A hospital-wide policy of administering tranexamic acid to high transfusion-risk patients undergoing noncardiac surgery significantly reduced red blood cell transfusions without elevating thromboembolic risk, according to findings from the TRACTION randomized trial published in the New England Journal of Medicine.
Researchers led by Ryan Zarychanski, MD, of the University of Manitoba, reported that patients receiving a single perioperative dose of tranexamic acid experienced a 27% reduction in red-cell transfusions during hospitalization compared to placebo (7.4% vs 9.8%, relative risk [RR] 0.73, 95% CI 0.61–0.86). The rate of venous thromboembolism within 90 days was equivalent between groups at 2.1%, meeting noninferiority criteria (RR 0.96, 95% CI 0.65–1.38).
“This concern about thrombosis is one of the main barriers to the use of tranexamic acid,” commented Michael F. Murphy, MBBS, MD, of the University of Oxford, and Ian Roberts, MBBCh, PhD, of the London School of Hygiene and Tropical Medicine, in an accompanying editorial. “The data from the TRACTION trial now reported are so welcome,” they wrote, adding that these results should encourage its broader adoption, including in low-blood-loss surgeries similar to protocols in the United Kingdom.
The trial enrolled 8,273 adults across 10 Canadian hospitals, randomized in 4-week intervals to institutional policies of intraoperative tranexamic acid or placebo. Participants underwent inpatient noncardiac surgeries expected to last at least 3 hours, with a ≥5% transfusion risk. Excluded were those with active clotting disorders, pregnancy, or routine tranexamic acid use cases like cardiac or joint surgeries.
Notably, 5,002 patients underwent oncologic surgery—a high-risk group often excluded from prior tranexamic acid trials due to thrombotic concerns. In this subgroup, 90-day venous thromboembolism risk remained low and statistically unchanged (2.4% vs 2.6%, RR 0.92, 95% CI 0.68–1.48), reinforcing the drug’s safety in cancer patients.
However, the editorialists noted limitations, including the small proportion of vascular surgery patients, where tranexamic acid use remains low. They emphasized the need for implementation strategies, such as clinical decision support and inclusion in the World Health Organization’s Safe Surgical Checklist, to improve uptake and patient outcomes.
