What is the role of tranexamic acid (TXA) in managing abdominal bleeding?

From the Guidelines

Tranexamic acid (TXA) can effectively stop abdominal bleeding when administered promptly, ideally within 3 hours of bleeding onset, at a loading dose of 1 gram over 10 minutes, followed by an infusion of 1 gram over 8 hours. This recommendation is based on the most recent and highest quality evidence from the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1. The guideline suggests that TXA should be administered to trauma patients who are bleeding or at risk of significant bleeding as soon as possible, with a Grade 1A recommendation.

The mechanism of action of TXA involves inhibiting plasminogen activation and preventing the breakdown of fibrin clots, thereby maintaining clot integrity and reducing blood loss. This makes TXA particularly useful in trauma-related abdominal hemorrhage, gastrointestinal bleeding, and during abdominal surgeries where significant blood loss is anticipated. While generally well-tolerated, clinicians should exercise caution in patients with a history of thromboembolic events, severe renal impairment, or active intravascular clotting.

Key points to consider when using TXA for abdominal bleeding include:

• Administration of TXA should not await results from a viscoelastic assessment, as recommended by the guideline 1
• Early treatment with TXA, ideally within 1 hour of injury, significantly reduces the risk of death due to bleeding, as shown in the CRASH-2 trial 1
• TXA should be considered as part of a comprehensive approach to hemorrhage control, which may include surgical intervention, endoscopic treatments, or other hemostatic measures depending on the specific cause and severity of abdominal bleeding.

Overall, the use of TXA in managing abdominal bleeding is supported by strong evidence, and its prompt administration can significantly improve outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Role of Tranexamic Acid (TXA) in Managing Abdominal Bleeding

• TXA is an antifibrinolytic agent that has been used to manage bleeding in various clinical contexts, including postpartum hemorrhage, trauma, and surgery 2, 3.
• The efficacy and safety of TXA for the treatment of bleeding differ according to the clinical context, timing of administration, and dose 2.
• In the context of abdominal bleeding, specifically gastrointestinal bleeding, the evidence for the use of TXA is mixed 4, 5.
• Some studies suggest that TXA can reduce the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding 4.
• However, other studies have found that extended-use high-dose IV TXA does not reduce mortality or bleeding outcomes and may increase adverse events, such as deep venous thrombosis, pulmonary embolism, and seizure 5.
• Low-dose IV/enteral TXA may be effective in reducing hemorrhage, but more evidence is required to demonstrate its safety 5.

Clinical Context and Timing of Administration

• Early administration of TXA is important for efficacy, particularly in trauma and postpartum hemorrhage 2, 6.
• The optimal dose and timing of TXA administration for abdominal bleeding are not well established and require further study 3, 6.
• The use of TXA in the prehospital setting for traumatic hemorrhage has been shown to be effective and safe, with a recommended loading dose of 1 g followed by 1 g infusion over 8 hours 6.

Safety and Adverse Events

• TXA has been associated with an increased risk of thrombotic events, particularly in patients with gastrointestinal bleeding 2, 3.
• High doses of TXA have been linked to an increased risk of seizures, particularly in patients with brain injury and cardiac surgery 3.
• The safety profile of TXA varies depending on the clinical context, dose, and timing of administration, highlighting the need for individual patient assessment and careful consideration of the risks and benefits 2, 3.