In this episode I’ll:
1. Discuss an article about inhaled tranexamic acid for hemoptysis.
2. Answer the drug information question “Can milrinone be used in patients on CRRT?”
3. Share a tip for responding to inpatient medical emergencies.
Lead author: Ori Wand
Currently in press to be published in the journal Chest
Tranexamic acid (TA) is an antifibrinolytic medication. It forms a reversible complex that displaces plasminogen from fibrin resulting in inhibition of fibrinolysis. Tranexamic acid is commonly used systemically to reduce bleeding in trauma or topically or systemically to reduce bleeding in orthopedic surgical procedures. Until now, there have been no prospective studies of the effectiveness of inhaled tranexamic acid for the treatment of hemoptysis. The authors of this study sought to prospectively assess the effectiveness of nebulized tranexamic acid for hemoptysis treatment.
The study was a double-blind, randomized controlled trial of treatment with nebulized tranexamic acid vs normal saline placebo in patients admitted with hemoptysis. Patients with massive hemoptysis (defined as expectorated blood > 200 mL/24 h) and hemodynamic or respiratory instability were excluded. Mortality and hemoptysis recurrence rate was assessed at 30 days and 1 year.
Forty-seven patients were randomized to receive tranexamic acid inhalations (n = 25) or normal saline (n = 22). Tranexamic acid was associated with a significantly reduced expectorated blood volume starting from day 2 of admission. Resolution of hemoptysis within 5 days of admission was observed in almost all of the tranexamic acid-treated patients compared to only half of those receiving placebo (96% vs 50%; P < .0005).
Mean hospital length of stay was 2 days shorter for the tranexamic acid group (5.7 ± 2.5 days vs 7.8 ± 4.6 days; P = .046). Fewer patients in the tranexamic acid group required invasive procedures such as interventional bronchoscopy or angiographic embolization to control the bleeding (0% vs 18.2%; P = .041). There were no side effects noted in either group throughout the follow-up period. A reduced hemoptysis recurrence rate was noted at the 1-year follow-up (P = .009 in the tranexamic acid group).
The authors concluded:
Tranexamic acid inhalations can be used safely and effectively to control bleeding in patients with nonmassive hemoptysis.
This study appears to demonstrate a very strong and beneficial treatment effect for tranexamic acid in the setting of hemoptysis. Patients in the active group got undiluted inhalations of IV form of tranexamic acid 500 mg/5 ml 3-4 times a day. If possible, I prefer the preservative-free version of IV tranexamic acid due to the potential adverse effects of nebulized preservatives.
Drug information question
Q: Can milrinone be used in patients on CRRT?
A: It is unclear if milrinone can be used in this setting. Only 1 article in adult patients is available to guide the use of milrinone in patients with CRRT. The article is a case series of 6 patients with severe heart failure who got milrinone while undergoing continuous venovenous hemofiltration. The half-life of milrinone was increased nearly 10-fold in these patients.
All patients died of severe ventricular arrhythmia within 1 month of receiving milrinone. If I can’t use an alternative to milrinone such as dobutamine in patients on CRRT, I would start at the lowest dose possible and use milrinone for the shortest amount of time.
Tip for responding to inpatient medical emergencies
Remember the general rule “don’t treat sinus tachycardia, treat the cause.”
Think of sinus tachycardia the same way you think of a fever. It’s a sign that means you need to do further investigation until you determine the cause.
Sinus tachycardia can result from homeostatic mechanisms in response to severe hypovolemia, anemia, or low oxygen saturation.
If you treat sinus tachycardia in this setting with a rate controlling agent such as a beta blocker or calcium channel blocker, you will wipe out your patient’s only compensatory mechanism that is attempting to maintain oxygen delivery. This can result in rapid and profound cardiovascular collapse.
In my episode, Pharmacists as Members of the Rapid Response Team, I share more examples of potential underlying causes of sinus tachycardia. To find this episode, go to pharmacyjoe.com/episode3. I also provide more in-depth training on how to respond to code blue and rapid response calls in my Hospital Pharmacy Academy. To learn more, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.