Severely Injured Trauma Patients With Admission Hyperfibrinolysis; Is There A Role Of Tranexemic Acid? Findings From The PROPPR Trial

Introduction Administration of tranexemic acid (TXA) in coagulopathy-of-trauma (COT) gained popularity after the CRASH-2 trial. The aim of our analysis was to analyze the role of TXA in severely injured trauma patients with admission hyperfibrinolysis. Methods We reviewed the prospectively collected Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) database. We included patients with admission hyperfibrinolysis (Ly30>3%) on thromboelastography. Patients were stratified into two groups (TXA and No-TXA) and were matched in 1:2 ratio using propensity score matching for demographics, admission vitals, and injury severity. Primary outcome measures were 6h, 12h, 24hr, and 30d mortality, 24-hour transfusion requirements, time to achieve hemostasis and re-bleeding after hemostasis requiring intervention. Secondary outcome measures were thrombotic complications. Results We analyzed 680 patients. Of those, 118 had admission hyperfibrinolysis, and 93 patients (TXA: 31; No-TXA: 62) were matched. Matched groups were similar in age (p=0.33), gender (p=0.84), race (p=0.81), emergency department (ED) Glasgow coma scale (p=0.34), ED systolic blood pressure (p=0.28), ED heart rate (p=0.43), mechanism of injury (p=0.45), head-AIS (p=0.68), ISS (p=0.56), and blood products ratio (p=0.44). Patients who received TXA had a lower 6-hour mortality rate (34% vs. 13%, p=0.04) and higher 24h transfusion of plasma (15 units vs. 10 units, p=0.03) compared to the No-TXA group. However, there was no difference in 12h (p=0.24), 24h (p=0.25), and 30d mortality (p=0.82). Similarly, there was no difference in 24h transfusion of RBC (p=0.11) or platelets (p=0.13), time to achieve hemostasis (p=0.65), re-bleeding requiring intervention (p=0.13), and thrombotic complications (p=0.98). Conclusion Tranexamic acid (TXA) was associated with increased 6 hour survival but does not improve long term outcomes in severely injured trauma patients with hemorrhage who develop hyperfibrinolysis. Moreover, TXA administration was not associated with thrombotic complications. Further randomized clinical trials will identify the subset of trauma patients which may benefit from TXA. Level of Evidence Level-III, Therapeutic studies. Oral presentation at the 48th Annual Meeting of Western Trauma Association, February 25th-March 2nd, 2018, British Columbia, Canada. There are no identifiable conflicts of interest to report. Funding: The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial was sponsored by the U.S. National Heart, Lung, and Blood Institute (U01HL077863), the U.S. Department of Defense, as well as Defence Research and Development Canada in partnership with the Canadian Institutes of Health Research (CIHR), Institute of Circulatory and Respiratory Health (CRR-120612). Address for correspondence: Bellal Joseph, MD, University of Arizona, Department of Surgery, Division of Trauma, Critical Care, and Emergency Surgery. 1501 N. Campbell Ave, Room.5411, P.O. Box 245063, Tucson, AZ 85727. E-mail: bjoseph@surgery.arizona.edu. Tel 520-626-5056. Fax 520-626-5016 © 2018 Lippincott Williams & Wilkins, Inc.

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