Low-cost drug cuts transfusions across major surgeries

Clinical Takeaway: Consider routine intraoperative tranexamic acid for patients undergoing major noncardiac surgery with substantial bleeding risk; in this large trial, it reduced red-cell transfusions by about one-quarter without increasing venous thromboembolism.

Blood transfusions are common, costly, and resource-intensive in major surgery; a low-cost, widely available drug may safely reduce their use at scale.

In the TRACTION trial, investigators evaluated a hospital policy of routine tranexamic acid administration in 8,273 adults undergoing major noncardiac surgery at 10 Canadian hospitals. More than 60% of procedures were cancer-related, a population often excluded from prior studies because of concerns about thrombotic risk.

Patients treated under a tranexamic acid policy were significantly less likely to require red-cell transfusion during their hospitalization than those treated under a placebo policy (7.4% vs 9.8%), representing a 27% relative reduction (relative risk [RR], 0.73; 95% confidence interval [CI], 0.61-0.86) and an absolute reduction of 2.7 percentage points. Investigators estimated a number needed to treat of 37 patients to prevent one transfusion. Red-cell use also declined, with approximately 10 fewer units transfused per 100 patients treated.

Importantly, safety outcomes were reassuring. Venous thromboembolism within 90 days occurred in 2.1% of patients in both groups (RR, 0.96; 95% CI, 0.65-1.38), meeting the study’s prespecified noninferiority criterion. Rates of myocardial infarction, stroke, ICU admission, and mortality were also similar between groups. Findings were consistent across surgical subgroups, including patients undergoing oncologic surgery.

“This is transformative to patient care and globally has the potential to save millions of units of red blood cells each year,” said co-first author Dr. Brett Houston.

The authors conclude that routine tranexamic acid use should be considered a safe, effective, and inexpensive strategy to reduce perioperative transfusions in major noncardiac surgery.

Source: Houston BL, et al. (2026, June 10). N Engl J Med. Hospital Policy of Tranexamic Acid to Reduce Transfusion in Major Noncardiac Surgery