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CARDIOVASCULAR ANESTHESIA

Plasma Tranexamic Acid Concentrations During Cardiopulmonary Bypass

Bridget K. Fiechtner, MD^*, Gregory A. Nuttall, MD^*, Michael E. Johnson, MD, PhD^*, Yue Dong, MD^*, Nuntiya Sujirattanawimol, MD^*, William C. Oliver, Jr., MD^*, Rajbir S. Sarpal, MD, Lance J. Oyen, PharmD, BCPS^*, and Mark H. Ereth, MD^*

*Mayo Graduate School of Medicine, Rochester, Minnesota; and Department of Biology, University of Wisconsin Critical Care, Madison, Wisconsin

Address correspondence and reprint requests to Gregory A. Nuttall, MD, Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905. Address e-mail to nuttall.gregory{at}mayo.edu

Although tranexamic acid is used to reduce bleeding after cardiac surgery, there is large variation in the recommended dose, and few studies of plasma concentrations of the drug during cardiopulmonary bypass (CPB) have been performed. The plasma tranexamic acid concentration reported to inhibit fibrinolysis in vitro is 10 µg/mL. Twenty-one patients received an initial dose of 10 mg/kg given over 20 min followed by an infusion of 1 mg · kg^-1 · h^-1 via a central venous catheter. Two patients were removed from the study secondary to protocol violation. Perioperative plasma tranexamic acid concentrations were measured with high-performance liquid chromatography. Plasma tranexamic acid concentrations (µg/mL; mean ± SD [95% confidence interval]) were 37.4 ± 16.9 (45.5, 29.3) after bolus, 27.6 ± 7.9 (31.4, 23.8) after 5 min on CPB, 31.4 ± 12.1 (37.2, 25.6) after 30 min on CPB, 29.2 ± 9.0 (34.6, 23.8) after 60 min on CPB, 25.6 ± 18.6 (35.1, 16.1) at discontinuation of tranexamic acid infusion, and 17.7 ± 13.1 (24.1, 11.1) 1 h after discontinuation of tranexamic acid infusion. Four patients with renal insufficiency had increased concentrations of tranexamic acid at discontinuation of the drug. Repeated-measures analysis revealed a significant main effect of abnormal creatinine concentration (P = 0.02) and time (P < 0.001) on plasma tranexamic acid concentration and a significant time x creatinine concentration interaction (P < 0.001).

Implications: A 10 mg/kg initial dose of tranexamic acid followed by an infusion of 1 mg·kg^-1·h^-1produced plasma concentrations throughout the cardiopulmonary bypass period sufficient to inhibit fibrinolysis in vitro. The dosing of tranexamic acid may require adjustment for renal insufficiency.

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