Tranexamic Acid and Vitamin K Administration
Tranexamic acid (TXA) can be administered as a 1g stat dose intravenously over 10 minutes, followed by an infusion of 1g over 8 hours, and vitamin K can be given both intramuscularly and intravenously with appropriate dosing adjustments based on clinical indication and renal function.
Tranexamic Acid Administration
Dosing and Administration
- The recommended dosage of TXA for bleeding patients is 1g administered intravenously over 10 minutes, followed by an infusion of 1g over 8 hours 1
- TXA should be administered as soon as possible after significant bleeding is identified, ideally within 3 hours of injury onset for maximum efficacy 2
- For intravenous infusion, TXA may be mixed with most solutions for infusion such as electrolyte solutions, carbohydrate solutions, amino acid solutions, and Dextran solutions 3
- TXA should NOT be mixed with blood or solutions containing penicillin 3
- Infuse no more than 1 mL/minute to avoid hypotension 3
Dosage Adjustment for Renal Impairment
- For patients with moderate to severe renal impairment, dose adjustment is necessary as TXA is primarily eliminated through the renal route 3, 2:
- Serum creatinine 1.36-2.83 mg/dL: 10 mg/kg twice daily
- Serum creatinine 2.83-5.66 mg/dL: 10 mg/kg daily
- Serum creatinine >5.66 mg/dL: 10 mg/kg every 48 hours or 5 mg/kg every 24 hours 3
Efficacy and Evidence
- TXA has been shown to reduce mortality in bleeding trauma patients by approximately one-third when administered within 3 hours of injury 4, 5
- The CRASH-2 trial (n=20,211) demonstrated that TXA significantly reduced all-cause mortality (14.5% vs 16.0%; relative risk 0.91) and death due to bleeding (4.9% vs 5.7%; relative risk 0.85) compared to placebo 5
- TXA is effective in reducing blood loss in various surgical procedures and bleeding disorders 6, 7
Vitamin K Administration
Routes of Administration
- Vitamin K can be administered both intramuscularly (IM) and intravenously (IV) 1
- IV administration is preferred in urgent situations requiring rapid reversal of anticoagulation 1
Dosing for Anticoagulation Reversal
- For patients on oral vitamin K antagonists (VKAs) with major bleeding or requiring urgent procedures, the recommended reversal protocol includes:
- Intravenous four-factor prothrombin complex concentrates (4F-PCCs) AND
- 5 mg intravenous vitamin K 1
- Further doses may be administered if needed to achieve INR < 1.5 1
- Fresh frozen plasma (FFP) should only be used as a vitamin K antagonist reversal agent if no other treatment is available 1
Precautions and Monitoring
TXA Precautions
- Contraindications for TXA include:
- Subarachnoid hemorrhage
- Active intravascular clotting
- Hypersensitivity to tranexamic acid 3
- Monitor for potential adverse effects such as:
Monitoring During Treatment
- Evaluate clinical response through decreased bleeding and stabilization of hemoglobin levels 2
- Monitor coagulation parameters, especially in patients with massive bleeding 2
- Consider electroencephalogram (EEG) monitoring for patients with history of seizures 3
Special Considerations
Elderly and Frail Patients
- Carefully evaluate implementing permissive hypotension in managing selected elderly trauma patients 1
- Tissue perfusion should be constantly monitored by base excess level, arterial lactates, urine output, and neurologic assessment 1
Concomitant Medications
- Avoid concomitant use of TXA with pro-thrombotic medical products, as the risk of thrombosis may be increased 3
- These medications include Factor IX Complex concentrates, Anti-inhibitor Coagulant concentrates, and hormonal contraceptives 3