Abstract

Major spinal fusion procedures are associated with significant intraoperative blood loss, increasing transfusion exposure, morbidity, and length of hospitalization. Tranexamic acid (TXA) has demonstrated efficacy in reducing blood loss in orthopedic surgery; however, optimal dosing strategies in patients with significant comorbidities remain debated. Emerging evidence supports the use of high-dose TXA when appropriately adjusted for renal function. This case describes anesthetic management of a patient with chronic kidney disease (CKD) and coronary artery disease (CAD) undergoing complex posterior spinal surgery.

In adult patients undergoing major spinal surgery, how does high-dose TXA compared to standard-dose TXA affect intraoperative blood loss and transfusion requirements during the perioperative period?

Current literature supports the efficacy of TXA in reducing blood loss and transfusion requirements during major spine surgery, particularly with high-dose regimens. Meta-analyses demonstrate that bolus doses followed by weight-based infusions significantly decrease intraoperative bleeding. In this case, a renal-adjusted TXA regimen with a capped total dose of 6g was selected to balance antifibrinolytic benefit with the risk of accumulation in CKD. Despite an estimated blood loss of 1,500 mL, transfusion requirements were limited to three units each of packed red blood cells and fresh frozen plasma, consistent with reported reductions in transfusion needs associated with high-dose TXA.

Anesthetic management focused on maintaining hemodynamic stability, with hemoglobin above 9 g/dL to support myocardial oxygen delivery. Balanced fluid therapy preserved hemodynamic stability and prevented significant periorbital or airway edema. No thromboembolic, neurologic, or renal complications occurred. Normotensive anesthesia was maintained to preserve coronary perfusion, differing from controlled hypotension strategies but aligning with cardiac-specific recommendations.

This case supports selective use of renal-adjusted high-dose TXA as part of a multimodal blood conservation strategy in complex spine surgery. Standardized protocols incorporating patient-specific modifiers and interdisciplinary transfusion algorithms may improve safety and consistency, warranting future research in high-risk populations.

Author Details

Jordan G. Falkner, DNP(c), BSN, CCRN; David B. Sanford, DNP, CRNA, EMT-P

Sigma Membership

Non-member

Type

DNP Capstone Project

Format Type

Text-based Document

Study Design/Type

Case Study/Series

Research Approach

Translational Research/Evidence-based Practice

Keywords:

Spinal Fusions, Orthopedic Surgeries, Tranexamic Acid, TXA, Transfusions, Blood Loss Mitigation, Blood Conservation Strategies

Advisor

Terri M. Cahoon

Degree

DNP

Degree Grantor

Samford University

Degree Year

2026

Rights Holder

All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

Review Type

None: Degree-based Submission

Acquisition

Proxy-submission

Date of Issue

2026-01-28

Full Text of Presentation

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Additional Files

Abstract.pdf (201 kB)

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