting with a coagulopathy were not included.

Inclusion criteria

Types of intervention(s)/phenomena of interest

Inclusion criteria

Studies explored were those that evaluated the effectiveness of intravenous tranexamic acid administration on perioperative blood loss.

Inclusion criteria

Types of studies

Inclusion criteria

This review considered both experimental and epidemiological study designs which included randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after, prospective and retrospective cohort, case control and analytical cross sectional studies.

Inclusion criteria

Types of outcomes

Inclusion criteria

The outcome measures were intraoperative and postoperative blood loss and the total amount of the two collectively referred to as perioperative blood loss.

Search strategy

The three-step search strategy aimed to find both published and unpublished studies in 12 databases. Keywords used were: tranexamic acid or tranexamic, spine surgery or diskectomy or laminectomy or spinal fusion, blood loss or perioperative blood loss or intraoperative blood loss and postoperative blood loss, or surgical blood loss.

Methodological quality

Papers that were selected for retrieval were assessed by the primary reviewer and then independently by the secondary reviewer for methodological quality prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta- Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). The primary reviewer conducted the final assessment, based on the two previous assessments to make the determination to include or exclude each study. Disagreements that arose between the reviewers were resolved through discussion.

Data collection

Data was extracted from papers included in the review by two independent reviewers using the standardized data extraction tool from JBI-MAStARI The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. An attempt to contact one author was made to retrieve missing data.

Data synthesis

Quantitative data was pooled for statistical meta-analysis using JBI-MAStARI. All results were subject to double data entry. The effect sizes were expressed as weighted mean differences for continuous data with 95 %confidence intervals. Heterogeneity was assessed statistically using the standard Chi-squared test.

Results

This review included 12 studies with a total of 934 participants. Studies measured patient blood loss for both the control and treatment groups. Intraoperative, postoperative, and perioperative blood loss were outcome measures that underwent meta-analysis. The meta-analysis showed a statistically significant higher amount of blood loss both intraoperatively and postoperatively in the control group when compared to the treatment group that received tranexamic acid.

Conclusions

Analysis of available evidence demonstrates that administration of intravenous tranexamic acid reduces blood loss in patients during the intraoperative and postoperative phases of spine surgery.

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