Impact of tranexamic acid on intraoperative fluid intake in patients undergoing posterior spine fixation: a retrospective cohort study

Background: Significant intraoperative bleeding is followed by infusion of a large amount of fluid. However, massive fluid intake itself, even when not necessarily associated with a largely positive input-output balance, is associated with poor functional outcomes and in-hospital complications. Tranexamic acid (TXA) attenuates intraoperative bleeding in various studies. This study compared the total intraoperative crystalloid intake in patients undergoing posterior spine fixation in those who were administered TXA versus those who were not. Methods: This retrospective cohort study included adult patients who underwent posterior spinal fixation at the Department of Neurosurgery. The primary outcome was the adjusted fluid infusion rate, which was calculated as the total volume of crystalloid fluid administered divided by (total anesthetic time × body weight). The secondary outcomes were intraoperative transfusion and 30-day postoperative complications. A propensity score matching adjusting age, sex, anesthesia time, and physical status was done. Results: A total of 302 patients met eligibility criteria, and 94 patients were included in each group after the propensity score matching. The adjusted fluid infusion rate was less in the TXA group than the control group (8.7 ± 3.6 vs. 6.4 ± 1.7 mL/kg/h, mean difference 2.3 mL/kg/h (95% confidence interval 1.5–3.1); p < 0.001). Intraoperative transfusions were less frequent in the TXA group than in the control group. Postoperative complications including thromboembolism were comparable between the two groups. Conclusions: TXA administration in spine fixation resulted in less intraoperative crystalloid input and transfusion, presumably owing to attenuated intraoperative bleeding. TXA could be beneficial in patients at risk of major bleeding and fluid overload.

Tranexamic acid; Posterior spine fixation; Intraoperative bleeding; Crystalloid infusion rate; Blood transfusion; Postoperative complications

[1] Lee MH, Park HR, Chang JC, Park HK, Lee GS. A nationwide study on the impact of COVID-19 pandemic on volume of spine surgery in South Korea. Journal of Korean Neurosurgical Society. 2022; 65: 741–750.

[2] Oezel L, Okano I, Hughes AP, Sarin M, Shue J, Sama AA, et al. Longitudinal trends of patient demographics and morbidity of different approaches in lumbar interbody fusion: an analysis using the American College of Surgeons national surgical quality improvement program database. World Neurosurgery. 2022; 164: e183–e193.

[3] Pirot C, Tantrakansakun C, Sirithiantong T. Clinical prediction model for red cell blood transfusion in elective primary posterior lumbar spine fusion. Scientific Reports. 2024; 14: 14339.

[4] Tubert P, Kalimouttou A, Bouzat P, David JS, Gauss T. Are crystalloid-based fluid expansion strategies still relevant in the first hours of trauma induced hemorrhagic shock? Critical Care. 2024; 28: 416.

[5] Voldby AW, Aaen AA, Loprete R, Eskandarani HA, Boolsen AW, Jønck S, et al. Perioperative fluid administration and complications in emergency gastrointestinal surgery-an observational study. Perioperative Medicine. 2022; 11: 9.

[6] Rass V, Gaasch M, Kofler M, Schiefecker AJ, Ianosi BA, Steinkohl F, et al. Fluid intake but not fluid balance is associated with poor outcome in nontraumatic subarachnoid hemorrhage patients. Critical Care Medicine. 2019; 47: e555–e562.

[7] Sentilhes L, Sénat MV, Le Lous M, Winer N, Rozenberg P, Kayem G, et al.; Groupe de Recherche en Obstétrique et Gynécologie. Tranexamic acid for the prevention of blood loss after cesarean delivery. The New England Journal of Medicine. 2021; 384: 1623–1634.

[8] Zufferey PJ, Lanoiselée J, Graouch B, Vieille B, Delavenne X, Ollier E. Exposure-response relationship of tranexamic acid in cardiac surgery. Anesthesiology. 2021; 134: 165–178.

[9] Yang YZ, Cheng QH, Zhang AR, Yang X, Zhang ZZ, Guo HZ. Efficacy and safety of single- and double-dose intravenous tranexamic acid in hip and knee arthroplasty: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2023; 18: 593.

[10] Franchini M, Mannucci PM. The never ending success story of tranexamic acid in acquired bleeding. Haematologica. 2020; 105: 1201–1205.

[11] Wongtangman K, Wilartratsami S, Hemtanon N, Tiviraj S, Raksakietisak M. Goal-directed fluid therapy based on pulse-pressure variation compared with standard fluid therapy in patients undergoing complex spine surgery: a randomized controlled trial. Asian Spine Journal. 2022; 16: 352–360.

[12] Kouz K, Thiele R, Michard F, Saugel B. Haemodynamic monitoring during noncardiac surgery: past, present, and future. Journal of Clinical Monitoring and Computing. 2024; 38: 565–580.

[13] Park LJ, Marcucci M, Ofori SN, Borges FK, Nenshi R, Kanstrup CTB, et al. Safety and efficacy of tranexamic acid in general surgery. JAMA Surgery. 2025; 160: 267–274.

[14] Heyns M, Knight P, Steve AK, Yeung JK. A single preoperative dose of tranexamic acid reduces perioperative blood loss: a meta-analysis. Annals of Surgery. 2021; 273: 75–81.

[15] Fodor GH, Habre W, Balogh AL, Südy R, Babik B, Peták F. Optimal crystalloid volume ratio for blood replacement for maintaining hemodynamic stability and lung function: an experimental randomized controlled study. BMC Anesthesiology. 2019; 19: 21.

[16] Hahn RG. Adverse effects of crystalloid and colloid fluids. Anaesthesiology Intensive Therapy. 2017; 49: 303–308.

[17] Hahn RG, Drobin D, Zdolsek J. Distribution of crystalloid fluid changes with the rate of infusion: a population-based study. Acta Anaesthesiologica Scandinavica. 2016; 60: 569–578.

[18] Shim JS, Noh TI, Ku JH, Lee S, Kwon TG, Kim TH, et al.; Korean Robot Assisted Radical Cystectomy (KORARC) Study Group. Effect of intraoperative fluid volume on postoperative ileus after robot-assisted radical cystectomy. Scientific Reports. 2021; 11: 10522.

[19] Kulemann B, Fritz M, Glatz T, Marjanovic G, Sick O, Hopt UT, et al. Complications after pancreaticoduodenectomy are associated with higher amounts of intra- and postoperative fluid therapy: a single center retrospective cohort study. Annals of Medicine and Surgery. 2017; 16: 23–29.

[20] Voldby AW, Aaen AA, Møller AM, Brandstrup B. The association of the perioperative fluid balance and cardiopulmonary complications in emergency gastrointestinal surgery: exploration of a randomized trial. Perioperative Medicine. 2024; 13: 32.

[21] Horibe M, Kayashima A, Ohbe H, Bazerbachi F, Mizukami Y, Iwasaki E, et al. Normal saline versus Ringer’s solution and critical-illness mortality in acute pancreatitis: a nationwide inpatient database study. Journal of Intensive Care. 2024; 12: 27.

[22] Østergaard AM, Jørgensen AN, Bøvling S, Ekeløf NP, Mose FH, Bech JN. Effect of 0.9% NaCl compared to plasma-lyte on biomarkers of kidney injury, sodium excretion and tubular transport proteins in patients undergoing primary uncemented hip replacement—a randomized trial. BMC Nephrology. 2021; 22: 111.

[23] Ker K, Sentilhes L, Shakur-Still H, Madar H, Deneux-Tharaux C, Saade G, et al.; Anti-fibrinolytics Trialists Collaborators Obstetric Group. Tranexamic acid for postpartum bleeding: a systematic review and individual patient data meta-analysis of randomised controlled trials. The Lancet. 2024; 404: 1657–1667.

[24] Bosboom JJ, Wijnberge M, Geerts BF, Kerstens M, Mythen MG, Vlaar APJ, et al. Restrictive versus conventional ward fluid therapy in non-cardiac surgery patients and the effect on postoperative complications: a meta-analysis. Perioperative Medicine. 2023; 12: 52.