GA5-95
Ulnar Artery Thrombosis Following Tranexamic Acid Administration for Craniosyostosis Repair
Chung E, Karlberg H
Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United states
Pediatric craniosynostosis repair with cranial vault reconstructive surgery is associated with significant blood loss.1. Tranexamic acid (TXA), an antifibrinolytic, has been shown to decrease blood loss and transfusion in craniofacial surgery.2 Data regarding the safety of TXA is limited. A recent study evaluating the safety of TXA showed no difference in the incidence of adverse events in children treated with or without antifibrinolytics in pediatric craniofacial surgery.3 We describe a case of ulnar artery thrombosis following an ulnar arterial line placement in a patient who received TXA for cranial vault reconstructive surgery.
A four-year-old female with a history of chromosomal abnormalities, developmental delay, and craniosynostosis presented for bifrontal craniectomy and frontal orbital advancement. A left ulnar arterial line was placed under ultrasound guidance for hemodynamic monitoring and lab draws. The patient received a 10 mg/kg bolus of TXA followed by an infusion of 3 mg/kg/h. The case was notable for bleeding, for which the patient received both PRBCs and FFP. Following the case in the PACU, the left hand was noted to be cold and mottled. The arterial line was removed, and interventional radiology discovered an ulnar artery thrombus. The patient underwent two interventional radiology procedures which transiently improved ulnar artery patency, but ultimately needed surgical ulnar artery thrombectomy and reconstruction with a saphenous vein graft.
Recent studies suggest the use of TXA is both safe and efficacious in cranial vault repair. However, TXA use has been associated with both arterial and venous thrombosis in other types of surgeries.4-6 To our knowledge, this is the first report of arterial thrombosis associated with the use of TXA in cranial vault repair.
References
1. Stricker PA, Shaw TL, Desouza DG et al. Blood loss, replacement, and associated morbidity in infants and children undergoing craniofacial surgery. Pediatr Anesth 2010;
20: 150–159
2. Goobie SM, Meier PM, Pereira LM et al. Efficacy of tranexamic acid in pediatric craniosynostosis surgery: a double-blind, placebo-controlled trial. Anesthesiology 2011; 114: 862–871.
3. Goobie SM, Cladis FP, Glover CD et al.; the Pediatric Craniofacial Collaborative Group. Safety of antifibrinolytics in cranial vault reconstructive surgery: a report from the pediatric craniofacial collaborative group. Paediatr Anaesth. 2017 Mar;27(3):271-281.
4. Upadhyay SP, Mallick PN, Jagia M, Singh RK. Acute arterial thrombosis associated with inadvertent high dose of tranexamic acid. Indian J Crit Care Med.2013 Jul;17(4):237-9.
5. Hajmurad OS, Choxi AA, Zahid Z, Dudaryk R. Aortoiliac Thrombosis Following Tranexamic Acid Administration During Urgent Cesarean Hysterectomy: A Case Report. A A Case Rep. 2017 Aug 1;9(3):90-93.
6. Johnston LR, Rodriguez CJ, Elster EA, Bradley MJ. Evaluation of Military Use of Tranexamic Acid and Associated Thromboembolic Events. JAMA Surg. 2017 Oct 25.
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