No IV, No Problem: Intraosseous Administration of Tranexamic Acid is as Effective as Intravenous in a Porcine Hemorrhage Model

ABSTRACT BACKGROUND The acute coagulopathy of trauma is often accompanied by hyperfibrinolysis. TXA can reverse this phenomenon, and, when given early, decreases mortality from bleeding. Establishing IV access can be difficult in trauma and IO access is often preferred for drug administration. Currently, there is no data on the efficacy of IO administered TXA. Our objectives were to compare serum concentrations of tranexamic acid (TXA) when given IV and intraosseous (IO) and to compare the efficacy of IO administered TXA to IV at reversing hyperfibrinolysis METHODS Using a porcine hemorrhage and ischemia-reperfusion (IR) model, 18 swine underwent hemorrhagic shock followed by a tissue plasminogen activator (tPA) infusion to induce hyperfibrinolysis. Animals then received an IV or tibial IO infusion of TXA over 10 minutes. Blood was then analyzed using ROTEM to monitor reversal of hyperfibrinolysis. Serum was analyzed for drug concentrations. RESULTS After hemorrhage and IR, there were no significant differences in MAP (48 vs 49.5), lactate (11.1 vs 10.8), and pH (7.20 vs 7.22) between groups. Intraosseous TXA corrected the lysis index at 30 minutes in EX-TEM and IN-TEM, like IV infusion. Peak serum levels of TXA after IV and IO administration show concentrations of 160.9μg/mL and 132.57μg/mL respectively (p=0.053). Peak levels occurred at the completion of infusion. Drug levels were tracked for four hours. At the end of monitoring, plasma concentrations of TXA were equivalent. CONCLUSION Intraosseous administration of TXA is as effective as intravenous in reversing hyperfibrinolysis in a porcine model of hemorrhagic shock. Intraosseous administration was associated with a similar peak levels, pharmacokinetics, and clearance. Intraosseous administration of TXA can be considered in hemorrhagic shock when IV access cannot be established. LEVEL OF EVIDENCE III STUDY TYPE Therapeutic Study Conflicts of Interest: The authors have no conflicts of interest to declare and have received no financial or material support related to this manuscript Disclaimer: The results and opinions expressed in this article are those of the authors, and do not reflect the opinions or official policy of the United States Army or the Department of Defense. This project was supported through a research grant from the US Air Force, 711HPW/XPT under cooperative agreement number FA8650-14-2-6D18 Author contact information: COL Matthew J. Martin, MD, FACS, Trauma Medical Director, Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Avenue, Tacoma, Washington 98431, 253/968-2361. matthew.j.martin16.mil@mail.mil © 2017 Lippincott Williams & Wilkins, Inc.

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