Effect of Tranexamic acid on the reduction of blood loss in Neuro Oncosurgical patients A Randomized control study

Tranexamic acid (TXA) is a anti fibrinolytic agent that has been shown to reduce bleeding and blood transfusions in a variety of surgical disciplines. In neuro-onco-surgeries, significant blood loss requiring blood transfusion can occur in the perioperative period. However, there are few studies evaluating the use and challenges of Tranexamic acid in neuro-onco-surgeries, where significant blood loss can occur and perioperative thromboprophylaxis can be challenging. In this study we assess the effect of tranexamic acid in the reduction of blood loss. We also attempt to assess the need for blood transfusions, incidence of deep vein thrombosis and surgeon’s satisfaction about intraoperative bleeding.

Significance of study:

This study will assess the effect of tranexamic acid in reducing blood loss and blood transfusion, and development of deep vein thrombosis in oncological patients undergoing neurosurgery. This will help in reducing the blood transfusion requirements and load in the blood bank in our hospital.

Methodology

For all patients, pre anaesthetic checkup will be done as per department protocol. Patients with demographic data, namely age, weight, height, details of the size and type of tumour from the CT scan are collected. On the day of surgery, haemoglobin will be collected. Screening of deep vein thrombosis will be done by one of the primary investigators with Colour Doppler imaging and compression ultrasound to assess proximal and distal lower limb veins in pre op holding area.

Before induction, patients will be randomised by computer generated numbers into two groups

Group A Patients receiving Tranexamic acid 20 mg per kg actual body weight (diluted in 50 ml Normal saline at 150 ml/hour) over 20 minutes  + 1 mg/kg/hour (20 mg per kg of Tranexamic acid diluted in 50 ml of Normal saline at 2.5 ml per hour) infused till the completion of surgery.

Group B Patients receiving saline 150 ml per hour for 20 minutes + 2.5 ml per hour infusion till the completion of surgery.

Intraoperatively, arterial blood gases will be done at the discretion of the anaesthesiologist. Blood loss will be estimated based on collection in the suction bottle and soakage of mops and pads by the anaesthesiologist who will be unaware of the treatment group of the patient. . Blood will be transfused if Hb< 8 gm%, in cardiac patients if haemoglobin is between 8 to 10 g%, otherwise unexplained tachycardia or high vasopressor support. The use of Abgel and surgicel will be noted. At the end of the surgery, the satisfaction of the surgeon will be evaluated and documented by the Boezaart score for intraoperative surgical field.

Post operative haemoglobin and haematocrit will be measured on post operative day 2 and 5.

In ICU, mechanical thromboprophylaxis will be provided to all patients. No low molecular weight heparin will be administered as per hospital policy. Screening for deep vein thrombosis as done in the pre operative period will be done on day 5 and 1 month after surgery by the primary investigator who will be blinded to the allocation of the patient. Length of hospital stay will also be documented. Neurological improvement will be assessed based on the Glasgow outcome scale on post operative day 5 and post operative day 30. Any other complications occurring during hospital stay will be documented.