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Background Prophylactic administration of tranexamic acid has been associated with reduced postpartum blood loss after cesarean delivery in several small trials, but evidence of its benefit in this clinical context remains inconclusive.Methods In a multicenter, double-blind, randomized, controlled trial, we assigned women undergoing cesarean delivery before or during labor at 34 or more gestational weeks to receive an intravenously administered prophylactic uterotonic agent and either tranexamic acid (1 g) or placebo. The primary outcome was postpartum hemorrhage, defined as a calculated estimated blood loss greater than 1000 ml or receipt of a red-cell transfusion within 2 days after delivery. Secondary outcomes included gravimetrically estimated blood loss, provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, and postpartum blood transfusion.Results Of the 4551 women who underwent randomization, 4431 underwent cesarean delivery, 4153 (93.7%) of whom had primary outcome data available. The primary outcome occurred in 556 of 2086 women (26.7%) in the tranexamic acid group and in 653 of 2067 (31.6%) in the placebo group (adjusted risk ratio, 0.84; 95% confidence interval [CI], 0.75 to 0.94; P=0.003). There were no significant between-group differences in mean gravimetrically estimated blood loss or in the percentage of women with provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, or postpartum blood transfusion. Thromboembolic events in the 3 months after delivery occurred in 0.4% of women (8 of 2049) who received tranexamic acid and in 0.1% of women (2 of 2056) who received placebo (adjusted risk ratio, 4.01; 95% CI, 0.85 to 18.92; P=0.08).Conclusions Among women who underwent cesarean delivery and received prophylactic uterotonic agents, tranexamic acid treatment resulted in a significantly lower incidence of calculated estimated blood loss greater than 1000 ml or red-cell transfusion by day 2 than placebo, but it did not result in a lower incidence of hemorrhage-related secondary clinical outcomes. (Funded by the French Ministry of Health; TRAAP2 ClinicalTrials.gov number, NCT03431805.)Blood-Loss Prevention after Cesarean Delivery In this trial involving women undergoing cesarean delivery (all of whom received prophylactic uterotonic medication), tranexamic acid treatment resulted in a significantly lower incidence of estimated blood loss greater than 1000 ml or red-cell transfusion by day 2 than placebo, but it did not reduce the risk of hemorrhage-related secondary clinical outcomes.

In a randomized trial, over 4500 patients undergoing cardiac surgery were assigned to receive tranexamic acid or placebo. There was no difference between groups in the rate of death or thrombotic complications. The tranexamic acid group had less bleeding and more seizures. Excessive bleeding and blood transfusions are common in patients undergoing cardiac surgery, 1 and in some of these patients, there is a need for reoperation because of life-threatening bleeding. 2 Both blood transfusion and reoperation are strongly associated with poor outcomes after cardiac surgery. 2 , 3 Antifibrinolytic therapy reduces the risk of blood loss and transfusion among patients undergoing cardiac surgery, 4 , 5 but it is unclear whether such therapy reduces the risk of reoperation for bleeding. 4 Antifibrinolytic agents that have been used in patients undergoing cardiac surgery include aprotinin 6 , 7 and the lysine analogues tranexamic acid and aminocaproic acid. 8 – 11 These agents may . . .

This trial compared a restrictive hemoglobin threshold with a liberal threshold for blood transfusion among hip-surgery patients with risk factors for CVD. The liberal strategy resulted in more transfusions and did not reduce death or inability to walk independently. In the United States, more than 17 million red-cell units are collected annually, and 15 million units are transfused. 1 Blood transfusions are frequently given to surgical patients and to the elderly. 2 , 3 Yet, the indications for postoperative transfusion have not been adequately evaluated and remain controversial. Most clinical trials have been small. 4 One adequately powered trial involving adults in intensive care units showed a nonsignificant decrease in 30-day mortality with a restrictive transfusion strategy, as compared with a liberal strategy (18.7% vs. 23.3%). 5 However, the effect of a restrictive approach on functional recovery or risk of myocardial infarction in patients . . .

Background Placenta accreta spectrum (PAS) disorders have become a significant life-threatening issue due to its increased incidence, morbidity and mortality. Several studies have tried to identify the risk factors for PAS disorders. The ideal management for PAS disorders is a matter of debate. The study objectives were to evaluate the incidence and risk factors of PAS disorders and to compare different management strategies at a tertiary referral hospital, Minia, Egypt. Methods This prospective study included 102 women diagnosed with PAS disorders admitted to Minia Maternity university hospital, Egypt between January 2017 to August 2018. These cases were categorized into three groups according to the used approach for management: Group (A) , ( n  = 38) underwent cesarean hysterectomy, group (B) , ( n  = 48) underwent cesarean section (CS) with cervical inversion and ligation of both uterine arteries and group (C) , ( n  = 16): the placenta was left in place. Results The incidence of PAS disorders during the study period was 9 / 1000 maternities (0.91%). The mean age of cases was 32.4 ± 4.2 years, 60% of them had a parity ≥3 and 82% of them had ≥2 previous CSs. Also, 1/3 of them had previous history of placenta previa. Estimated blood loss (EBL) and blood transfusion in group A were significantly higher than other groups. Group (C) had higher mean hospital stay duration. Group A was associated with significantly higher complication rate. Conclusions The incidence of PAS disorders was 0.91%. Maternal age > 32 years, previous C.S. (≥ 2), multiparity (≥ 3) and previous history of placenta previa were risk factors. The management of PAS disorders should be individualized. Women with PAS disorders who completed their family should be offered cesarean hysterectomy. Using the cervix as a tamponade combined with bilateral uterine artery ligation appears to be a safe alternative to hysterectomy in patients with focal placenta accreta and low parity desiring future fertility. Patients with diffuse placenta accreta keen to preserve the uterus could be offered the option of leaving the placenta aiming at conservative management after proper counseling. Trial registration Registered 28th October 2015, ClinicalTrials.gov NCT02590484 .

We aimed to compare the outcomes of mini-percutaneous nephrolithotomy (mPNL) and standard PNL techniques in the treatment of renal stones ≥ 2 cm. The study was designed as a randomized prospective study between January 2016 and April 2017. The patients with a kidney stone ≥ 2 cm were included in the study. Patients who had uncorrectable bleeding diathesis, abnormal renal anatomy, skeletal tract abnormalities, pregnant patients and pediatric patients (< 18 years old) were excluded from the study. The remaining patients were randomly divided into two groups as standard PNL and mPNL. For both group, demographic data, stone characteristics, operative data and postoperative data were recorded prospectively. The study included 160 consecutive patients who had kidney stone ≥ 2 cm. Of these, patients who met the exclusion criteria and patients who had missing data were excluded from the study. Remaining 97 patients were randomly divided into two groups as mPNL (n: 46) and standard PNL (n: 51). The mean age was 46.9 ± 13.7 and 47.4 ± 13.9 years for mPNL group and sPNL group, respectively. According to Clavien–Dindo classification, no statistical difference was detected between the groups in terms of complication rates (p 0.31). However, the rates of hemoglobin drop and transfusion rates were significantly in favour of mPNL (p 0.012 and p 0.018, respectively). Nephrostomy time and hospitalization time was found to be significantly shorter in mPNL group (p 0.017 and p 0.01, respectively). The success rate in the mPCNL group was higher than standard PNL group, however, this difference was statistically insignificant (76.5 vs 71.7%, p 0.59). Both mPNL and standard PNL are safe and effective treatment techniques for the treatment of kidney stones of ≥ 2 cm. Although there was no significant difference in success rates of both techniques; nephrostomy time, hospitalization time, bleeding and transfusion rates were in favour of mPNL.

The outcome of patients undergoing major surgery treated with HES for hemodynamic optimization is unclear. This post-hoc analysis of a randomized clinical pilot trial investigated the impact of low-molecular balanced HES solutions on the coagulation system, blood loss and transfusion requirements. The Trial was registered: EudraCT 2008-004175-22 and ethical approval was provided by the ethics committee of Berlin. Patients were randomized into three groups receiving either a 10% HES 130/0.42 solution, a 6% HES 130/0.42 solution or a crystalloid following a goal-directed hemodynamic algorithm. Endpoints were parameters of standard and viscoelastic coagulation laboratory, blood loss and transfusion requirements at baseline, at the end of surgery (EOS) and the first postoperative day (POD 1). Fifty-two patients were included in the analysis (HES 10% (n = 15), HES 6% (n = 17) and crystalloid (n = 20)). Fibrinogen decreased in all groups at EOS (HES 10% 338 [298;378] to 192 [163;234] mg dl-1, p<0.01, HES 6% 385 [302;442] to 174 [163;224] mg dl-1, p<0.01, crystalloids 408 [325;458] to 313 [248;370] mg dl-1, p = 0.01). MCF FIBTEM was decreased for both HES groups at EOS (HES 10%: 20.5 [16.0;24.8] to 6.5 [5.0;10.8] mm, p = <0.01; HES 6% 27.0 [18.8;35.2] to 7.0 [5.0;19.0] mm, p = <0.01). These changes did not persist on POD 1 for HES 10% (rise to 16.0 [13.0;24.0] mm, p = 0.88). Blood loss was not different in the groups nor transfusion requirements. Our data suggest a stronger but transient effect of balanced, low-molecular HES on the coagulation system. Despite the decline of the use of artificial colloids in clinical practice, these results may help to inform clinicians who use HES solutions.

Background Mortality benefit of transfusion with leucoreduced whole blood has not been demonstrated in the sub-Saharan Africa (SSA). We compared mortality in patients with cancer transfused with leucoreduced and non-leucoreduced whole blood in a SSA setting. Methods An open-label randomized controlled trial was conducted at the Uganda Cancer Institute where participants were randomized in a 1:1 ratio into the leucoreduced and non-leucoreduced whole blood transfusion arms. Leucocyte filtration of whole blood was performed within 72 h of blood collection. Patients aged ≥ 15 years who were prescribed blood transfusion by the primary physicians were eligible for study enrolment. Mortality difference was analyzed using intention-to-treat survival analysis and cox proportional hazard model was used to analyze factors associated with mortality. Results There were 137 participants randomized to the leucoreduced and 140 to the non-leucoreduced arms. Baseline characteristics were similar between the two arms. The median number of blood transfusions received was 1 (IQR, 1–3) unit and 2 (IQR, 1–3) units in the leucoreduced and non-leucoreduced arms respectively, p  = 0.07. The 30-day mortality rate in the leucoreduced arm was 4.6% (95% CI, 2.1–10) and was 6.2% (95% CI, 3.2–12.1) in the non-leucoreduced arm ( p  = 0.57), representing an absolute effect size of only 1.6%. Increasing age (HR = 0.92, 95% CI, 0.86–0.98, p  = 0.02) and Eastern Co-operative Oncology Group (ECOG) performance score of 1 (HR = 0.03, 95% CI, 0.00–0.31, p  < 0.01) were associated with reduced 30-day mortality. Conclusions The study failed to demonstrate mortality difference between cancer patients transfused with leucoreduced and non-leucoreduced whole blood. Although this study does not support nor refute universal leucoreduction to reduce mortality in patients with cancer in SSA, it demonstrates the feasibility of doing transfusion RCTs in Uganda, where a multi-center trial with an appropriate sample size is needed. Trial registration Pan African Clinical Trial Registry, https://pactr.samrc.ac.za/ (PACTR202302787440132). Registered on 06/02/2023.

Background This study examined the differences in total blood loss, the need for blood transfusions, length of hospital stay, wound grading scores, incidence of venous thromboembolism (VTE), and reoperation rates between conventional and limited tourniquet use during unilateral primary total knee arthroplasty (TKA). Methods This double-blind, randomized controlled trial included 90 patients undergoing unilateral primary TKA. Forty-five patients were allocated to the limited tourniquet use group (LIM-TKA), and 45 to the conventional tourniquet use group (CON-TKA). The study analyzed differences in total blood loss, the need for blood transfusions, wound grading scores, incidence of VTE, length of hospital stay, and reoperation rates. Results The mean total blood loss in the LIM-TKA group was 589.55 ± 238.2 ml, significantly lower than the 692.31 ± 276.15 ml observed in the CON-TKA group ( P  = 0.031). Significantly poorer wound grades were seen in the CON-TKA group compared to the LIM-TKA group, with 23 vs. 34, 15 vs. 11, 5 vs. 0, 1 vs. 0 and 1 vs. 0 patients, respectively, having grade 1, 2 A, 2B, 2 C and 3 A wounds according to the Southampton Scoring System ( P  = 0.032). Patients in the LIM-TKA group also had a shorter hospital stay versus the CON-TKA group (5.6 ± 1.28 vs. 7.2 ± 4.06 days, P  = 0.006). The rates of blood transfusion, VTE complications, and reoperation were similar between both groups. Conclusion LIM-TKA results in significantly lower total blood loss and improved wound grading scores, as well as a decreased length of hospital stay compared to CON-TKA. LIM-TKA could be a suitable option for surgeons aiming to minimize tourniquet-related adverse outcomes while maintaining a dry bone surface during TKA cementation. Clinical trial number This study was retrospectively registered at Thai Clinical Trials Registry (thaiclinicaltrials.org) on July 28, 2024. Clinical trial number: TCTR20240728002.

In this clinical trial involving patients undergoing high-risk cardiac surgery, aprotinin was somewhat more effective than either aminocaproic acid or tranexamic acid in reducing massive perioperative bleeding but at the expense of a higher rate of death, mainly from cardiac causes. Aprotinin cannot be recommended to control blood loss in this clinical setting. In patients undergoing high-risk cardiac surgery, aprotinin was somewhat more effective than either aminocaproic acid or tranexamic acid in reducing massive perioperative bleeding but at the expense of a higher rate of death, mainly from cardiac causes. Every year an estimated 1 million to 1.25 million patients worldwide undergo cardiac surgery, including high-risk procedures such as repeat coronary-artery bypass grafting (CABG), valve replacements, and combined procedures. 1 High-risk procedures present an increased risk of death, massive bleeding, renal failure, and thrombotic complications, as compared with first-time isolated CABG. 2 – 4 Three antifibrinolytic agents have been used in cardiac surgery to minimize bleeding and reduce the need for transfusion: aprotinin, a naturally occurring serine protease inhibitor, and two lysine analogues, tranexamic acid and aminocaproic acid. 5 In clinical trials, all three drugs have been shown to be effective in reducing the . . .

Background Tranexamic acid (TXA), delivered intravenously or topically, has been shown to reduce blood loss, the need for transfusion, and relevant healthcare costs when administered in primary standard total hip arthroplasty (THA). Whether the same is true of oral TXA is unclear, the purpose of this study was to determine if oral tranexamic acid is equivalent to intravenous TXA in the case of patients undergoing THA via the direct anterior approach. Methods In this prospective randomized controlled trial, 120 patients undergoing primary THA by the direct anterior approach were randomized to receive oral TXA (two doses of 20 mg/kg), intravenous TXA (two doses of 15 mg/kg), or no TXA. Primary outcomes were haemoglobin drop, haematocrit levels, total blood loss, intra-operative blood loss, need for transfusion, and volume transfused. Secondary outcomes included thromboembolic events, wound complications, the length of post-operative hospital stay, and 30-day readmission. Results Demographic characteristics were similar among the three patient groups ( p  > 0.05, n  = 40 per group). Haemoglobin drop, haematocrit levels, total blood loss, and intra-operative blood loss were similar in the oral and intravenous groups ( p  > 0.05), and significantly smaller than in the control group ( p  < 0.05). Transfusions were given to significantly fewer patients in the oral group (3%) and intravenous group (6%) than in the control group (27%, p  = 0.01). Costs of TXA and transfusions were significantly lower in the oral group than the intravenous group ( p  < 0.05). The three groups were similar in thromboembolic events, wound complications, the length of post-operative hospital stay, and 30-day readmission ( p  > 0.05). Conclusion Oral TXA shows similar efficacy and safety as intravenous TXA for reducing haemoglobin drop, haematocrit levels, total blood loss, and transfusion rate following THA by the direct anterior approach. Therefore, the much less-expensive oral formulation may be superior to the intravenous form.