Glanzmann’s Thrombastenia: The Role of Tranexamic Acid in Oral Surgery
The patient GM of 36 years old with GT type 1 needs extractions of the dental teeth 4.7 and 4.8 for an endo-perio lesion, diagnosed by ortopanthomography, at the “Tor Vergata” University Hospital in Rome. Past laboratory tests revealed normal platelet counts and morphology, prolonged bleeding times, clotting time of 4.15 minutes, decreased clot retraction (20%), and abnormal platelet aggregation responses to physiologic stimuli such as adenosine diphosphate and epinephrine used during the aggregometer study. They have no family history of any bleeding disorder. The diagnosis occurred prematurely for the presence of frequent epistaxis, and the diagnosis was ascertained by light transmission aggregometry (LTA). The LTA evaluates shape change, lag phase, percent of aggregation, slope of aggregation, and deaggregation before and after the addition of an agonist (ADP, collagen, epinephrine, arachidonic acid, ristocetin, thrombin receptor-activating peptide, and thromboxane A2 mimetic). There was no history of consanguineous marriages in the family. The patient is looked after at the hematological center of Rome “Tor Vergata”. Preoperative examination was conducted by anesthesiologists. A hematological consult was requested. Oral surgery is classified as simple surgery because risk of bleeding is low. The hematology has advised against performing blood transfusions. The specialist suggests that 3 days before surgery, the patient must take by mouth 6 vials every day of tranexamic acid because the half-life of this drug is 2 hours. The patient shows loss of multiple teeth and had executed other dental extraction with the same methods with no adverse events. A prophylactic assumption of amoxicillina and clavulanic acid has been started one day at the dose of 2 g daily before the surgery and continued for another 4 days.
A peripheral block of the inferior alveolar nerve with bupivacaine without adrenaline and paraperiosteal anesthesia with articain and adrenaline in concentration 1/100000 was also performed. The surgery was conducted with atraumatic technique without osteotomies and mucoperiosteal flaps. The syndesmotomy of the elements 4.7 and 4.8 was performed; they were dislocated through a straight lever and extracted through an appropriate clamp. The socket was courted, washed with saline solution. At the end, oxidized regenerated cellulose was inserted in the socket, and the mucous membrane was sutured with silk 3-0.
Postoperative indications of oral surgery were given to the patient; she was monitored for about 4 hours postintervention. During the postoperatory time, an intravenous paracetamol infusion was performed because it does not interfere with the platelet aggregation. Mouth rinse with tranexamic acid was recommended to the patient. During the hospitalization, no major episode of bleeding was observed. The patient did not present any problems of any kind, and after 7 days, the sutures were removed. A maximum dose of 4 g daily of paracetamol is prescribed. Other nonsteroidal anti-inflammatory drugs are dissuaded because they stop the platelet aggregation. The patient did not present excessive and uncontrolled bleeding during the postoperative period and during the days following the operation.
GT is a rare pathology that complicates surgical treatment for possible uncontrolled bleeding. Correct management of oral surgery in literature is the employment of endovenous tranexamic acid or platelet transfusion. Tranexamic acid, as shown in literature, works by slowing the breakdown of blood clots, which helps to prevent prolonged bleeding. It belongs to antifibrinolytic drugs. This drug is used to prevent excessive bleeding during menstrual period. Tranexamic acid is well tolerated; nausea and diarrhea are the most common adverse events. Increased risk of thrombosis with the drug has not been demonstrated in all clinical trials.
The blood or platelet transfusion in a GT patient has a high risk of alloimmunization (cross-reaction) against the platelet glycoprotein IIb and/or IIIa. Specifically, the patient produces auto-antibodies against the glycoprotein. The occurrence of such alloantibodies is usually due to repeated blood transfusion and greatly complicates the treatment of these patients since they prevent effective platelet transfusion and might, theoretically, cause posttransfusion purpura.
Other rare reaction against transfusion observed in all patients are acute hemolytic reaction, allergic reaction, anaphylactic reaction, coagulation problems in massive transfusion, febrile nonhemolytic reaction, metabolic derangements, mistransfusion (transfusion of the incorrect product to the incorrect recipient), septic or bacterial contamination, transfusion-associated circulatory overload, transfusion-related acute lung injury, urticarial reaction, delayed hemolytic reaction, posttransfusion purpura, transfusion-associated graft-versus-host disease, transfusion-related immunomodulation, and infectious complications. These complications are very rare, and the medical guidelines have greatly reduced these complications. In literature, only 16 studies treat the correct management during oral surgery of GT. Eight studies recommended platelet transfusion before oral surgery together with the use of endovenous tranexamic acid, four studies, in alternative to transfusion, recommended the use of recombinant-activated factor VII, one study recommended the use of plasma rich in platelet, and another the use of acrylic splint. Two studies recommended the intravenous infusion of an antifibrinolytic agent.
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