A landmark clinical trial published in the prestigious New England Journal of Medicine found that tranexamic acid reduced transfusions across major surgeries without increasing the risk of dangerous blood clots. The trial was sponsored and coordinated by the University of Manitoba (UM) and co-led by researchers at UM and The Ottawa Hospital.
Tranexamic acid is an inexpensive drug that prevents excessive bleeding and stabilizes blood clots. It has been used in cardiac and some orthopedic surgeries for over 30 years, but doctors have been uncertain if it can safely be used in other major surgeries, especially cancer surgeries.
This pan-Canadian clinical trial studied over 8,000 major surgeries to determine if tranexamic acid reduced bleeding and blood transfusion without increasing the risk of clots. The results of the trial support expanding its use to all major surgeries where patients face a high risk of blood loss.
"This is transformative to patient care and globally has the potential to save millions of units of red blood cells each year,” said Dr. Brett Houston , co-first author and hematologist and clinician-scientist at the University of Manitoba and CancerCare Manitoba.
Major surgery includes procedures of the head, chest, abdomen, or pelvis, and typically requires general anesthetic and a hospital stay. For these surgeries, more than one in 20 patients will need a blood transfusion.
"If tranexamic acid is universally adopted across major surgeries, it will improve surgical safety for millions of patients around the world. In Canada alone, adopting this drug across the board could reduce the number of patients who need a transfusion by 25 per cent annually and reduce the number of blood units required by 10 per cent," said Dr. Daniel McIsaac , co-first author and anesthesiologist and senior scientist at The Ottawa Hospital and Clinical Research Chair in Perioperative Innovation at the University of Ottawa.
Universal adoption of the drug also has the potential to save significant money.
"One transfusion in Canada costs more than $700 CAD, compared to under $10 for tranexamic acid. We estimate that the routine adoption of tranexamic in major non-cardiac surgeries could save 50,000 units of blood each year in Canada and millions of units around the world; the savings to health-care systems will be profound," said the trial chair and co-senior author Dr. Ryan Zarychanski , a hematologist, critical care physician, and clinician-scientist at the University of Manitoba and CancerCare Manitoba.
To discover if tranexamic acid reduces blood transfusion without increasing the risk of blood clots, the team used a cluster-crossover trial design to randomly assign hospitals to treat patients having major surgery with high risk of blood loss to tranexamic acid or placebo. The hospitals would then switch treatment every four weeks for approximately two years. The Ottawa Hospital's Ottawa Methods Centre played a key role in designing this trial to answer the research question quickly and efficiently.
The study team accessed hospital information on transfusions and clots directly from clinical and administrative health data sources housed in Manitoba and at ICES . They analyzed data from 8,273 major surgeries performed at 10 Canadian hospitals between February 2022 and March 2024.
The researchers found that 7.4 per cent of the patients who received tranexamic acid needed transfusions compared to 9.8 per cent in the placebo group. For every 100 patients treated with tranexamic acid, 10 units of blood could be saved. Importantly, they found that tranexamic acid did not increase the risk of venous blood clots 90 days after surgery. The rate of blood clotting in both the treatment and placebo groups was the same, at 2.1 per cent.
One unique aspect of the study was that 60 percent, or about 5,000 participants, had surgery to remove cancer. People with cancer are often left out of these kinds of studies, even though they are a large part of the surgical population. The trial found that tranexamic acid during major surgery was safe and effective even for cancer patients, who are at a higher risk of blood clots due to cancer.
"We hope our findings will reassure care providers that this drug is safe and effective at reducing bleeding and remove a barrier to its use in most major surgeries," said Dr. Dean Fergusson , co-senior author and Deputy Scientific Director, Clinical Research and senior scientist at The Ottawa Hospital and professor at the University of Ottawa.
Full reference:
A hospital policy of tranexamic acid to reduce transfusion in major noncardiac surgery: The TRACTION trial. Brett L. Houston, Daniel I. McIsaac, Rodney H. Breau, Salmaan Kanji, Peter Greenstreet, Meghan Andrews, Sinziana Avramescu, Hema S. Bagry, Robert Balshaw, Jayesh Daya, Kaitlin Duncan, Christopher C. Harle, Eric Jacobsohn, Tina Kerelska, Marshall Pitz, Paul Komenda, Sarah McIsaac, Tim Ramsay, Tarit Saha, Alan Tinmouth, Angela Recio, Daniel Szoke, Marshall Tenenbein, Sarah Slagerman, Dayna Solvason, Robert Talarico, Dean A. Fergusson, Ryan Zarychanski, New England Journal of Medicine. Pub date: June 10, 2026.
Funding:
The trial was funded by the Canadian Institutes of Health Research, Health Science Centre Foundation, Government of Manitoba through the Ministry of Health, Seniors and Long-Term Care, and the Ontario Ministry of Health’s Innovation Fund.
The University of Manitoba (UM) is recognized as Western Canada's first university. It is part of the U15, ranking among Canada’s top research-intensive universities and provides exceptional undergraduate and graduate liberal arts, science and professional programs of study. UM campuses and research spaces are located on original lands of Anishinaabeg, Ininiwak, Anisininewuk, Dakota Oyate, Dene and Inuit, and on the National Homeland of the Red River Métis. Our collaboration with Indigenous communities is grounded in respect and reciprocity and this guides how we move forward as an institution. For more information, please visit umanitoba.ca
The Ottawa Hospital (TOH) is one of Canada’s top learning and research hospitals where we are guided by our vision to provide the world-class and compassionate care we would all want for our loved ones. Our multi-campus hospital, affiliated with the University of Ottawa, is home to the Regional Trauma Centre and Cancer Centre, and to discoveries that are adopted globally. Backed by generous support from the community, we are focused on reshaping the future of health care to improve the health of our diverse population of patients from Eastern Ontario, Western Quebec, and Nunavut. For more information on research at The Ottawa Hospital, visit ohri.ca .
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New England Journal of Medicine
Randomized controlled/clinical trial
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A hospital policy of tranexamic acid to reduce transfusion in major noncardiac surgery: The TRACTION trial.
10-Jun-2026