Tranexamic Acid at Cesarean Delivery
I recently read a report in the American Journal of Obstetrics and Gynecology (AJOG) concerning deaths caused by mistakingly using tranexamic acid for the lidocaine used in spinals.
“This improvement in the care of women with postpartum hemorrhage has come at a price. For the anesthetist, having tranexamic acid ampules close at hand would seem {to be} an obvious strategy to facilitate its use during cesarean delivery, an important setting for severe hemorrhage.”
The report sadly notes that having the two medications available nearby helps the anesthesiologist. What is never discussed in this article is why two medications which have very similar looking bottles are even allowed in the same room. The real question here is how many women would die if the tranexamic acid were stored in a different room for safety’s sake compared to the number who die with the two medicines stored side by side.
In medical school, on the second day of our pharmacology class, we were cautioned about storing similarly packaged drugs in the same place. It is very easy to get those mixed up because you look for the size, shape and color of the ampoule. We were told at that time to never store like containers with different contents in the same place. So simply stated, these two entirely different medications should be stored in two entirely different places to prevent grabbing one instead of the other.
My recommendation would be to keep the local anesthetic handy, in the operating room, but to remove the tranexamic ampoule from the operating room so it can’t be mistakenly picked up instead of lidocaine. Is this such a difficult concept?
The toxicity of tranexamic acid has been recognized as far back as 1980. Typically, the patient develops strong shaking of the muscles, convulsions, and heart rate arrhythmias which are not compatible with life. This 2019 review of 21 cases revealed 10 fatalities and 10 other life-threatening episodes. Granted, separating the transexamic acid from the lidocaine would take a small amount of work, but it would be an important system response to improve safety. Picking up the bottle and reading the label should be a given. After 40 years, why is anyone still agonizing over keeping these two similar looking medications in separate rooms?
Storing the tranexamic acid in a dangerous place is one of the problems I have with this report. The other problem is why there should be hemorrhaging at all with a cesarean section. I have done hundreds of cesarean sections and I have taught other doctors how to do them. The single most important lesson to be learned about doing a cesarean section is to have a good plan for ingress. In other, words, easy in and easy out.
Have a good plan to get in and getting out is quick and easy. There should be very little bleeding. I’ve never used tranexamic acid for any reason and certainly not as a volume expander because of significant hemorrhage during a cesarean section. My nurses and anesthesiologists, if asked, would report I could do a C-section in 15 minutes with no blood on the floor.
For me, the issue of so much blood loss on a regular basis causes me to ask what skill sets are learned in residency? The skill set to do a cesarean section in 15 or 20 minutes with no blood on the floor is neither difficult nor complex; however, it does need to be learned. For the most part, whether the patient weighs 100 pounds or 450 pounds, there’s very little difference when it comes to getting into the anterior abdominal wall or making the appropriate incisions in the appropriate place in the uterus. There is no such thing as an obese uterus.
In summary, place containers which look like lidocaine but contain different medications in different locations so they won’t be confused. And finally, develop a skill set and mind set sufficient to minimize C-section bleeding.