From the Guidelines
Tranexamic acid (TXA) is recommended for patients with hematemesis at a dose of 1 gram administered intravenously over 10 minutes, followed by a continuous infusion of 1 gram over 8 hours, as supported by the most recent evidence from 2021 1. This protocol should be initiated as soon as possible after the onset of bleeding, ideally within 3 hours, as earlier administration is associated with better outcomes. Before administration, ensure the patient does not have contraindications such as active thromboembolic disease, subarachnoid hemorrhage, or severe renal impairment. The medication should be diluted in 100mL of normal saline or 5% dextrose for the initial bolus, and in 500mL for the continuous infusion. Monitor the patient for potential side effects including nausea, vomiting, hypotension, and rarely seizures or thrombotic events. TXA works by inhibiting fibrinolysis, thereby stabilizing blood clots that have formed at sites of vascular injury. This mechanism helps maintain clot integrity and reduces rebleeding risk in patients with upper gastrointestinal hemorrhage. The medication should be used as part of a comprehensive management approach that includes resuscitation, correction of coagulopathy, and definitive endoscopic or surgical intervention as appropriate.
Some key points to consider when using TXA in patients with hematemesis include:
- The importance of early administration, as supported by studies such as the one published in 2019 1, which showed a 40% risk reduction in mortality when TXA was given promptly.
- The need for careful patient selection, taking into account potential contraindications and the risk of thromboembolic events, as noted in the 2021 guidelines 1.
- The role of TXA as part of a broader management strategy, including endoscopic and surgical interventions, as outlined in the 2010 consensus recommendations 1.
- The potential benefits of TXA in reducing rebleeding and mortality, as suggested by the meta-analyses published in 2003 1.
Overall, the use of TXA in patients with hematemesis is supported by a range of evidence, and its inclusion in a comprehensive management approach can help to improve outcomes for these patients.
From the Research
Tranexamic Acid Infusion Protocols for Hematemesis
- Tranexamic acid is an antifibrinolytic agent that may reduce acute hemorrhage through inhibition of plasminogen 2.
- The optimal dosing regimen for tranexamic acid in traumatic major hemorrhage remains unknown, with different doses and treatment strategies proposed, including single bolus, repeated bolus, or bolus plus infusion 3.
- Extended-use high-dose IV tranexamic acid does not improve mortality or bleeding outcomes and increases adverse events in gastrointestinal bleeding, while low-dose IV/enteral tranexamic acid may be effective in reducing hemorrhage 4.
Dosage and Administration
- A single bolus administration of tranexamic acid is likely preferable to a bolus plus infusion regimen 3.
- Low-dose IV/enteral tranexamic acid may reduce the risk of rebleeding and need for surgery in gastrointestinal bleeding 4, 5.
- Early administration of tranexamic acid may be recommended for treating upper gastrointestinal bleeding in the emergency department 6.
Clinical Outcomes
- Tranexamic acid appears to have a beneficial effect on mortality in upper gastrointestinal bleeding, but high dropout rates in some trials mean that further research is needed to confirm this 5.
- Tranexamic acid significantly reduces the rates of continued bleeding, urgent endoscopic intervention, and mortality compared with placebo in upper gastrointestinal bleeding 6.
- The effects of tranexamic acid on lower gastrointestinal bleeding warrant further clarification 6.