Use of tranexamic acid in burn excision and grafting procedures: a case series [abstract #137]
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Introduction: Blood loss associated with tangential excision (TE) is substantial, with estimates ranging between 0.5–1 mL for every 1 cm2 or 5–11% of the blood volume per 1% BSA of burn skin removed. This amount can be reduced by using tourniquets, but 26% to 50% (BMI > 40) of the body’s surface is contained on the trunk and is out of reach of these devices. Tranexamic acid (TXA) is a lysine derivative that blocks the lysine site on plasminogen and inhibits fibrinolysis. This agent has been shown to decrease death from hemorrhage in trauma patients. We sought to determine if the use of TXA could decrease operative blood loss in the excision of truncal burns. Methods: This was a retrospective, observational case series of burn patients >= 18 years old treated at our ABA verified burn center who required excision of truncal burns as part of their staged reconstruction. A 1 gm dose of TXA was given over 10 minutes at the time of incision, and no continuous infusion was used. Patient demographic information and operative variables were abstracted and summarized. The estimated EBL was calculated using the Gross equation and compared to two EBL prediction formulas: Warden and Steadman. Results: From June 2013 - April 2014, there were 8 patients included in this pilot study, ages 18–59. Patients underwent TE with placement of a dermal replacement product between postburn day 1–5 (mean 3 days). The average TBSA burned was 32% (15–61%), with a mean excision of 2713 cm2 (1700–5250 cm2) or 13% BSA (8.5–26.1%). Patients received an average of 3,525 mL fluid intraoperatively (2200–5900 mL). Only 2 of 8 patients received transfusions within 24 hours of their operation, averaging 0.63 U per patient). The median post-operative hemoglobin drop was 5.7 g/dL to a value of 7 g/dL the following day. The calculated EBL was 1.1 mL/cm2 and 141 mL/%TE. This compares favorably with the Warden (110%) and Steadman (63%) estimates. There were no episodes of venous thromboembolism. Conclusions: Blood loss associated with burn excision of the trunk after TXA was similar to that described in the literature using tourniquets and subcutaneous infiltration with vasoactive agents. Perioperative transfusion was performed in only a quarter of these patients despite an average excision of 2713 cm2 (13% BSA). There were no episodes of VTE diagnosed during their hospitalization. A multi-center randomized trial would be necessary to determine a true benefit. Applicability of Research to Practice: This agent may be effective in reducing the blood loss during excision of areas not amenable to other adjuncts, such as tourniquets and clysis.