Case Series on 2g Tranexamic Acid Flush From the 75th Ranger Regiment Casualty Database.

Early tranexamic acid (TXA) administration for resuscitation of critically injured warfighters provides a mortality benefit. The 2019 Tactical Combat Casualty Care (TCCC) recommendations of a 1g drip over 10 minutes, followed by 1g drip over 8 hours, is intended to limit potential TXA side effects, including hypotension, seizures, and anaphylaxis. However, this slow and cumbersome TXA infusion protocol is difficult to execute in the tactical care environment. Additionally, the side effect cautions derive from studies of elderly or cardiothoracic surgery patients, not young healthy warfighters. Therefore, the 75th Ranger Regiment developed and implemented a 2g intravenous or intraosseous (IV/IO) TXA flush protocol. We report on the first six cases of this protocol in the history of the Regiment. After-action reports (AARs) revealed no incidences of post-TXA hypotension, seizures, or anaphylaxis. Combined, the results of this case series are encouraging and provide a foundation for larger studies to fully determine the safety of the novel 2g IV/IO TXA flush protocol toward preserving the lives of traumatically injured warfighters.

Surgical ventricular restoration in end-stage ischemic cardiomyopathy patients.

BACKGROUND: Surgical ventricular restoration (SVR) has generally been contraindicated in patients with an ejection fraction (EF) <20%, with pulmonary arterial (PA) pressure >60 mm Hg, and being treated with inotropic agents. PATIENTS AND METHODS: The patients in this study were 6 men and 5 women 50 to 78 years of age (mean, 62.4 years). Three patients were in New York Heart Association (NYHA) class III with an EF <30%. Eight patients were in NYHA class IV with EF <20%, PA pressure >70 mm Hg, and left ventricular asynergy. Three patients had had recent myocardial infarction (MI) with shock and multiple organ failure. Three patients had mitral regurgitation, 1 patient had ventricular septal defect (VSD), 4 patients had diabetes mellitus, and 5 had morbid obesity. All patients underwent intraoperative transesophageal echocardiography and were being treated with milrinone or nesiritide. Seven patients had intraaortic balloon pumps. All patients underwent coronary artery bypass (CAB), receiving 1 to 5 (average, 3.54) grafts per patient. The SVR (Dor) procedure was performed with a Chase Mannequin device. Preoperative end-diastolic volume was 240 to 330 mL, and postoperative volume decreased to 110 to 130 mL. Two patients underwent mitral valve repair, and 1 underwent VSD closure. One patient underwent microwave ablation for atrial fibrillation. RESULTS: Ten (91%) of 11 patients were discharged home in 10 to 14 days. There was 1 death: A 78-year-old man with acute MI died 43 days later of septic shock due to hemodialysis. CONCLUSION: End-stage ischemic cardiomyopathy patients with EF <20% can safely undergo surgery after meticulous preoperative preparation to decrease PA pressure, pulmonary capillary wedge pressure, and peripheral vascular resistance and to increase CO by SVR, CAB, and correction of associated lesions. Mortality was 9% with improved hemodynamics and relief of congestive heart failure in all survivors for 3 to 12 months.