Can topical administration of tranexamic acid be a good adjuvant to the intravenous route for decreasing postoperative seizure incidence? A double blinded randomized study

Background Antifibrinolytic therapy has become a mainstay in complex cardiac surgical procedures for decreasing bleeding and minimizing transfusion requirements. Tranexamic acid (TA) is an antifibrinolytic agent that can be used both systemically and topically. Current studies and case series reports mention an increased incidence of seizures after administration of high doses of TA (60–260 mg/kg body weight). Thus, we hypothesize that adding a topical dose of TA to a small dose intravenously could reduce postoperative bleeding in patients who have undergone cardiac surgery with subsequent decrease in the overall complications associated with this drug, mainly seizures. Materials and methods A total of 120 patients were randomly allocated to two groups, the intravenous TA group (group Ι) and the topical and intravenous TA group (group II), with 60 patients in each. Every patient in group Ι received an initial bolus dose of TA consisting of a bolus of 50 mg/kg body weight at the beginning and at the end of cardiopulmonary bypass (CPB), and 100 mg/100 ml priming volume was added to the priming fluid of the CPB system. In group II every patient received an initial bolus dose of TA at 30 mg/kg infused over 15 min followed by a 16 mg/kg/h infusion until chest closure with a 2 mg/kg load within the pump prime; in addition, before sternotomy closure, patients received another 2 g of TA diluted in 500 ml of warm saline (37°C), which was poured into the pericardial cavity. Results Hemoglobin concentration, hematocrit value, platelet count, international normalized ratio, bleeding time, activated partial thromboplastin time, total volume of blood loss, and total volume of blood transfused into the patients showed no significant differences between the two groups throughout the study. In contrast, prothrombin time and activated clotting time were significantly higher in group II when compared with group Ι at 2 h postoperatively. Seizure incidence was significantly lower in group II when compared with group Ι. However, the number of re-explored cases was insignificant when the two groups were compared. Conclusion Topical application of TA in addition to a small intravenous dose in patients undergoing open cardiac surgery using CPB reduces perioperative blood loss and transfusion in those patients to the same extent as sole large intravenous dose with less incidence of seizures.