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Abstract(s)
Introdução: O ácido tranexâmico é um antifibrinolítico amplamente utilizado para
controlo de hemorragia. Entre as mortes por trauma, a hemorragia é a causa
potencialmente evitável mais comum. Devido à ampla utilização do ácido tranexâmico e
dos resultados comprovados no restabelecimento da hemostasia na hemorragia em
intervenções cirúrgicas, foi estabelecido um paralelismo, colocando a hipótese de que
este poderia ter utilidade no trauma. Assim sendo, o ácido tranexâmico é um dos
antifibrinolíticos mais estudados para controlo de hemorragia em contexto de trauma.
Apesar de existirem vários estudos que comprovam a sua eficácia e segurança no
contexto pré-hospitalar, existem alguns estudos que argumentam que o uso precoce de
ácido tranexâmico não traz benefícios e que poderá estar associado a efeitos adversos
como eventos tromboembólicos. Este poderá levar a um aumento relativo dos fatores de
coagulação e, se os fatores pró-coagulantes predominarem, há um risco acrescido de
eventos tromboembólicos.
Objetivo: O objetivo desta revisão sistemática é avaliar a segurança do uso préhospitalar do ácido tranexâmico em doentes com trauma, principalmente a ocorrência
de eventos tromboembólicos. Esta revisão sistemática propõe-se ainda a avaliar a
ocorrência de outros eventos adversos associados ao uso do TXA.
Métodos: Esta revisão sistemática foi realizada de acordo com as Guidelines PRISMA
2020. A pesquisa foi conduzida nas bases de dados PubMed, Web of Science e
ScienceDirect, utilizando a estratégia de pesquisa PICO. Foram incluídos artigos
científicos originais de estudos experimentais e observacionais com grupo controlo,
prospetivos ou retrospetivos, revistos por pares, publicados em língua portuguesa ou
inglesa e que tivessem como outcome primário ou secundário eventos tromboembólicos,
trombose venosa profunda, tromboembolismo pulmonar, síndrome coronário agudo ou
acidente vascular cerebral. Foram incluídos artigos com participantes com idades iguais
ou superiores a 15 anos de idade que receberam ácido tranexâmico na emergência préhospitalar por lesões traumáticas.
Resultados: Dois estudos mostraram uma maior incidência de eventos
tromboembólicos no grupo de intervenção, mas nenhum apresentou diferenças
estatisticamente significativas. A maioria dos estudos mostrou uma maior incidência de
tromboses venosas no grupo de intervenção, mas apenas um estudo evidenciou aumento
significativo, em especial o subgrupo que recebeu transfusão maciça. Quatro estudos mostraram uma maior incidência de eventos tromboembólicos arteriais no grupo de
intervenção, no entanto nenhuma estatisticamente significativa.
Dois estudos mostraram uma maior incidência de convulsões no grupo de intervenção,
enquanto outro mostrou uma maior incidência de convulsões no grupo controlo. No
entanto, nenhuma diferença foi estatisticamente significativa.
A mortalidade global foi menor no grupo de intervenção em sete estudos e quatro deles
apresentaram uma redução estatisticamente significativa. A mortalidade nas primeiras
24 horas após trauma foi menor no grupo de intervenção em quatro estudos, mas apenas
um apresentou uma diminuição estatisticamente significativa. As mortalidades às 6 e às
12 horas após trauma foram ambas estatisticamente menores no grupo de intervenção
em dois estudos.
Conclusão: A administração pré-hospitalar do ácido tranexâmico em pacientes com
trauma parece ser segura e benéfica, sem evidência significativa de aumento de
tromboembólicos ou de convulsões. Além disso, confirmou-se a sua eficácia na redução
da mortalidade. No entanto, evidencia-se a necessidade de mais estudos para uma
melhor compreensão dos possíveis efeitos adversos do ácido tranexâmico em contexto
pré-hospitalar.
Introduction: Tranexamic acid is an antifibrinolytic widely used for hemorrhage control. Among trauma-related deaths, hemorrhage is the most common potentially preventable cause. Due to the extensive use of tranexamic acid and its proven results in restoring hemostasis in bleeding during surgical interventions, a parallelism was established, hypothesizing that it could be useful in trauma. Thus, tranexamic acid is one of the most studied antifibrinolytics for hemorrhage control in the context of trauma. Although there are several studies proving its effectiveness and safety in the pre-hospital setting, some studies argue that early use of tranexamic acid does not bring benefits and may be associated with adverse effects such as thromboembolic events. This could lead to a relative increase in coagulation factors, and if pro-coagulant factors predominate, there is an increased risk of thromboembolic events. Objective: The objective of this systematic review is to evaluate the safety of prehospital use of tranexamic acid in trauma patients, mainly the occurrence of thromboembolic events. This systematic review also aims to assess the occurrence of other adverse events associated with TXA use. Methods: This systematic review was conducted according to the PRISMA 2020 guidelines. The search was conducted in the PubMed, Web of Science, and ScienceDirect databases using the PICO search strategy. Original scientific articles from experimental and observational studies with control groups were included, prospective or retrospective, peer-reviewed, published in Portuguese or English, and that had thromboembolic events, deep venous thrombosis, pulmonary embolism, acute coronary syndrome, or stroke as primary or secondary outcomes. Articles included had participants aged 15 years or older, who received tranexamic acid in pre-hospital emergency care for traumatic injuries. Results: Two studies showed a higher incidence of thromboembolic events in the intervention group, but none showed statistically significant differences. Most studies showed a higher incidence of venous thromboses in the intervention group, but only one study showed a significant increase, especially in the subgroup that received massive transfusion. Four studies showed a higher incidence of arterial thromboembolic events in the intervention group, however, none were statistically significant. Two studies showed a higher incidence of seizures in the intervention group, while another showed a higher incidence of seizures in the control group. However, no difference was statistically significant. Overall mortality was lower in the intervention group in seven studies, and four of them showed a statistically significant reduction. Mortality within the first 24 hours after trauma was lower in the intervention group in four studies, but only one showed a statistically significant decrease. Mortality at 6 and 12 hours after trauma was both statistically lower in the intervention group in two studies. Conclusion: Pre-hospital administration of tranexamic acid in trauma patients appears to be safe and beneficial, with no significant evidence of increased thromboembolic events or seizures. Additionally, its effectiveness in reducing mortality was confirmed. However, more studies are needed for a better understanding of the potential adverse effects of tranexamic acid in the pre-hospital setting.
Introduction: Tranexamic acid is an antifibrinolytic widely used for hemorrhage control. Among trauma-related deaths, hemorrhage is the most common potentially preventable cause. Due to the extensive use of tranexamic acid and its proven results in restoring hemostasis in bleeding during surgical interventions, a parallelism was established, hypothesizing that it could be useful in trauma. Thus, tranexamic acid is one of the most studied antifibrinolytics for hemorrhage control in the context of trauma. Although there are several studies proving its effectiveness and safety in the pre-hospital setting, some studies argue that early use of tranexamic acid does not bring benefits and may be associated with adverse effects such as thromboembolic events. This could lead to a relative increase in coagulation factors, and if pro-coagulant factors predominate, there is an increased risk of thromboembolic events. Objective: The objective of this systematic review is to evaluate the safety of prehospital use of tranexamic acid in trauma patients, mainly the occurrence of thromboembolic events. This systematic review also aims to assess the occurrence of other adverse events associated with TXA use. Methods: This systematic review was conducted according to the PRISMA 2020 guidelines. The search was conducted in the PubMed, Web of Science, and ScienceDirect databases using the PICO search strategy. Original scientific articles from experimental and observational studies with control groups were included, prospective or retrospective, peer-reviewed, published in Portuguese or English, and that had thromboembolic events, deep venous thrombosis, pulmonary embolism, acute coronary syndrome, or stroke as primary or secondary outcomes. Articles included had participants aged 15 years or older, who received tranexamic acid in pre-hospital emergency care for traumatic injuries. Results: Two studies showed a higher incidence of thromboembolic events in the intervention group, but none showed statistically significant differences. Most studies showed a higher incidence of venous thromboses in the intervention group, but only one study showed a significant increase, especially in the subgroup that received massive transfusion. Four studies showed a higher incidence of arterial thromboembolic events in the intervention group, however, none were statistically significant. Two studies showed a higher incidence of seizures in the intervention group, while another showed a higher incidence of seizures in the control group. However, no difference was statistically significant. Overall mortality was lower in the intervention group in seven studies, and four of them showed a statistically significant reduction. Mortality within the first 24 hours after trauma was lower in the intervention group in four studies, but only one showed a statistically significant decrease. Mortality at 6 and 12 hours after trauma was both statistically lower in the intervention group in two studies. Conclusion: Pre-hospital administration of tranexamic acid in trauma patients appears to be safe and beneficial, with no significant evidence of increased thromboembolic events or seizures. Additionally, its effectiveness in reducing mortality was confirmed. However, more studies are needed for a better understanding of the potential adverse effects of tranexamic acid in the pre-hospital setting.
Description
Keywords
Ácido Tranexâmico Efeitos Adversos Medidas de Segurança Tromboembolismo