The Administration of Tranexamic Acid For Complex Spine Surgery

Kristen Jockel, is a staff CRNA at Yale New Haven Hospital and a clinical preceptor for the Yale New Haven Hospital School of Nurse Anesthesia, New Haven, Connecticut.
Amanda Lee, is a staff CRNA at Yale New Haven Hospital, and a clinical preceptor for the Yale New Haven Hospital School of Nurse Anesthesia, New Haven, Connecticut.
Marianne S. Cosgrove, is the Program Director of the Yale New Haven School of Nurse Anesthesia, Adjunct Faculty at Central CT State University, and a staff CRNA at Yale New Haven Hospital, New Haven, Connecticut. Email: marianne.cosgrove@ynhh.org.
Drew Reilly, is a staff CRNA at Maine Medical Center, Portland, Maine.
Shirvinda Wijesekera, is an orthopedic spine surgeon at Connecticut Orthopedics. He serves as the Associate Chief of Orthopedics at Yale New Haven Hospital, New Haven, Connecticut. Email: swijesekera@ct.ortho.com.

Abstract

Currently, there are approximately 1.62 million instrumented spinal surgeries performed each year in the United States. Complex procedures such as wide exposures and composite osteotomies, compounded by the spine's extensive vascular network, often result in major blood loss and increased fibrinolysis. Substantial intraoperative blood loss often necessitates blood transfusion and is a significant predictor of postoperative morbidity. Antifibrinolytic medications have been utilized prophylactically to reduce perioperative blood loss, particularly in surgeries where excessive blood loss is common. Tranexamic acid (TXA), a lysine analog that reversibly binds to plasminogen, inhibits the activation of plasminogen to plasmin, delaying clot degradation. The intravenous and topical administration of TXA during the perioperative period safely and effectively reduces blood loss, transfusion requirements, and/or hospital length of stay in patients undergoing major or complex spine surgery. Although the use of TXA for multilevel spine surgery is increasing, there remains widespread equivocality regarding ideal dosing regimens. Recent evidence suggests that high-dose TXA significantly reduces perioperative blood loss when compared with low-dose TXA, with no increase in perioperative morbidity and mortality. Translating this evidence into sustained change in clinical practice has the potential to improve both outcomes and blood product utilization in patients undergoing major or complex spine surgery.