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Ghorbani M, Sadrian SH, Ghaderpanah R, Neitzke CC, Chalmers BP, Esmaeilian S, Rahmanipour E, Parsa A. Tranexamic acid in total hip arthroplasty: An umbrella review on efficacy and safety. J Orthop 2024; 54:90-102. [PMID: 38560591 PMCID: PMC10978533 DOI: 10.1016/j.jor.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024] Open
Abstract
Purpose This comprehensive review was conducted to assess the effects of tranexamic acid (TXA) on blood loss, venous thromboembolism (VTE) risk, and wound complications following total hip arthroplasty (THA). Additionally, it sought to evaluate the effects of various TXA dosages, modes of administration, and combinations with other antifibrinolytic drug. Methods In search of systematic reviews and meta-analyses on the use of TXA in THA patients, we searched extensively through databases including Scopus, the Cochrane Library, Embase, Medline, the Web of Science, PubMed, and Google Scholar. We discovered 23 meta-analyses covering 32,442 patients overall that fulfilled our study criteria, spanning the period from the creation of these databases until May 2023. Results This comprehensive review's meta-analyses, which together examined over 35,000 patients, repeatedly demonstrated how TXA administration during THA successfully lowers perioperative blood loss and the need for transfusions. TXA reduced total blood loss by an average of 151-370 ml, postoperative hemoglobin levels by 0.5-1.1 g/dL, and transfusion rates by 19-26% on average when compared to control groups. The information gathered did not indicate that using TXA significantly increased the risk of VTE or wound complications. When comparing different TXA doses, administration techniques, or its use in conjunction with other anti-fibrinolytic therapies, no discernible differences were found in terms of efficacy or safety outcomes. Conclusion The comprehensive review clearly indicates that TXA improves THA outcomes without increasing the risk of adverse events by lowering blood loss and the requirement for transfusions. This insightful information can help surgeons decide whether to use TXA during THA procedures.
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Affiliation(s)
- Mohammad Ghorbani
- Orthopedic Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Hassan Sadrian
- Students Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Rezvan Ghaderpanah
- Students Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Colin C. Neitzke
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Brian P. Chalmers
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Saeid Esmaeilian
- Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Elham Rahmanipour
- Immunology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Parsa
- Orthopedic Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Butler JJ, Rajivan R, Konar K, Anil U, Azam MT, Walls R, Kennedy JG. Tranexamic acid reduces perioperative blood loss and postoperative hemoglobin loss during total ankle arthroplasty: A systematic review and meta-analysis of clinical comparative studies. J ISAKOS 2024:S2059-7754(24)00054-3. [PMID: 38521460 DOI: 10.1016/j.jisako.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 12/31/2023] [Accepted: 03/09/2024] [Indexed: 03/25/2024]
Abstract
IMPORTANCE Peri-operative blood loss during joint replacement procedures is a modifiable risk factor that impacts wound complications, hospital stay and total costs. Tranexamic acid (TXA) is an anti-fibrinolytic that has been widely used in orthopedic surgery, but its efficacy in the setting of total ankle arthroplasty (TAA) has not been quantified to date. AIM The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of administering TXA in patients undergoing TAA. EVIDENCE REVIEW The Medline, Embase and Cochrane library databases were systematically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five comparative studies examining blood loss following administration of TXA for patients undergoing TAA were included. The outcome measures of interest were blood loss, reduction in hemoglobin concentration, transfusion requirements, total complications and wound complications. FINDINGS In total, 194 patients received TXA and 187 patients did not receive TXA while undergoing TAA. Based on the common-effects model for total blood loss for the TXA group versus control, the standardized mean difference (SMD) was -0.7832 (95% CI, -1.1544, -0.4120; P < 0.0001), in favor of lower total blood loss for TXA. Based on the random-effects model for reduction in hemoglobin for the TXA group versus control, the SMD was -0.9548 (95% CI, -1.7850, -0.1246; P = 0.0242) in favor of lower hemoglobin loss for TXA. Based on the random-effects model for total complications for the TXA group versus control, the risk ratio was 0.512 (95% CI, 0.1588, 1.6512; P = 0.1876), in favor of lower total complications for TXA but this was not statistically significant. CONCLUSIONS This current review demonstrated that administration of TXA led to a reduction in blood loss and hemoglobin loss without an increased risk of the development of venous thromboembolism in patients undergoing TAA. No difference was observed with respect to total complication rates between the TXA cohort and the control group. TXA appears to be an effective hemostatic agent in the setting of TAA, but further studies are necessary to identify the optimal timing, dosage and route of TXA during TAA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- James J Butler
- Foot and Ankle Division, Department of Orthopaedic Surgery, NYU Langone Health, New York City, 10002, USA.
| | - Ragul Rajivan
- University of Buckingham, Buckingham, England, MK18 1EG, United Kingdom
| | - Kishore Konar
- University of Buckingham, Buckingham, England, MK18 1EG, United Kingdom
| | - Utkarsh Anil
- Foot and Ankle Division, Department of Orthopaedic Surgery, NYU Langone Health, New York City, 10002, USA
| | - Mohammad T Azam
- Foot and Ankle Division, Department of Orthopaedic Surgery, NYU Langone Health, New York City, 10002, USA
| | - Raymond Walls
- Foot and Ankle Division, Department of Orthopaedic Surgery, NYU Langone Health, New York City, 10002, USA
| | - John G Kennedy
- Foot and Ankle Division, Department of Orthopaedic Surgery, NYU Langone Health, New York City, 10002, USA.
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Ghobrial PG, Eikani CK, Schmitt DR, Brown NM, Pinzur MS, Schiff AP. Safety and Efficacy of Tranexamic Acid in Total Ankle Arthroplasty. Foot Ankle Spec 2023:19386400231207276. [PMID: 37916469 DOI: 10.1177/19386400231207276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Tranexamic acid has been shown to significantly reduce blood loss in patients undergoing total knee arthroplasty and total hip arthroplasty. However, there is a paucity of data regarding its safety and efficacy in total ankle arthroplasty. The purpose of this study was to determine whether tranexamic acid use in patients with total ankle arthroplasty affects blood loss or overall complication rate. A retrospective chart review was conducted for 64 patients who underwent total ankle arthroplasty with (n = 32) and without (n = 32) intraoperative tranexamic acid from 2014 to 2023 at a single academic medical center. Recorded blood loss, pre-to-postoperative hemoglobin changes, hidden blood loss, and complication rates were recorded and compared. There was no statistically significant difference in recorded blood loss, total calculated blood loss, pre-to-postoperative hemoglobin difference, hidden blood loss, or overall complications between the groups (all, P > .05). A lower rate of wound complications was observed in the tranexamic acid group, but the difference between each group was not statistically significant (P > .05). Tranexamic acid did not decrease blood loss during total ankle arthroplasty, as measured in our study. Tranexamic acid was not associated with any increase in overall complications. Based on our findings, tranexamic acid may be a safe intervention in total ankle arthroplasty, but further studies are needed to better elucidate its clinical impact.Level of Evidence: Level 3.
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Affiliation(s)
- Philip G Ghobrial
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Carlo K Eikani
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Daniel R Schmitt
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
| | - Nicholas M Brown
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
| | - Michael S Pinzur
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
| | - Adam P Schiff
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
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Arumugam A, Tan SE, Tan SL, Tan JE, Hussin F@H, Zenian MS, Idris Z, Abdullah JM. Tranexamic Acid in Non-Traumatic Intracerebral Haemorrhage (TANICH II): Introducing the Potential Role of 3 g Tranexamic Acid in Haematoma Reduction. Malays J Med Sci 2023; 30:93-102. [PMID: 37425386 PMCID: PMC10325132 DOI: 10.21315/mjms2023.30.3.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 09/16/2022] [Indexed: 07/11/2023] Open
Abstract
Background Intracerebral haemorrhage (ICH) can be devastating, particularly if haematoma expansion occurs. The efficacy of tranexamic acid (TXA), an anti-fibrinolytic agent, in reducing haematoma expansion is now being studied worldwide. However, the optimal dosage of TXA has yet to be determined. This study was designed to further establish the potential of different doses of TXA. Methods A double-blinded, randomised, placebo-controlled study was carried out among adults with non-traumatic ICH. Eligible study subjects were randomly assigned to receive placebo, 2-g TXA treatment or 3-g TXA treatment. Haematoma volumes before and after intervention were measured using the planimetric method. Results A total of 60 subjects with 20 subjects in each treatment group were recruited for this study. Among the 60 subjects, the majority were male (n = 36, 60%), had known cases of hypertension (n = 43, 71.7%) and presented with full Glasgow coma scale (GCS) (n = 41, 68.3%). The results showed that there was no statistically significant difference (P = 0.315) in the mean changes of haematoma volume when compared with three study groups using ANCOVA, although the 3-g TXA group was the only group that showed haematoma volume reduction (mean reduction of 0.2 cm3) instead of expansion as in placebo (mean expansion 1.8 cm3) and 2-g TXA (mean expansion 0.3 cm3) groups. Good recovery was observed in all study groups, with only three subjects being moderately disabled. No adverse effects were reported in any of the study groups. Conclusion To the best of our knowledge, this is the first clinical study using 3 g of TXA in the management of non-traumatic ICH. From our study, 3 g of TXA may potentially be helpful in reducing haematoma volume. Nonetheless, a larger-scale randomised controlled trial should be carried out to further establish the role of 3 g of TXA in non-traumatic ICH.
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Affiliation(s)
- Ananda Arumugam
- Department of Neurosurgery, Hospital Queen Elizabeth II, Sabah, Malaysia
- Department of Neurosurgery, Hospital Queen Elizabeth I, Sabah, Malaysia
| | - Shze Ee Tan
- Department of Neurosurgery, Hospital Queen Elizabeth II, Sabah, Malaysia
- Department of Neurosurgery, Hospital Queen Elizabeth I, Sabah, Malaysia
- Department of Neurosciences, Brain and Behaviour Cluster, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Sze Ling Tan
- Department of Pharmacy, Hospital Queen Elizabeth II, Sabah, Malaysia
| | - Jun Ee Tan
- Department of Radiology, Hospital Queen Elizabeth I, Sabah, Malaysia
| | | | - Mohd Sofan Zenian
- Department of Neurosurgery, Hospital Queen Elizabeth II, Sabah, Malaysia
- Department of Neurosurgery, Hospital Queen Elizabeth I, Sabah, Malaysia
| | - Zamzuri Idris
- Department of Neurosciences, Brain and Behaviour Cluster, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Jafri Malin Abdullah
- Department of Neurosciences, Brain and Behaviour Cluster, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kelantan, Malaysia
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Bildik C, Pehlivanoglu T. Arthroscopic rotator cuff repair performed with intra-articular tranexamic acid: could it provide improved visual clarity and less postoperative pain? A prospective, double-blind, randomized study of 63 patients. J Shoulder Elbow Surg 2023; 32:223-231. [PMID: 36403924 DOI: 10.1016/j.jse.2022.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/21/2022] [Accepted: 10/04/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) has been widely used in orthopedic surgery with the aim of reducing intraoperative and postoperative bleeding, as well as bleeding-related complications. The purpose of this study was to assess whether intra-articular use of TXA during arthroscopic rotator cuff tear (RCT) repair could improve visual clarity, shorten the duration of the operation, and provide superior pain management as compared with placebo. METHODS We conducted a prospective, randomized, double-blind, placebo-controlled study. Patients aged ≥18 years with a magnetic resonance imaging-confirmed RCT and a history of failed conservative treatment for ≥6 months were included. Patients with a history of coagulopathy; a history of cardiac, renal, or hepatic disease; a history of conservative treatment for <6 months; and/or acute RCTs were excluded. Visual clarity as the primary outcome was assessed using an arthroscopic visual scale comprising 5 grades-ranging from grade 1, best visual clarity, to grade 5, worst visual clarity (requiring conversion to open surgery)-after the procedure by the operating surgeon every 10 minutes throughout the video of the operation. Secondary outcomes were operative duration and postoperative pain scores. RESULTS A total of 63 patients with similar demographic data (age and sex) and intraoperative mean arterial pressure were enrolled and randomized into 2 groups: The TXA group comprised 32 patients with a mean age of 56.46 years, and the placebo group comprised 31 patients with a mean age of 57.83 years. The TXA group was reported to have significantly superior visual clarity (mean arthroscopic visual scale score, 1.5 ± 0.5 vs. 2.86 ± 1.7; P < .001), with a significantly higher percentage of grade 1 visual clarity (78.1% vs. 32.2%, P < .001) and a significantly lower percentage of grade 4 visual clarity (0% vs. 3.2%, P = .003). Grade 5 visual clarity was not recorded in any patient in either group. The TXA group showed a significantly shorter operative duration (55.73 minutes vs. 67.26 minutes, P = .001) and superior pain scores at 8 hours (2.3 vs. 3.6, P = .002) and 24 hours (1.6 vs. 2.4, P < .001) postoperatively. No complications were recorded in either group. CONCLUSIONS This study showed that during arthroscopic rotator cuff repair procedures, intra-articular use of TXA was able to provide superior arthroscopic visual clarity while shortening the total operative duration significantly and providing significantly superior pain management in the first 8 and 24 hours postoperatively as compared with placebo. This study underlines the safety and efficacy of intra-articular TXA use in arthroscopic rotator cuff repair.
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Affiliation(s)
- Celaleddin Bildik
- Orthopedic Surgery and Traumatology, Faculty of Health Sciences, Yeni Yüzyıl University, Istanbul, Turkey
| | - Tuna Pehlivanoglu
- Orthopedic Surgery and Traumatology, Faculty of Health Sciences, Yeni Yüzyıl University, Istanbul, Turkey; Department of Orthopaedic Surgery, Liv Hospital Ulus, Istanbul, Turkey.
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Safety and clinical outcomes associated with the routine use of tranexamic acid (TXA) in abdominal-based free flap autologous breast reconstruction — a case control study. EUROPEAN JOURNAL OF PLASTIC SURGERY 2023. [DOI: 10.1007/s00238-022-02027-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Jungwirth-Weinberger A, Do HT, Krell EC, Valle AGD, Chalmers BP, Boettner F. Blood management in direct anterior versus posterior primary total hip arthroplasty using tranexamic acid: a matched cohort study. Arch Orthop Trauma Surg 2023; 143:91-95. [PMID: 34152489 DOI: 10.1007/s00402-021-03965-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/18/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Proponents of the direct anterior approach (DAA) for THA claim patients recover faster compared to primary THA through the posterior approach (PA). Blood loss and transfusion have substantially declined with the use of tranexamic acid (TXA). However, it is still controversial if hemoglobin drops and transfusion rates are affected by the surgical approach when TXA is routinely used. MATERIALS AND METHODS 2418 patients undergoing DAA THA were matched 1:1 with patients undergoing PA THA according to preoperative hemoglobin (± 1 g/dl), age (± 5 years), sex, BMI (± 5 kg/m2) and year of surgery (± 2 years). All patients received perioperative TXA. None of the patients donated autologous blood. Hemoglobin levels, drain placement and output, blood transfusion rates and volume as well as length of stay were recorded. RESULTS A closed suction drain was used in 121 (5.0%) DAA and in 135 (5.6%) PA THAs (p = 0.369). Mean drain output was higher in the DAA compared to the PA group (134 ml (0-520 ml) versus 92.3 ml (0-600 ml), p = 0.004). There was no difference in hemoglobin drop [2.6 g/dl versus 2.6 g/dl (p = 0.143)] and transfusion rate [n = 31 (1.3%) versus n = 29 (1.2%), p = 0.793)] between DAA and PA THA. Mean transfusion amounts were 421.8 ml (250-1120.8 ml) in the DAA and 353.9 ml (250-560 ml) in the PA group (p = 0.801). The length of stay was shorter in the DAA group with a mean 1.6 days versus 2.1 days in the PA group (p ≤ 0.001). CONCLUSION In this large matched cohort study, there was no difference in the perioperative hemoglobin drop, the transfusion rate and the transfusion amount between DAA and PA THA.
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Affiliation(s)
- Anna Jungwirth-Weinberger
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedics and Traumatology, Cantonal Hospital Baden, Im Ergel 1, 5404, Baden, Switzerland
| | - Huong T Do
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ethan C Krell
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | | | - Brian P Chalmers
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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Fang Q, Zhang Z, Wang D, Wang L, Xiong W, Tang Y, Liu W, Wang G. Effect of Tranexamic Acid on Blood Management during a High Tibial Osteotomy: A Systematic Review and Meta-analysis. Orthop Surg 2022; 14:1940-1950. [PMID: 35913385 PMCID: PMC9483069 DOI: 10.1111/os.13407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 05/31/2022] [Accepted: 06/26/2022] [Indexed: 02/05/2023] Open
Abstract
This study aimed to evaluate the efficiency and safety of tranexamic acid for blood management during high tibial osteotomy (HTO). A systematic search was conducted in Medline, Embase, and the Cochrane library database. Six studies and 208 patients were included in this meta‐analysis using Review Manager V.5.3 and Stata 15.1 software. For primary outcomes, tranexamic acid lowered the total blood loss (WMD = –219.47, 95% CI [−355.61, −83.33], P = 0.002). For secondary outcomes, a significant reduction was found for decreased hemoglobin (POD1: WMD = –9.86, 95% CI [−13.45, −6.28], P < 0.05; POD2: WMD = –8.41, 95% CI [−11.50, −5.32], P < 0.05; POD5: WMD = –11.48, 95% CI [−14.56, −8.39], P < 0.05) and drainage (total: WMD = –105.93, 95% CI [−187.08, −24.78], P < 0.05; POD1: WMD = –122.195, 95% CI [−168.902, −75.488], P < 0.05). The sex difference (male/female ratio) was determined (total blood loss: P = 0.025; total drainage amount: p = 0.018) using meta‐regression analysis. Females benefited more from tranexamic acid in terms of total blood loss (M/F > 40%: WMD = –53.11, 95% CI [−100.16, −6.05], P = 0.03; 40% ≥ M/F ≥ 20%: WMD = –362.20, 95% CI [−423.96, −300.45], P < 0.05; M/F < 20%: WMD = –263.00, 95% CI [−277.17, −248.83], P < 0.05) and total drainage (M/F > 40%: WMD = –7.11, 95% CI [−10.75, −3.47], P < 0.05; 40% ≥ M/F ≥ 20%: WMD = –104.72, 95% CI [−155.36, −54.08], P < 0.05; M/F < 20%: WMD = –222.00, 95% CI [−297.42, −146.58], P < 0.05). No significant differences were found for drainage on POD2 and POD3, wound complications, orthromboembolic events. In conclusion, tranexamic acid is effective and safe for blood management during HTO. Females appeared to benefit more from it, and an additional postoperative dose is suggested fora better effect.
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Affiliation(s)
- Qian Fang
- West China Hospital, Sichuan University, Chengdu, China
| | - Zhen Zhang
- West China Hospital, Sichuan University, Chengdu, China
| | - Dong Wang
- West China Hospital, Sichuan University, Chengdu, China
| | - Limin Wang
- West China Hospital, Sichuan University, Chengdu, China
| | - Wei Xiong
- West China Hospital, Sichuan University, Chengdu, China
| | - Yunfeng Tang
- West China Hospital, Sichuan University, Chengdu, China
| | - Wenzheng Liu
- West China Hospital, Sichuan University, Chengdu, China
| | - Guanglin Wang
- West China Hospital, Sichuan University, Chengdu, China
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Efficacy of preoperative autologous blood storage in one-stage bilateral total knee arthroplasty. J Orthop Sci 2022; 27:648-651. [PMID: 35370041 DOI: 10.1016/j.jos.2020.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/12/2020] [Accepted: 12/25/2020] [Indexed: 02/09/2023]
Abstract
BACKGROUND One-stage bilateral total knee arthroplasty (TKA) has the advantages of a single hospital stay, shorter rehabilitation, and reduced financial burden on patients. However, perioperative bleeding is greater with one-stage bilateral TKA than with unilateral TKA and is more likely to require allogeneic blood transfusion. At our hospital, we normally store autologous blood about 1 month before surgery to reduce the need for allogeneic blood transfusion and avoid its adverse reactions as much as possible. The purpose of this study was to determine the efficacy of preoperative autologous blood storage for patients undergoing one-stage bilateral TKA. METHODS We retrospectively examined the allogeneic blood transfusion avoidance rate and the perioperative decrease in hemoglobin (Hb) level in 166 patients according to whether or not they had preoperative autologous blood stored. The patients for whom blood was stored were then subdivided according to whether the amount of blood stored was 400 mL or 200 mL. RESULTS Excluding allogeneic transfusion cases, the mean perioperative decrease in Hb was significantly lower in the patients with stored blood than in those without stored blood (3.5 g/dL vs 4.4 g/dL, p < 0.001). The allogeneic blood transfusion avoidance rate was significantly higher in the group with stored blood (98.5% vs 86.7%, p < 0.01). In the group with stored blood, the transfusion avoidance rate was higher, but not significantly, in the subgroup with 400 mL of blood stored than in those with 200 mL of blood stored (100% vs 97.5%) and the mean perioperative decrease in Hb was 3.5 g/dL in both blood storage volume groups. CONCLUSIONS Preoperative autologous blood storage can help increase the likelihood of avoiding allogeneic blood transfusion in patients undergoing one-stage bilateral TKA.
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Wong D, Lam TK. The role of tranexamic acid in breast and body contouring surgery: a review of the literature. AUSTRALASIAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.34239/ajops.v5n1.277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Postoperative seroma and haematoma are two of the most common complications follow-ing large surface area surgeries. A review of the literature was performed to evaluate evidence for the use of tranexamic acid in reducing postoperative seroma and haematoma formation in breast surgery and body contouring surgery.
Methods A literature search was performed using MEDLINE, the Cochrane Database of Systematic Review, the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Ef-fect (DARE) and PubMed in English from 1 Jan 1990–30 Mar 2020. The search terms ‘TXA’, ‘breast reduction’, ‘mammaplasty’, ‘breast implants’, ‘breast implantation’, ‘breast reconstruction’, ‘mastectomy’, ‘tissue ex-pansion’, ‘body contouring’, ‘breast’ and ‘abdominoplasty’ were used alone and in combination.
Results: A total of six articles were found including three randomised controlled trials, two cohort studies and one retrospective study. Two ongoing trials were found on The Cochrane Central Register of Con-trolled Trials (CENTRAL). No systematic reviews were found.
Conclusion: Literature surrounding the use of TXA in breast and body contouring surgery is sparse com-pared to what is available in other surgical sub-specialties. The literature available shows promising results with the use of TXA in controlling haematoma, drain output and seroma formation in breast surgery and body contouring surgery with minimal morbidity in these patient groups.
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Nakamura M, Shimakawa T, Nakano S, Sato R, Kondo K, Goto H, Sugimine Y, Enishi T, Sairyo K. Effectiveness of Primary Total Hip Arthroplasty Combined with Intra-articular and Intravenous Tranexamic Acid: A Retrospective Analysis of Number of Doses and Dose Strength. Indian J Orthop 2022; 56:1234-1239. [PMID: 35813550 PMCID: PMC9232659 DOI: 10.1007/s43465-021-00595-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 12/14/2021] [Indexed: 02/04/2023]
Abstract
Introduction Total hip arthroplasty is a very effective reconstructive surgery but is often associated with massive perioperative bleeding, which leads to anemia. Tranexamic acid (TXA) minimizes bleeding and the need for blood transfusion. However, no universal standard TXA dosing regimen has been established. The objectives of this study were (1) whether there was a difference in the amount of decrease in perioperative mean hemoglobin (Hb) level between a single topical administration of TXA and intravenous and topical combination administration, and we also investigated whether there was a difference in the amount of decrease in the perioperative mean Hb level due to the difference in the local dose of TXA. Methods We retrospectively reviewed 292 hips between June 2013 and October 2020. The decrease in Hb level (difference between the preoperative value and the 7-day postoperative value) was used to estimate total perioperative blood loss. The mean perioperative reduction in Hb was compared between hips that received intravenous TXA preoperatively and intra-articular TXA at wound closure (combination administration group) and those that received only intra-articular TXA (single dose group). It was also compared by different local doses of tranexamic acid. Results The mean reduction in Hb was significantly smaller in the combination administration group than in the single dose group. However, no significant difference was observed due to the difference in the local dose of TXA administered at the time of wound closure. Conclusion Reducing perioperative bleeding decreases the invasiveness of surgery, which is important from the perspective of medical safety.
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Affiliation(s)
- Masaru Nakamura
- Tokushima Municipal Hospital, 2-34 Kita-Josanjima, Tokushima, 770-0812 Japan
| | - Tateaki Shimakawa
- Tokushima Municipal Hospital, 2-34 Kita-Josanjima, Tokushima, 770-0812 Japan
| | - Shunji Nakano
- Tokushima Municipal Hospital, 2-34 Kita-Josanjima, Tokushima, 770-0812 Japan
| | - Ryosuke Sato
- Tokushima Municipal Hospital, 2-34 Kita-Josanjima, Tokushima, 770-0812 Japan
| | - Kenji Kondo
- Tokushima Municipal Hospital, 2-34 Kita-Josanjima, Tokushima, 770-0812 Japan
| | - Hitoshi Goto
- Tokushima Municipal Hospital, 2-34 Kita-Josanjima, Tokushima, 770-0812 Japan
| | - Yuto Sugimine
- Tokushima Municipal Hospital, 2-34 Kita-Josanjima, Tokushima, 770-0812 Japan
| | - Tetsuya Enishi
- Tokushima Municipal Hospital, 2-34 Kita-Josanjima, Tokushima, 770-0812 Japan
| | - Koichi Sairyo
- Department of Orthopedics, Institute of Health Biosciences, The University of Tokushima Graduate School, 3-18-5 Kuramoto, Tokushima, 770-8503 Japan
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Expanded use of tranexamic acid is safe and decreases transfusion rates in patients with geriatric hip fractures. OTA Int 2021; 4:e147. [PMID: 34765898 PMCID: PMC8575430 DOI: 10.1097/oi9.0000000000000147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 07/19/2021] [Indexed: 12/01/2022]
Abstract
Objectives: To determine the effect of a standardized tranexamic acid (TXA) protocol on red blood cell transfusions and adverse events in fragility hip fracture patients. Design: Retrospective cohort study. Setting: Academic Tertiary Care Center. Patients/Participants: Series of 209 patients with fragility hip fractures treated operatively from April 1, 2019 to September 30, 2019. Intervention: Eligible patients received 4 intravenous doses of TXA. Some patients missed doses and only received between 1 and 3 doses of TXA: Ineligible patients received no TXA. Patients with medical conditions precluding the use of TXA were deemed ineligible: allergy to TXA; creatinine clearance <30 mL/min; active malignancy; vascular event in the past year; anticoagulant use; fracture > 48 hours prior to presentation. Main Outcome Measures: Red blood cell transfusion; major adverse vascular events; minor drug related adverse events. Results: Patients who received all 4 doses of TXA (n = 70) had a significantly lower transfusion rate compared to those who did not receive any TXA (7.1% vs 28.1%, P = .003). There were no significant differences in the number of major or minor adverse events between the 2 groups. Conclusions: The use of a standardized TXA protocol of 4 doses significantly decreases transfusion rates in eligible patients undergoing operative intervention for fragility hip fracture without an increase in major or minor adverse events. These findings are even more pronounced in patients with decreased preoperative hemoglobin. Level of Evidence: Prognostic Level III
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Haratian A, Shelby T, Hasan LK, Bolia IK, Weber AE, Petrigliano FA. Utilization of Tranexamic Acid in Surgical Orthopaedic Practice: Indications and Current Considerations. Orthop Res Rev 2021; 13:187-199. [PMID: 34703327 PMCID: PMC8541761 DOI: 10.2147/orr.s321881] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/05/2021] [Indexed: 01/16/2023] Open
Abstract
Tranexamic acid (TXA) is a lysine analog that exhibits an anti-fibrinolytic effect by directly preventing the activation of plasminogen as well as inhibiting activated plasmin from degrading fibrin clots, thereby promoting hemostasis and reducing the duration and quantity of blood loss. The aims of this study were to summarize the indications, routes of administration, safety, and clinical outcomes of TXA use throughout the different subspecialities in orthopedic surgery. Given that orthopedic procedures such as TKA, THA, fracture fixation, and various spine surgeries involve significant intraoperative blood loss, TXA is indicated in providing effective perioperative hemostasis. Additionally, use of TXA in orthopedic trauma has been indicated as a measure to reduce blood loss especially in a group with potential for hemodynamic compromise. TXA has been implicated in reducing the risk of blood transfusions in orthopedic trauma, joint surgery, and spine surgery, although this effect is not seen as prominently in sports medicine procedures. There remains disagreement in literature as to whether TXA via any route of administration can improve other clinically significant outcomes such as hospital length of stay and total operative time. Procedures that rely extensively on clarity on visualization of the surgical field such as knee and shoulder arthroscopies can greatly benefit from the use of TXA, thereby leading to less intraoperative bleeding, with better visual clarity of the surgical field. While most studies agree thrombosis due to TXA is unlikely, new research in cells and animal models are evaluating whether TXA can negatively impact other aspects of musculoskeletal physiology, however with conflicting results thus far. As of now, TXA remains a safe and effective means of promoting hemostasis and reducing intraoperative blood loss in orthopedic surgery.
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Affiliation(s)
- Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Tara Shelby
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith K Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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Tan TK, Ng KT, Lim HJ, Radic R. Effect of tranexamic acid in arthroscopic anterior cruciate ligament repair: A systematic review and meta-analysis of randomised clinical trials. J Orthop Surg (Hong Kong) 2021; 29:23094990211017352. [PMID: 34027721 DOI: 10.1177/23094990211017352] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Perioperative blood loss remains a major challenge to surgeons in anterior cruciate ligament reconstruction (ACLR) surgery, despite of the introduction of minimally invasive approach. Tranexamic acid (TXA) is believed to reduce blood loss, which may minimise the complication of postoperative haemarthrosis with insufficient evidence on its effectiveness in ACLR. The primary aim of this study was to examine the effect of TXA on postoperative blood loss and other secondary outcomes in patients undergoing arthroscopic ACLR surgery. METHOD PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched from its inception until November 2020. All randomised clinical trials (RCTs) comparing TXA (intravenous or intra-articular) versus placebo in the arthroscopic ACLR surgery were included. Case series, case report and editorials were excluded. RESULTS Five RCTs comprising of a total of 580 patients (291 in TXA group, 289 in control group) were included for qualitative and quantitative meta-analysis. In comparison to placebo, TXA group was significantly associated with lower postoperative blood loss (mean difference (MD): -81.93 ml; 95% CI -141.80 to -22.05) and lower incidence of needing knee aspiration (odd ratio (OR): 0.19; 95% CI 0.08 to 0.44). Patients who randomised to TXA were also reported to have better range of movement (MD: 2.86; 95% CI 0.54 to 5.18), lower VAS Pain Score (MD: -1.39; 95% CI -2.54 to -0.25) and higher Lysholm Score (MD: 7.38; 95% CI 2.75 to 12.01). CONCLUSION In this meta-analysis, TXA reduced postoperative blood loss with lesser incidence of needing knee aspiration along with better range of knee movement and Lysholm score in patients undergoing arthroscopic ACLR surgery.
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Affiliation(s)
| | - Ka Ting Ng
- Department of Anaesthesiology, Faculty of Medicine, 37447University of Malaya, Kuala Lumpur, Malaysia
| | - Hui Jane Lim
- 155310Altnagelvin Area Hospital, Londonderry, UK
| | - Ross Radic
- Perth Orthopaedics and Sports Medicine Research Institute, West Perth, WA, Australia
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Hartland AW, Teoh KH, Rashid MS. Clinical Effectiveness of Intraoperative Tranexamic Acid Use in Shoulder Surgery: A Systematic Review and Meta-analysis. Am J Sports Med 2021; 49:3145-3154. [PMID: 33475421 PMCID: PMC8411466 DOI: 10.1177/0363546520981679] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is widely used across surgical specialties to reduce perioperative bleeding. It has been shown to be effective in spinal surgery and lower limb arthroplasty. Among all languages, there are no systematic reviews or meta-analyses investigating its clinical effectiveness for all types of shoulder surgery. PURPOSE To investigate the clinical effectiveness of TXA in all types of shoulder surgery, including open and arthroscopic procedures. To investigate the effect of TXA on bleeding and non-bleeding-related outcomes. STUDY DESIGN Systematic review and meta-analysis. METHODS A protocol for the study was designed and registered with PROSPERO (CRD42020185482). The literature search included the MEDLINE, Embase, PsycINFO, and Cochrane Library databases. All randomized controlled trials evaluating the use of TXA against placebo, in all types of shoulder surgery, were included. Assessments were undertaken for risk of bias and certainty of evidence. The primary outcome was total blood loss. Secondary outcomes included those not directly related to bleeding. Data from comparable outcomes were pooled and analyzed quantitatively or descriptively, as appropriate. RESULTS Eight randomized controlled trials were included in the systematic review, and data from 7 of these studies were pooled in the meta-analysis. Pooled analysis demonstrated a significant reduction in 2 of 3 outcomes measuring perioperative bleeding with TXA compared with controls: estimated total blood loss (mean difference, -209.66 mL; 95% CI, -389.11 to -30.21; P = .02) and postoperative blood loss as measured by drain output (mean difference, -84.8 mL; 95% CI, -140.04 to -29.56; P = .003). Hemoglobin reduction was reduced but not statistically significant (mean difference, -0.33 g/dL; 95% CI -0.69 to 0.03; P = .07). This result became significant with sensitivity analysis excluding arthroscopic procedures. CONCLUSION This systematic review and meta-analysis indicated that TXA was effective in reducing blood loss in shoulder surgery. Larger randomized controlled trials with low risk of bias for specific surgical shoulder procedures are required. CLINICAL RELEVANCE TXA can be used across shoulder surgery to reduced perioperative blood loss. The use of TXA may have other beneficial features, including reduced postoperative pain and reduced operative time.
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Affiliation(s)
| | - Kar H. Teoh
- Princess Alexandra Hospital, Harlow,
Essex, UK
| | - Mustafa S. Rashid
- Nuffield Department of Orthopaedics,
Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK,Mustafa S. Rashid, MB ChB,
MSc, PhD, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal
Sciences, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK (
)
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Johnson-Arbor K, Verstraete R. Bloodless Management of the Anemic Patient in the Emergency Department. Ann Emerg Med 2021; 79:48-57. [PMID: 34353645 DOI: 10.1016/j.annemergmed.2021.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/26/2021] [Accepted: 06/14/2021] [Indexed: 11/16/2022]
Abstract
Anemia is a commonly encountered condition in emergency medicine; transfusion of packed red blood cells is commonly performed for anemic patients in the emergency department (ED), but some patients are unable to accept transfusion of blood products due to medical or religious concerns. The unique, acute, and time-sensitive nature of emergency medicine practice requires that physicians maintain an enhanced awareness of bloodless medicine treatment modalities. Identification of bloodless medicine patient preferences in the ED can help guide physicians in the recommendation of acceptable methods of treating anemia in this patient population. A focus on early hemostasis and resuscitation, instead of attempts to convince the patient to accept blood transfusion, can be lifesaving in patients with acute bleeding. Treatment strategies including the use of methods to reduce unnecessary blood loss, enhance red blood cell production, and increase the oxygen-carrying capacity of blood should also be considered early in patient presentation. Timely involvement of the Hospital Liaison Committee can help facilitate successful interpersonal communication and shared decisionmaking between emergency physicians and bloodless medicine patients. By embracing an understanding of bloodless medicine patient needs as well as available treatment strategies, ED physicians can contribute to optimal overall outcomes for anemic bloodless medicine patients.
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Affiliation(s)
- Kelly Johnson-Arbor
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC; MedStar Institute for Quality and Safety, MedStar Health, Columbia, MD.
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18
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Allen G. A Meta-Analysis of Complications of Tranexamic Acid Use in Lower-Limb Orthopedic Surgery. AORN J 2021; 113:657-660. [PMID: 34048048 DOI: 10.1002/aorn.13415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 11/10/2022]
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Safety of Tranexamic Acid in Hip and Knee Arthroplasty in High-risk Patients. Anesthesiology 2021; 135:57-68. [PMID: 33857300 DOI: 10.1097/aln.0000000000003772] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND With increasing use of tranexamic acid in total hip and knee arthroplasties, safety concerns remain. Using national claims data, this study examined tranexamic acid use in patients with preexisting comorbidities. The hypothesis was that tranexamic acid use is not associated with increased complication risk in hip and knee arthroplasty patients with comorbidities. METHODS Among 765,011 total hip/knee arthroplasties (2013 to 2016, Premier Healthcare claims), tranexamic acid use was assessed in three high-risk groups: group I with patients with a history of venous thromboembolism, myocardial infarction, seizures, or ischemic stroke/transient ischemic attack (n = 27,890); group II with renal disease (n = 44,608); and group III with atrial fibrillation (n = 45,952). The coprimary outcomes were blood transfusion and new-onset "composite complications" (venous thromboembolism, myocardial infarction, seizures, and ischemic stroke/transient ischemic attack). Associations between tranexamic acid use and outcomes were measured separately by high-risk group. The odds ratios and Bonferroni-adjusted 99.9% CIs are reported. RESULTS Overall, 404,974 patients (52.9%) received tranexamic acid, with similar frequencies across high-risk groups I (13,004 of 27,890 [46.6%]), II (22,424 of 44,608 [50.3%]), and III (22,379 of 45,952 [48.7%]). Tranexamic acid use was associated with decreased odds of blood transfusion in high-risk groups I (721 of 13,004 [5.5%] vs. 2,293 of 14,886 [15.4%]; odds ratio, 0.307; 99.9% CI, 0.258 to 0.366), group II (2,045 of 22,424 [9.1%] vs. 5,159 of 22,184 [23.3%]; odds ratio, 0.315; 99.9% CI, 0.263 to 0.378), and group III (1,325 of 22,379 [5.9%] vs. 3,773 of 23,573 [16.0%]; odds ratio, 0.321; 99.9% CI, 0.266 to 0.389); all adjusted comparisons P < 0.001. No increased odds of composite complications were observed in high-risk group I (129 of 13,004 [1.0%] vs. 239 of 14,886 [1.6%]; odds ratio, 0.89, 99.9% CI, 0.49 to 1.59), group II (238 of 22,424 [1.1%] vs. 369 of 22,184 [1.7%]; odds ratio, 0.98; 99.9% CI, 0.58 to 1.67), and group III (187 of 22,379 [0.8%] vs. 290 of 23,573 [1.2%]; odds ratio, 0.93; 99.9% CI, 0.54 to 1.61); all adjusted comparisons P > 0.999. CONCLUSIONS Although effective in reducing blood transfusions, tranexamic acid is not associated with increased complications, irrespective of patient high-risk status at baseline. EDITOR’S PERSPECTIVE
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Ngarmukos S, Kim KI, Wongsak S, Chotanaphuti T, Inaba Y, Chen CF, Liu D. Asia-Pacific venous thromboembolism consensus in knee and hip arthroplasty and hip fracture surgery: Part 1. Diagnosis and risk factors. Knee Surg Relat Res 2021; 33:18. [PMID: 34147134 PMCID: PMC8214263 DOI: 10.1186/s43019-021-00099-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/04/2021] [Indexed: 12/11/2022] Open
Affiliation(s)
- Srihatach Ngarmukos
- Department of Orthopaedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kang-Il Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu Seoul, Seoul, 134-727, Korea. .,Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University, Seoul, Korea.
| | - Siwadol Wongsak
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thanainit Chotanaphuti
- Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - David Liu
- Gold Coast Centre for Bone & Joint Surgery, Gold Coast, Australia
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21
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Fathimani K, Perenack J, Christensen BJ. The Use of Tranexamic Acid in Facial Cosmetic Surgery Procedures: A Technical Note. J Oral Maxillofac Surg 2021; 79:2334-2338. [PMID: 34245699 DOI: 10.1016/j.joms.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 12/19/2022]
Abstract
Tranexamic acid (TXA) has been widely used as an antifibrinolytic in dentoalveolar surgery and only recently has its effects been explored in facial procedures. Multiple studies have reported the use of TXA in facial cosmetic surgery; and to date, only a limited number of them utilized TXA as a local infiltrative technique for rhytidectomy procedures. We present a technical note to using lower concentrations of TXA in tumescent anesthesia for an array of facial cosmetic procedures. Our experience thus far has shown improved hemostasis, reduction of intraoperative bleeding and a more profound reduction in postoperative ecchymosis, edema and seroma formation.
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Affiliation(s)
- Kayvan Fathimani
- Facial Cosmetic Surgery Fellow, Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, School of Dentistry, New Orleans, LA.
| | - Jon Perenack
- Facial Cosmetic Surgery Fellowship Director and Associate Clinical Professor, Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Brian J Christensen
- Assistant Professor, Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
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22
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Zhang S, Wang F, Wang C, Chu P, Shi L, Xue Q. Are The Applications of Tranexamic Acid in Reverse Hybrid Total Knee Arthroplasty (TKA) The Same as Those in Fully Cemented TKA?: A Randomized Controlled Trial. Adv Ther 2021; 38:2542-2557. [PMID: 33830462 DOI: 10.1007/s12325-021-01719-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Traditional fully cemented prosthesis for total knee arthroplasty (TKA) has many disadvantages. Current studies have shown that the effects of mixed fixation TKA are the same as or even better than those of fully cemented TKA. We aimed to compare the total blood loss (TBL) in the two fixation types of TKA and the hemostatic effects of different doses of tranexamic acid (TXA) for reverse hybrid TKA. METHODS From September 2018 to November 2020, 233 patients with knee osteoarthritis undergoing unilateral TKA were randomly divided into four groups: groups 1 and 2: fully cemented TKA + intra-articular injection (IAI) of either 1 g TXA (n = 54) or 2 g TXA (n = 60); groups 3 and 4: reverse hybrid TKA + IAI of either 1 g TXA (n = 56) or 2 g TXA (n = 63). All patients were administered intravenous drip of TXA (20 mg/kg) as the basic drug. Perioperative and follow-up data of all patients were compared. RESULTS The TBL in groups 1, 2, and 3 was higher than that in group 4 (P < 0.0001). The TBL in group 1 was significantly less than that in group 3 (P < 0.05). Although there was no significant difference in blood transfusion demand among the four groups (P > 0.05), the number of anemic patients who did not meet the standard of blood transfusion in group 4 decreased significantly (P < 0.0001). There was no significant difference in pain, function or thrombotic complications among all patients. CONCLUSION The TBL in reverse hybrid TKA is larger than in fully cemented TKA. For reverse hybrid TKA, the hemostatic effect of TXA with 2 g of IAI was significantly better than with 1 g. Although this method does not reduce the need for blood transfusion, it can significantly reduce the incidence of postoperative anemia.
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Affiliation(s)
- Shenqi Zhang
- Department of Orthopedics, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
- Department of Joint and Sports Medicine, Zaozhuang Municipal Hospital Affiliated to Jining Medical University, Shandong, 277100, China
| | - Fengyan Wang
- Department of Joint and Sports Medicine, Zaozhuang Municipal Hospital Affiliated to Jining Medical University, Shandong, 277100, China
| | - Chengbin Wang
- Department of Joint and Sports Medicine, Zaozhuang Municipal Hospital Affiliated to Jining Medical University, Shandong, 277100, China
| | - Pengfei Chu
- Department of Orthopedics, Weishan People's Hospital, Shandong, 277600, China
| | - Lei Shi
- Department of Orthopedics, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Qingyun Xue
- Department of Orthopedics, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China.
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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Zhang XC, Sun MJ, Pan S, Rui M, Zhao FC, Zha GC, Pang Y, Zheng X, Guo KJ. Intravenous administration of tranexamic acid in total hip arthroplasty does not change the blood coagulopathy: a prospective thrombelastography analysis. J Orthop Surg (Hong Kong) 2021; 28:2309499020959516. [PMID: 32985369 DOI: 10.1177/2309499020959516] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Despite the wide use of tranexamic acid (TXA) in the perioperative period of total hip arthroplasty (THA), whether the hemostatic state changes after the application of intravenous (IV)-TXA are still unknown. The aim of this study was to investigate whether IV administration of TXA changes the blood coagulation following primary THA via thrombelastography (TEG) analysis and conventional laboratory tests. METHODS A total of 174 patients who underwent primary THA from September 2016 to July 2018 were selected. They were randomly divided into two groups, 86 patients with IV administration of 15 mg/kg TXA and 88 controls without TXA usage. Demographic data, TEG paremeters, d-dimer levels, fibrin degradation products, hemoglobin, hematocrit concentration, platelet, transfusion rates, perioperative blood loss, and the occurrence of deep vein thrombosis were collected. TEG and conventional laboratory tests were performed the day before operation, the first day after operation, and seventh day after operation. RESULTS There were no differences with regard to TEG or conventional laboratory tests between the two groups (p > 0.05). The total blood loss and drain blood loss in the TXA group were significantly lower than those in the control group (p < 0.05). The transfusion rates and the volume of blood transfusion of the control group were higher than those of the TXA group (p < 0.05). CONCLUSION The administration of IV-TXA resulted in a significant reduction in total blood loss, transfusion volumes, and transfusion rates without the increase of thromboembolic complications. Moreover, it was confirmed that TXA would not change the coagulation via the TEG analysis.
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Affiliation(s)
- Xing-Chen Zhang
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Ma-Ji Sun
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Sheng Pan
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Min Rui
- Department of Orthopaedics, Jiangsu Jiangyin People's Hospital, Jiangyin, China
| | - Feng-Chao Zhao
- Department of Orthopaedics, 71069The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Guo-Chun Zha
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yong Pang
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xin Zheng
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Kai-Jin Guo
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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Belk JW, McCarty EC, Houck DA, Dragoo JL, Savoie FH, Thon SG. Tranexamic Acid Use in Knee and Shoulder Arthroscopy Leads to Improved Outcomes and Fewer Hemarthrosis-Related Complications: A Systematic Review of Level I and II Studies. Arthroscopy 2021; 37:1323-1333. [PMID: 33278534 DOI: 10.1016/j.arthro.2020.11.051] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review the literature to compare the efficacy and safety of tranexamic acid (TXA) as a means to minimize hemarthrosis-related complications after arthroscopic procedures of the knee, hip, and shoulder. METHODS A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed by searching PubMed, Cochrane Library, and Embase databases to locate randomized controlled trials comparing the clinical outcomes and postoperative complications of patients undergoing arthroscopy with and without TXA. Search terms used were "tranexamic acid," "arthroscopy," "knee," "hip," and "shoulder." Patients were evaluated based on early (<6 weeks) postoperative signs of hemarthrosis using the Coupens and Yates classification, postoperative complications (myocardial infarction, stroke, venous thromboembolism events), range of motion (ROM), and patient-reported outcome scores (Visual analog scale, Subjective International Knee Documentation Committee, Lysholm, and Tegner activity scores). RESULTS Five studies (2 level I and 3 level II) met inclusion criteria, including a total of 299 patients undergoing arthroscopy with TXA and 299 patients without TXA. The average follow-up duration for all patients was 43.9 days. Procedures performed were partial meniscectomy, anterior cruciate ligament reconstruction, and rotator cuff repair. No studies evaluating TXA use in hip arthroscopy were identified. Coupens-Yates hemarthrosis grades significantly improved in the TXA groups across all studies. Three studies found TXA patients to experience significantly less postoperative pain at latest follow-up, 1 study found TXA patients to have significantly better postoperative Lysholm scores, and 1 study found TXA patients to have significantly more ROM at latest follow-up compared with non-TXA patients (P < .05). CONCLUSION Patients undergoing arthroscopy, particularly arthroscopic meniscectomy, arthroscopic-assisted anterior cruciate ligament reconstruction, and arthroscopic rotator cuff repair, with TXA can be expected to experience improved outcomes and less hemarthrosis-related complications in the early postoperative period compared with non-TXA patients. LEVEL OF EVIDENCE II, systematic review of level I and II studies.
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Affiliation(s)
- John W Belk
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A..
| | - Eric C McCarty
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Darby A Houck
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Jason L Dragoo
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Felix H Savoie
- Department of Orthopaedics, Tulane University, New Orleans, Louisiana, U.S.A
| | - Stephen G Thon
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
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Evaluation of local tranexamic acid on septoplastic surgery quality. J Plast Reconstr Aesthet Surg 2021; 74:2744-2750. [PMID: 34266802 DOI: 10.1016/j.bjps.2021.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 01/26/2021] [Accepted: 03/11/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Even a small amount of bleeding during nose surgery can impair the surgeon's vision, prolong the duration of operation, and affect surgery quality; therefore, various techniques have been proposed to control the bleeding. The aim of this study was to compare the efficacy of the local use of tranexamic acid (TXA) in the dry field of surgery. METHOD This randomized, double-blinded, controlled trial was conducted in the operation room of Imam Reza Hospital, Tehran, Iran, from January 10, 2016 to February 8, 2017. Sixty patients with age range from 20 to 60 years and the American Society of Anesthesiologists physical status classes I candidates who require septoplasty enrolled. Patients were randomized through white and black cards to receive either syringes. Thirty patients in the intervention group received lidocaine + adrenaline + TXA and 30 patients in the control group received lidocaine + adrenaline. Bleeding volume accumulated in the suction chamber, the nasopharyngeal pack, and hemodynamic variations were measured. Surgeon's satisfaction scores and suitability of operation field were obtained from the surgeon by using the Likert scale and Boezaart grading scale, respectively. RESULTS The intervention group had a higher score of surgeon satisfaction [4.1 vs 3.16 in the control group (P = 0.001)] and fewer hemodynamic variations. The mean bleeding volume in the intervention was 187.23 ± 54.61 mL and in the control group was 341.22 ± 49.17 mL (P = 0.001). The mean Boezaart score (suitability of operation field) in the intervention group was 1.8 (score range: 1-3) and in the control group was 2.53 (score range: 2-4) and it was statistically significant (P = 0.001). CONCLUSION The local use of TXA + lidocaine + adrenaline is associated with reduced bleeding, greater surgeon satisfaction, reduced need for Karpol injection, and better hemodynamic stability.
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Hood M, Dilley JE, Ziemba-Davis M, Meneghini RM. Greater Blood Loss in Contemporary Cementless Total Knee Arthroplasty than Cemented Total Knee Arthroplasty despite Tranexamic Acid Use: A Match-Controlled Retrospective Study. J Knee Surg 2021; 34:351-356. [PMID: 31470452 DOI: 10.1055/s-0039-1695796] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this retrospective study was to assess whether tranexamic acid (TXA) reduces blood loss in cementless total knee arthroplasty (TKA) comparable to levels observed with cemented fixation. After exclusions from 109 consecutive TKAs, 76 cementless knees were matched to 78 cemented knees of identical implant and surgeon. Blood loss with and without TXA was compared. There was no difference between cohorts in sex, age, body mass index, American Society of Anesthesiologists Physical Status classification, or preoperative hemoglobin (p ≥ 0.119). Use of TXA reduced median drain output by only 205 mL in cementless knees compared to 470 mL in cemented knees (p < 0.001). Median drain output per hour was highest in cementless knees without TXA (39.5 mL) followed by cemented knees without TXA (38.2 mL), cementless knees with TXA (28.5 mL), and cemented knees with TXA (12.7 mL; p < 0.001). Hemoglobin drop and total blood loss did not differ between cohorts regardless of TXA use. Cementless fixation in TKA resulted in greater intra-articular blood loss as measured by drain output, despite the use of TXA. Further research is warranted to examine whether a higher TXA dose, TXA delivery method, or the application of bone wax sealant would mitigate blood loss in cementless TKA, and subsequently whether intra-articular blood accumulation resulting in postoperative hemarthrosis affects recovery, function, and clinical outcomes.
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Affiliation(s)
- Mark Hood
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Julian E Dilley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mary Ziemba-Davis
- Department of Orthopedics and Sports Medicine, Indiana University Health Physicians, Fishers, Indiana
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Complications of Tranexamic Acid in Orthopedic Lower Limb Surgery: A Meta-Analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6961540. [PMID: 33532495 PMCID: PMC7834786 DOI: 10.1155/2021/6961540] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/23/2020] [Indexed: 12/21/2022]
Abstract
Objective Tranexamic acid (TXA) is increasingly used in orthopedic surgery to reduce blood loss; however, there are concerns about the risk of venous thromboembolic (VTE) complications. The aim of this study was to evaluate TXA safety in patients undergoing lower limb orthopedic surgical procedures. Design A meta-analysis was performed on the PubMed, Web of Science, and Cochrane Library databases in January 2020 using the following string (Tranexamic acid) AND ((knee) OR (hip) OR (ankle) OR (lower limb)) to identify RCTs about TXA use in patients undergoing every kind of lower limb surgical orthopedic procedures, with IV, IA, or oral administration, and compared with a control arm to quantify the VTE complication rates. Results A total of 140 articles documenting 9,067 patients receiving TXA were identified. Specifically, 82 studies focused on TKA, 41 on THA, and 17 on other surgeries, including anterior cruciate ligament reconstruction, intertrochanteric fractures, and meniscectomies. The intravenous TXA administration protocol was studied in 111 articles, the intra-articular in 45, and the oral one in 7 articles. No differences in terms of thromboembolic complications were detected between the TXA and control groups neither in the overall population (2.4% and 2.8%, respectively) nor in any subgroup based on the surgical procedure and TXA administration route. Conclusions There is an increasing interest in TXA use, which has been recently broadened from the most common joint replacement procedures to the other types of surgeries. Overall, TXA did not increase the risk of VTE complications, regardless of the administration route, thus supporting the safety of using TXA for lower limb orthopedic surgical procedures.
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Carbone A, Poeran J, Zubizarreta N, Chan J, Mazumdar M, Parsons BO, Galatz LM, Cagle PJ. Administration of tranexamic acid during total shoulder arthroplasty is not associated with increased risk of complications in patients with a history of thrombotic events. J Shoulder Elbow Surg 2021; 30:104-112. [PMID: 32807373 DOI: 10.1016/j.jse.2020.04.050] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) has been shown to reduce blood loss and transfusion risk in various orthopedic surgeries including shoulder arthroplasty. However, concerns still exist regarding its use in patients with a history of thrombotic events. Using national claims data, we aimed to study the safety of TXA administration in shoulder arthroplasty patients with a history of thrombotic events. METHODS We used retrospective national claims data (Premier Healthcare) on 71,174 patients who underwent a total or reverse shoulder arthroplasty between 2010 and 2016. TXA use was evaluated specifically within a subgroup of patients with a history of thrombotic events such as myocardial infarction, deep venous thrombosis, pulmonary embolism, transient ischemic attack, or ischemic stroke. Studied outcomes were blood transfusion need, complications (including acute renal failure, new onset myocardial infarction, deep venous thrombosis, pulmonary embolism, transient ischemic attack, or ischemic stroke), and cost and length of hospitalization. Mixed-effects models measured the association between TXA use and outcomes, separately in patients with and without a history of thrombotic events. Odds ratios (OR) or percent change for continuous outcomes with 95% confidence intervals (CI) were reported. RESULTS Overall, TXA was used in 13.7% (n = 9735) of patients, whereas 10.5% (n = 7475) of patients had a history of a thrombotic event. After adjustment for relevant covariates, TXA use (compared with no TXA use) in patients without a history of thrombotic events was associated with decreased odds of blood transfusions (OR, 0.48; CI, 0.24-0.98; P = .0444), whereas no increased odds for complications were observed (OR, 0.83; CI, 0.40-1.76; P = .6354). Similar results were observed in patients with a history of thrombotic events. Moreover, in this subgroup, TXA use was associated with a slight reduction in hospitalization cost (-8.9% CI: -13.1%; -4.6%; P < .0001; group median $18,830). CONCLUSIONS Among shoulder arthroplasty patients, TXA use was not associated with increased complication odds, independent of a history of thrombotic events. These findings are in support of wider TXA use.
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Affiliation(s)
- Andrew Carbone
- Leni & Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Jashvant Poeran
- Leni & Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Healthy Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Zubizarreta
- Leni & Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Healthy Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jimmy Chan
- Leni & Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Department of Population Healthy Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bradford O Parsons
- Leni & Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Leesa M Galatz
- Leni & Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul J Cagle
- Leni & Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Wang Q, Yeersheng R, Li D, Yang Z, Kang P. Intravenous tranexamic acid for reducing perioperative blood loss during revision hip arthroplasty: A retrospective study. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:519-523. [PMID: 33155563 DOI: 10.5152/j.aott.2020.19044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This study aimed to explore the efficacy and safety of intravenous tranexamic acid (TXA) for reducing perioperative blood loss and allogeneic blood transfusions in revision hip arthroplasty. METHODS TXA was routinely administered as an intravenous preoperative dose in all the revision hip arthroplasty cases in our institution from December 2012. We retrospectively reviewed 803 patients who underwent revision hip arthroplasty from January 2008 to September 2018. These patients were divided into 2 groups based on whether they received intravenous TXA (n=482; 231 men and 251 women; mean age: 63.27±11.73 years) or not (n=321; 159 men and 162 women; mean age: 63.91±11.69 years). The 2 groups were compared in terms of estimated intraoperative blood loss, visible blood loss, hidden blood loss, the rate and volume of allogeneic blood transfusions, and the incidence of symptomatic venous thromboembolism. The patients were also compared depending on whether they underwent total hip revision, isolated acetabular revision, or isolated femoral revision. RESULTS Regardless of the type of revision involved, the patients who received TXA showed significantly lower estimated intraoperative blood loss, visible blood loss, hidden blood loss, and allogeneic blood transfusion rate and volume (all p values were less than 0.001). Use of TXA was not associated with significant changes in the incidence of postoperative symptomatic venous thromboembolism (p=0.911). Similar results were obtained with subgroups of patients who underwent different types of revision surgeries, except hidden blood loss (p=0.994) of patients in the isolated femoral revision subgroup. CONCLUSION The administration of intravenous TXA can safely and effectively reduce the perioperative blood loss and allogeneic blood transfusions in revision hip arthroplasty. LEVEL OF EVIDENCE Level III, Therapeutic study.
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Affiliation(s)
- Qiuru Wang
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Releken Yeersheng
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Donghai Li
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Zhouyuan Yang
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Pengde Kang
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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Lee JW, Kim SG, Kim SH, Cho HW, Bae JH. Intra-articular Administration of Tranexamic Acid Has No Effect in Reducing Intra-articular Hemarthrosis and Postoperative Pain After Primary ACL Reconstruction Using a Quadruple Hamstring Graft: A Randomized Controlled Trial. Orthop J Sports Med 2020; 8:2325967120933135. [PMID: 32743011 PMCID: PMC7376302 DOI: 10.1177/2325967120933135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/01/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Insufficient data are available to support the routine use of tranexamic acid
(TXA) in anterior cruciate ligament (ACL) surgeries with respect to
administration method and frequency, exposure duration, dose, and adverse
effects. Purpose: To investigate whether intra-articular (IA) administration of TXA could
reduce hemarthrosis and postoperative pain in patients after ACL
reconstruction. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 47 patients were included in this study, which was performed
between July 2017 and May 2019. Single-bundle reconstructions using
autologous hamstring tendon grafts were performed in all patients. The
patients were randomized into 2 groups: the TXA group (received the index
procedure with 100-mL IA injection of TXA [30 mg/mL]) and a control group
(did not receive IA injection of TXA). No patients received a drain. Blood
loss was calculated on the basis of hemoglobin balance at postoperative day
(PD) 2. The visual analog scale (VAS) for pain score was assessed at PD 3.
The midpatellar circumference was measured at PD 2 and PD 5. Knee range of
motion (ROM) was evaluated 6 weeks after surgery. Results: The mean ± SD blood loss was 467 ± 242 mL in the TXA group and 558 ± 236 mL
in the control group. No significant differences were found for blood loss
(P = .20), VAS pain scores (P = .28),
ROM at postoperative week 6 (P = .61), or patellar
circumference at PD 2 (P = .75) and PD 5
(P = .84). Conclusion: This study showed that IA administration of 3.0 g of TXA had no effect in
reducing blood loss and postoperative pain after primary anatomic
single-bundle ACL reconstruction using quadruple hamstring autografts. Registration: NCT04042688 (ClinicalTrials.gov
identifier).
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Affiliation(s)
- Ja-Woon Lee
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sang-Gyun Kim
- Department of Orthopedic Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Su-Hyun Kim
- Department of Orthopedic Surgery, Naval Maritime Medical Center, Jinju, Republic of Korea
| | - Hyun-Woo Cho
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hoon Bae
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Balachandar G, Abuzakuk T. Is there an optimal timing of administration of single-dose intravenous tranexamic acid in bilateral total knee arthroplasty? A comparison between preoperative and intraoperative dose. J Orthop Surg (Hong Kong) 2020; 27:2309499019880915. [PMID: 31635527 DOI: 10.1177/2309499019880915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE There is no consensus on the optimum timing of administration of tranexamic acid (TA) in bilateral total knee arthroplasty (TKA). We aimed to determine whether the timing of administration of single-dose intravenous TA (either given preoperatively or intraoperatively) has a significant effect on blood loss reduction. METHODS We compared two cohorts of patients with end-stage arthritis of knees who underwent bilateral TKA and were given single-dose intravenous TA (1 g or 15 mg/kg) at different times during surgery. The retrospective cohort group consisting of 40 patients (preoperative (PO) group) received TA before the skin incision. The prospective cohort consisting of 40 patients (intraoperative (IO) group) received TA 10 min before deflating the tourniquet on the first knee. Primary outcome measures were mean hemoglobin difference, A (between PO and day 1 postoperative hemoglobin), mean hemoglobin difference, B (between PO and lowest postoperative hemoglobin), and rate of allogeneic blood transfusion. Secondary measure was drain blood loss. RESULTS Both cohorts were well matched with respect to age, gender, duration of surgery, and length of hospital stay. The hemoglobin drop in the IO group was significantly lesser than the PO group on the first postoperative day (2 vs. 2.9 g/dL, p < 0.001). Although statistically insignificant, the patients in the IO group received less allogenic transfusion of packed cell units than in the PO group (11/40, 27.5% vs. 14/40, 35% ). Mean hemoglobin difference, B, and secondary drain loss were comparable in both groups. CONCLUSION Single-dose intravenous TA given before the start of surgery is as effective as a dose given during arthroplasty of the first knee in reducing blood loss in bilateral TKA.
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Affiliation(s)
| | - Tarek Abuzakuk
- Department of Orthopaedics, American Hospital, Dubai, United Arab Emirates
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Pérez-Chrzanowska H, Padilla-Eguiluz NG, Gómez-Barrena E. Defining the Most Effective Patient Blood Management Combined with Tranexamic Acid Regime in Primary Uncemented Total Hip Replacement Surgery. J Clin Med 2020; 9:jcm9061952. [PMID: 32580497 PMCID: PMC7355762 DOI: 10.3390/jcm9061952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 11/16/2022] Open
Abstract
The application of patient blood management (PBM) combined with tranexamic acid administration (TXA) results in decreased total blood loss volume (TVB) and transfusions in total hip replacements (THRs). Dosages, timing, and routes of administration of TXA are still under debate as all these aspects, as well as interpatient variations, may affect the efficacy of the protocol. This study aims to examine the effectiveness of timing and route of administration of TXA in combination with PBM by reducing the TBV following THR surgery. Consecutive primary uncemented THRs operated by a single surgical and anaesthetic team had the data prospectively collected and then retrospectively studied. Five treatment groups were formed, reflecting the progressive evolution of our protocol. Group 1 included patients managed with PBM alone (preoperative erythrocyte mass optimisation to at least 14 g/dL haemoglobin (Hb), hypotensive spinal anaesthesia and restrictive red blood cell transfusion criteria). Group 2 included patients with PBM and topical 3 g TXA diluted in normal saline to a total volume of 50 mL. Group 3 were patients with PBM and an IV dose of 20 mg/kg TXA at induction, followed by 20 mg/kg TXA as a continuous infusion for the duration of the operation. Group 4 consisted of patients managed as per Group 3 plus another 20 mg/kg TXA at three-hour post-procedure. Group 5 (combined): PBM and IV TXA as per Group 4 and topical TXA as per Group 2. A generalised linear model with the treatment group as an independent variable was modelled, using TBV as the dependent variable. The transfusion rate for all groups was 0%. TBV at 24 h, oscillated from 613.5 ± 337.63 mL in Group 1 to 376.29 ± 135.0 mL in Group 5. TBV at 48 h oscillated from 738.3 ± 367.3 mL (PBM group) to 434 ± 155.2 mL (PBM + combined group). The multivariate regression model confirmed a significant decrease of TBV in all groups with TXA compared with the PBM-only group. Overweight and preoperative Hb were confirmed to significantly influence TBV. The optimal regime to achieve the least TBV and a transfusion rate of 0% requires PBM and one loading 20 mg/kg dose of TXA, followed by continuous infusion of 20 mg/kg for the duration of the operation in uncemented THRs. Additional doses of TXA did not add a clear benefit.
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Affiliation(s)
| | - Norma G. Padilla-Eguiluz
- Department of Orthopaedics, Hospital Universitario “La Paz”, IdiPAZ, and Autónoma University, 28046 Madrid, Spain;
| | - Enrique Gómez-Barrena
- Department of Orthopaedics, Hospital Universitario “La Paz”, IdiPAZ, and Autónoma University, 28046 Madrid, Spain;
- Correspondence: or
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Patel R, Rhee PC. Team Approach: Multidisciplinary Perioperative Care in Upper-Extremity Reconstruction for Adults with Spasticity and Contractures. JBJS Rev 2020; 8:e0164. [DOI: 10.2106/jbjs.rvw.19.00164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Yao RZ, Gao WQ, Wang BW, Wang GL, Wu CX, A-Mu YD. Efficacy and Safety of Tranexamic Acid in Reducing Blood Loss of Lower Extremity Osteotomy in Peri-acetabulum and High Tibia: A Systematic Review and Meta-analysis. Orthop Surg 2020; 11:545-551. [PMID: 31456323 PMCID: PMC6712373 DOI: 10.1111/os.12515] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 06/19/2019] [Accepted: 07/18/2019] [Indexed: 02/05/2023] Open
Abstract
Objective To assess the efficacy of tranexamic acid (TXA) in reducing total blood loss and transfusion, and the risk of thromboembolic events in patients undergoing periacetabular osteotomy (PAO) and high tibial osteotomy (HTO). Methods A systematic literature search was performed using PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Embase (Ovid), Medline (Ovid), and Web of Science. ClinicalTrials.gov, American Academy of Orthopaedic Surgeons (AAOS), and Orthopaedic Trauma Association (OTA) conference proceedings were also searched to gain more eligible studies. The primary outcome measure was total blood loss and the blood transfusion rate of the TXA group versus control. The meta‐analysis was conducted using the RevMan 5.3 and Stata 14.0 software. Results A total of six studies were included involving 665 patients. Three studies were PAO, and the other three were HTO. The total blood loss in PAO (WMD, −330.49; 95% CI, −390.16 to −270.83; P < 0.001) and HTO (WMD, −252.50; 95% CI, −356.81 to −148.18; P < 0.001) and hemoglobin decline (WMD, −0.74; 95% CI, −1.09 to −0.38; P < 0.001) were significantly less in the TXA group than in the control group. TXA could reduce transfusion rates in PAO (RR, 0.26; 95% CI, 0.09 to 0.75; P = 0.01) but had no effect on HTO (RR, 0.20; 95% CI, 0.01 to 4.10; P = 0.30). The wound complications (RR, 0.62; 95% CI, 0.13 to 2.94; P = 0.54) had no significant difference between TXA and control groups. Conclusions This meta‐analysis demonstrated that TXA reduces total blood loss and hemoglobin decline in patients undergoing PAO and is safe, but it has little benefit in regard to reducing transfusion rates or wound complications in HTO, so TXA might be unwarranted for routine use for HTO.
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Affiliation(s)
- Ru-Zhan Yao
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Wei-Qiang Gao
- Deparment of Orthopedics, Chengdu Integrated Traditional Chinese and Western Medicine Hospital, The First People's Hospital of Chengdu Sichuan Province, Sichuan Sheng, China
| | - Bing-Wu Wang
- Department of Spinal Surgery, Weifang People's Hospital, Weifang, China
| | - Guang-Lin Wang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China.,Deparment of Orthopedics, The People's Hospital of Guang'an City, Sichuan, China
| | - Cheng-Xi Wu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Yi-da A-Mu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
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Porter SB, White LJ, Osagiede O, Robards CB, Spaulding AC. Tranexamic Acid Administration Is Not Associated With an Increase in Complications in High-Risk Patients Undergoing Primary Total Knee or Total Hip Arthroplasty: A Retrospective Case-Control Study of 38,220 Patients. J Arthroplasty 2020; 35:45-51.e3. [PMID: 31522854 DOI: 10.1016/j.arth.2019.08.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/20/2019] [Accepted: 08/05/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) administration to reduce postoperative blood loss and transfusion is a well-established practice for total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, clinical concerns remain about the safety of TXA in patients with a history of a prothrombotic condition. We sought to determine the risk of complications between high-risk and low-risk TKA and THA patients receiving TXA. METHODS We retrospectively reviewed 38,220 patients (8877 high-risk cases) who underwent primary TKA and THA between 2011 and 2017 at our institution. Intravenous TXA was administered in 20,501 (54%) of cases. The rates of thrombotic complications (deep vein thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], and cerebrovascular accident [CVA]) as well as mortality and readmission were assessed at 90 days postoperatively. Additionally, we evaluated 90-day postoperative occurrence of DVT and PE separate from occurrence of MI and CVA. Patients were categorized as high risk if they had a past medical history of a prothrombotic condition prior to surgery. RESULTS There was no significant difference in the odds of these adverse outcomes between high-risk patients who received TXA and high-risk patients who did not receive TXA (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.85-1.18). There were also no differences when evaluating the odds of 90-day postoperative DVT and PE (OR 0.84, 95% CI 0.59-1.19) nor MI and CVA (OR 0.91, 95% CI 0.56-1.49) for high-risk patients receiving TXA vs high-risk patients who did not receive TXA. CONCLUSION TXA administration to high-risk TKA and THA patients is not associated with a statistically significant difference in adverse outcomes. We present incremental evidence in support of TXA administration for high-risk patients undergoing primary arthroplasties.
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Affiliation(s)
- Steven B Porter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Launia J White
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Osayande Osagiede
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Christopher B Robards
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
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Tripathy SK, Rao PB, Nanda SN, Nayak C, Samal BP, Jain M, Srinivasan A, Hota D. Safety and efficacy of epsilon aminocaproic acid (EACA) as an antihemorrhagic drug in bilateral one stage total knee arthroplasty: A double-blind randomized controlled trial. Knee 2020; 27:229-234. [PMID: 31882387 DOI: 10.1016/j.knee.2019.09.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 07/05/2019] [Accepted: 09/25/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Antifibrinolytic drugs are widely used to minimize blood loss and transfusion requirements in total knee arthroplasty (TKA). Although tranexamic acid (TXA) has been widely studied for its use in TKA, there are limited studies on epsilon-aminocaproic acid (EACA). METHODS In a double-blind randomized control trial, all patients (n = 91) operated with bilateral simultaneous TKA were randomly given either intravenous EACA or placebo (normal saline). A single surgeon performed the TKA with posterior-stabilized implants under tourniquet. A suction drain was placed and kept for 48 h postoperatively. The intraoperative blood loss and drain output were calculated. The postoperative hemoglobin (Hb), drop in Hb, total blood loss, and number of blood transfusions in each group were calculated. RESULTS Both of the groups were comparable in terms of age, sex, body mass index, and pre-operative Hb. There was a significant difference between the EACA group and control group in terms of intraoperative blood loss (150 ml vs. 165 ml, P = 0.01), drain output (494 ml vs. 1062 ml, P < 0.001), postoperative Hb (9.9 g/dl vs. 8.6 g/dl, P = 0.002), drop in Hb (2.2 g/dl vs. 3.1 g/dl, P = 0.026) and transfusion rate (median transfusion 0 vs. 1, P < 0.001). The total blood loss, as calculated by the Hb balance method, was significantly less (P < 0.001) in the EACA group (0.99 l) compared with the control group (2.71 l). None of the patients developed any adverse reaction/complication to the drug. CONCLUSION Intraoperative administration of EACA significantly decreased the blood loss and postoperative transfusion rates compared with no antifibrinolytic therapy in bilateral simultaneous TKA.
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Affiliation(s)
- Sujit Kumar Tripathy
- Dept. of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar 751019, India.
| | - P Bhaskar Rao
- Dept. of Anesthesia and Critical Care, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Saurav Narayan Nanda
- Dept. of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar 751019, India
| | - Chandrakanta Nayak
- Dept. of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar 751019, India
| | - Barada P Samal
- Dept. of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar 751019, India
| | - Mantu Jain
- Dept. of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar 751019, India
| | - Anand Srinivasan
- Dept. of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Debasish Hota
- Dept. of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar, India
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Wang QR, Yeersheng R, Li DH, Yang ZY, Kang PD. Intravenous Tranexamic Acid for Reducing Perioperative Blood Loss During Revision Surgery for Vancouver Type B Periprosthetic Femoral Fractures After Total Hip Arthroplasty: A Retrospective Study. Orthop Surg 2019; 12:100-107. [PMID: 31884693 PMCID: PMC7031602 DOI: 10.1111/os.12592] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 11/09/2019] [Accepted: 11/18/2019] [Indexed: 02/05/2023] Open
Abstract
Objective To explore the efficacy and safety of intravenous tranexamic acid for reducing perioperative blood loss and allogeneic blood transfusions in revision surgery for Vancouver type B periprosthetic femoral fractures after total hip arthroplasty (THA). Methods We retrospectively reviewed 129 patients who underwent revision surgeries because of Vancouver type B periprosthetic femoral fractures from January 2008 to September 2018. Patients were divided into two groups according to whether they received intravenous tranexamic acid (n = 72) or not (n = 57). The two groups were compared in terms of estimated intraoperative blood loss, visible blood loss, hidden blood loss, the volume of allogeneic blood transfusion and the incidence of symptomatic venous thromboembolism (VTE). Patients were also compared depending on the Vancouver classification (Vancouver type B1, B2, and B3). Results Regardless of the subtype of Vancouver classification, patients who received tranexamic acid showed significantly lower estimated intraoperative blood loss, visible blood loss, hidden blood loss, and allogeneic blood transfusion volume. Use of tranexamic acid was not associated with significant changes in the incidence of postoperative symptomatic VTE. Similar results were obtained with subgroups of patients who had the Vancouver type B1, B2, or B3 periprosthetic femoral fractures. Conclusions The administration of intravenous tranexamic acid can safely and effectively reduce perioperative blood loss and allogeneic blood transfusions in revision surgery for Vancouver type B periprosthetic femoral fractures, without increasing the risk of symptomatic VTE.
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Affiliation(s)
- Qiu-Ru Wang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Releken Yeersheng
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Dong-Hai Li
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhou-Yuan Yang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Peng-de Kang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, Chengdu, China
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Nemoto A, Mizuno K, Goyagi T. The Effect of Tranexamic Acid Administration on Perioperative Bleeding in Patients Undergoing Knee or Hip Arthroplasty: A Single-Centre Retrospective Study. Turk J Anaesthesiol Reanim 2019; 48:142-147. [PMID: 32259146 PMCID: PMC7101183 DOI: 10.5152/tjar.2019.08364] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 08/06/2019] [Indexed: 01/13/2023] Open
Abstract
Objective Tranexamic acid (TXA) has been used to reduce perioperative bleeding in various surgeries because of its antifibrinolytic effect. Recently, patients undergoing orthopaedic surgery in our institution received a loading dose of TXA (10 00 mg) before surgery, followed by 100 mg h−1 until the end of surgery. The purpose of the present study was to evaluate the efficacy of TXA administration on the perioperative blood loss in patients undergoing knee arthroplasty or hip arthroplasty. Methods A retrospective cross-sectional study was conducted for the records in patients who underwent surgery without TXA administration (control group) and patients who underwent surgery with TXA administration (TXA group). Amount of intraoperative blood loss, intraoperative infusion volume, intraoperative blood transfusion volume, postoperative blood transfusion volume, changes in haemoglobin concentrations (ΔHb) and estimated blood loss were collected. Data were adjusted by propensity score method. Results A total of 126 (63 in the control group and 63 in the TXA group) patients were included during the study period. Intraoperative infusion, postoperative transfusion, ΔHb and estimated blood loss were significantly reduced in the TXA group, although there were no significant differences in the volumes of intraoperative transfusion and blood loss. Conclusion The administration of TXA (loading dose of 1000 mg and continuous infusion of 100 mg h−1) reduced postoperative transfusion and perioperative blood loss. These results indicated that TXA administration is useful for reducing perioperative blood loss in patients undergoing knee or hip arthroplasty.
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Affiliation(s)
- Akira Nemoto
- Department of Anaesthesia and Intensive Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Kana Mizuno
- Department of Anaesthesia and Intensive Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Toru Goyagi
- Department of Anaesthesia and Intensive Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
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Qi YM, Wang HP, Li YJ, Ma BB, Xie T, Wang C, Chen H, Rui YF. The efficacy and safety of intravenous tranexamic acid in hip fracture surgery: A systematic review and meta-analysis. J Orthop Translat 2019; 19:1-11. [PMID: 31844608 PMCID: PMC6896672 DOI: 10.1016/j.jot.2019.03.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE The present meta-analysis was conducted to compare the efficacy and safety of intravenous application of tranexamic acid (TXA) with placebo in patients with hip fracture undergoing hip surgeries. METHODS PubMed, EMBASE and Cochrane Library were searched from inception until March 2018. A combined searching strategy of subject words and random words was adopted. Only randomized clinical trials were included. The comparisons regarding transfusion rate, total blood loss, intraoperative blood loss, postoperative blood loss, postoperative haemoglobin and postoperative thromboembolic complications were conducted. The meta-analysis was performed using Review Manager 5.3, and the bias evaluation was based on the Cochrane Handbook 5.1.0. RESULTS Ten randomized controlled trials published from 2007 to 2018 were included in the meta-analysis. The results showed that there were significant differences in the two groups concerning transfusion rate of allogeneic blood [risk ratio (RR) = 0.66, 95% confidence interval (CI): 0.56 to 0.78, P = 0.003], total blood loss [mean difference (MD) = -273.00, 95% CI: -353.15 to -192.84, P < 0.00001], intraoperative blood loss (MD = -76.63, 95% CI: -139.55 to -13.71, P = 0.02), postoperative blood loss (MD = -125.29, 95% CI: -221.96 to -28.62, P = 0.01) and postoperative haemoglobin (MD = 0.80, 95% CI: 0.38 to 1.22, P = 0.0002). Nonsignificant differences were found in the incidence of thromboembolic events (RR = 1.38, 95% CI: 0.74 to 2.55, P = 0.31). CONCLUSIONS This meta-analysis of the available evidence implies that the intravenous route of TXA shows an ability to reduce transfusion requirements and total blood loss, not increasing the incidence of thromboembolic events in patients undergoing hip surgeries. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE The result of this meta-analysis shows that the utilization of intravenous TXA in patients with hip fracture undergoing hip surgeries possesses great potential in reducing blood loss and allogeneic blood transfusion safely.
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Key Words
- Allogeneic blood transfusion
- Blood loss
- Hip fracture
- Meta-analysis
- Randomized controlled trial, RCT
- Thromboembolic events
- Tranexamic acid
- Tranexamic acid, TXA
- cerebrovascular accident, CVA
- confidence interval, CI
- deep vein thrombolism, DVT
- haemoglobin, Hb
- mean difference, MD
- pulmonary embolism, PE
- risk ratio, RR
- standard deviation, SD
- total hip arthroplasty, THA
- total knee arthroplasty, TKA
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Affiliation(s)
- Yi-ming Qi
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Orthopaedic Trauma Institute of Southeast University, Nanjing, Jiangsu 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Hai-peng Wang
- The Department of Orthopedics, Jing' An District Centre Hospital of Shanghai (Huashan Hospital Fudan University Jing' An Branch), 20040, China
| | - Ying-juan Li
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Bin-bin Ma
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Orthopaedic Trauma Institute of Southeast University, Nanjing, Jiangsu 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Tian Xie
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Orthopaedic Trauma Institute of Southeast University, Nanjing, Jiangsu 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Chen Wang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Orthopaedic Trauma Institute of Southeast University, Nanjing, Jiangsu 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Orthopaedic Trauma Institute of Southeast University, Nanjing, Jiangsu 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Yun-feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Orthopaedic Trauma Institute of Southeast University, Nanjing, Jiangsu 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
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Evaluation of early wound leakage as a risk factor for prosthetic joint infection. J Am Assoc Nurse Pract 2019; 31:337-343. [PMID: 30681650 DOI: 10.1097/jxx.0000000000000159] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE Prosthetic joint infection (PJI) is a serious complication resulting from total knee arthroplasty (TKA) or total hip arthroplasty (THA). In this study, patients with a PJI are compared with patients with an uncomplicated postoperative course to identify relevant risk factors for PJI. METHODS A matched case-control study was performed with patients undergoing fast-track, elective unilateral TKA or THA. The following data were collected: demographics, surgery-related characteristics (perioperative blood loss, use of cement, body temperature), and postoperative characteristics (hematoma formation, wound leakage, blood transfusion, length of stay [LOS]). CONCLUSIONS When the PJI group was compared with the control group, there was significantly more wound leakage during hospital stay (88% vs. 36%, p = .001) and early wound dressing changes in the first 3 days after surgery (88% vs. 40%, p = .002). Hematoma formation was observed more in the PJI patients group (44% vs. 10%, p = .005). A trend test revealed a significant association between the total number of wound dressing changes and development of PJI (p < .001); 72% of PJI patients had a length of stay of ≥4 days compared with 34% of controls (odds ratio 10.5; 95% CI [2.1-52.3]; p = .004). IMPLICATIONS FOR PRACTICE Early postoperative wound drainage and hematoma formation directly correlate with PJI. This resulted in a significantly higher number of dressing changes and longer LOS. The nurse practitioner has a central role in postoperative care and is the first to recognize signs of an adverse postoperative clinical course.
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Zhang S, Wang C, Shi L, Xue Q. Multi-route applications of tranexamic acid to reduce blood loss after total knee arthroplasty: a randomized controlled trial. Medicine (Baltimore) 2019; 98:e16570. [PMID: 31348286 PMCID: PMC6709093 DOI: 10.1097/md.0000000000016570] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Perioperative bleeding during total knee arthroplasty (TKA) is an ongoing problem for surgeons. Intravenous or topical application of tranexamic acid (TXA) can effectively stop bleeding, but there is still no uniform standard for the best method of administration and dose. METHODS From October 2016 to September 2018, 218 patients with unilateral primary knee osteoarthritis requiring knee replacement were enrolled and randomly divided into four groups. Group 1 (n = 55) received intra-articular injection (IAI) of TXA and peri-articular injection (PAI) of placebo, group 2 (n = 55) received IAI of placebo and PAI of TXA, group 3 (n = 51) received IAI of TXA and PAI of TXA, and group 4 (n = 57) received double placebo (IAI of placebo and PAI of placebo). The demographic characteristics, surgical indices, hematological indices, wound healing history, and thromboembolic events were investigated. RESULTS Eight patients were lost to follow-up and 210 patients were included in the analysis. The median TBLs in patients who received IAI of TXA and PAI of placebo and those who received IAI of placebo and PAI of TXA were 470.81 ml and 481.54 ml, respectively. These TBL levels were significantly higher compared to those in patients who received IAI of TXA and PAI of TXA (359.18 ml, P ≤ .001), but significantly lower compared to those in patients who received the double placebo (522.71 ml, P ≤ .001). Compared to other groups, more patients in the double placebo group needed a blood transfusion (P = .013). In the short-term, the double placebo group had higher VAS pain scores and less ROM after surgery (P = .011 and P = .001, respectively). In the long-term (6-month follow-up), there were no significant differences in ROM, VAS, DVT, PE, or wound-related complications. CONCLUSION The combined use of IAI and PAI of TXA can significantly reduce the TBL and the need for blood transfusion without delaying wound healing or increasing the risk of DVT and PE. In the short-term after surgery, this combined method reduces the pain VAS scores and improves the ROM; however, there are no long-term effects on VAS and ROM.
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Affiliation(s)
- Shenqi Zhang
- Department of Orthopedics, Beijing Hospital ,National Center of Gerontology, PR China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing
- The Department of Joint and Sports Medicine, Zaozhuang Municipal Hospital, Shandong, China
| | - Chengbin Wang
- The Department of Joint and Sports Medicine, Zaozhuang Municipal Hospital, Shandong, China
| | - Lei Shi
- Department of Orthopedics, Beijing Hospital ,National Center of Gerontology, PR China
| | - Qingyun Xue
- Department of Orthopedics, Beijing Hospital ,National Center of Gerontology, PR China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing
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Multiple intravenous tranexamic acid doses in total knee arthroplasty without tourniquet: a randomized controlled study. Arch Orthop Trauma Surg 2019; 139:859-868. [PMID: 30903342 DOI: 10.1007/s00402-019-03173-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is widely used in the orthopedic field and particularly in total knee arthroplasty (TKA). Its efficacy and safety in reducing the blood loss in TKA have been well-documented in the current literature. Little data regarding TKA without tourniquet and TXA exist. Our aim is to compare three different dosages of intravenous (IV) TXA in TKA without tourniquet. MATERIALS AND METHODS A total of 180 patients undergoing TKA for knee osteoarthritis were stratified in three equal groups. All surgeries were performed under spinal anesthesia, without tourniquet. Group A (60 patients) received 15 mg/kg of IV TXA given on induction, Group B (60 patients) received an additional dose of IV TXA (15 mg/kg) 3 h after incision and Group C (60 patients) received an additional (third) dose 3 h later (15 mg/kg). The measured outcomes were the change in hemoglobin (Hb) from pre-operatively to post-operatively, the amount of blood transfusion given (units), the functional and quality of life (QoL) and pain assessment based on their corresponding scoring system. RESULTS Calculated blood loss, Hb decrease and transfusion rate were significantly lower in Group C (p value < 0.05). Additionally, patients that had been included in the three-dosage group benefited much more in terms of faster rehabilitation, better QoL, decreased post-operative pain, with no increase in complications. CONCLUSION According to our results, three doses of IV TXA have effectively and safely reduced blood loss and the need of allogeneic blood transfusion in patients undergoing TKA without tourniquet, with additional patients-related benefits. LEVEL OF EVIDENCE II.
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Ambra LF, de Girolamo L, Niu W, Phan A, Spector M, Gomoll AH. No effect of topical application of tranexamic acid on articular cartilage. Knee Surg Sports Traumatol Arthrosc 2019; 27:931-935. [PMID: 29119286 DOI: 10.1007/s00167-017-4746-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 10/04/2017] [Indexed: 12/24/2022]
Abstract
PURPOSE The objective of this study was to evaluate potential cytotoxicity of TXA on articular cartilage by assessing chondrocyte viability of osteochondral explants after exposure to different concentrations and durations of TXA. METHODS Thirty-nine osteochondral plugs (OCPs) were harvested from three adult Yucatan minipigs immediately after their death. OCPs were divided into 13 groups exposed to different concentrations of TXA (1, 2 and 4 mg/ml in saline solution) for 1, 3 and 6 h. Negative controls were exposed to saline solution for 0, 1, 3 and 6 h. Chondrocyte viability was assessed by Live/Dead cell assay and calculated as the ratio of live cells (green fluorescence) to overall cells (green + red cells) for each concentration of TXA and time point in a 50-µm scanned image. RESULTS No correlation was found between chondrocyte viability, and TXA concentration and time of exposure. Overall, chondrocyte viability ranged from 90 to 99%. There was no statistical difference among control group, 1, 2 and 4 mg/ml TXA solutions at each time point [1 h (n.s.), 3 h (n.s.), 6 h (n.s.)]. Similarly, no statistical difference among groups was observed when comparing cell viability at 1, 3 and 6 h of TXA exposure, (Fig. 2) [1 mg/ml (n.s.), 2 mg/ml (n.s.), and 4 mg/ml (n.s.)]. CONCLUSIONS In conclusion, doses of TXA approximating the current clinical protocols for topical use did not demonstrate any cytotoxic effects on cartilage explants in a Yucatan mini pig model. Thus, supporting the topical application for procedures with intact cartilage, such as partial knee replacement surgery and cartilage repair procedures.
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Affiliation(s)
- Luiz Felipe Ambra
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina/UNIFESP, Universidade Federal de São Paulo, Rua Borges Lagoa 783, 5° andar, São Paulo, Brazil. .,Center for Regenerative Medicine and Cartilage Repair Center, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA.
| | - Laura de Girolamo
- Orthopedic Biotechnology Laboratory, Galeazzi Orthopaedic Institute, Milan, Italy
| | - Wanting Niu
- Tissue Engineering Labs, VA Boston Healthcare System, Boston, MA, USA.,Department of Orthopedics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy Phan
- Center for Regenerative Medicine and Cartilage Repair Center, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA
| | - Myron Spector
- Tissue Engineering Labs, VA Boston Healthcare System, Boston, MA, USA.,Department of Orthopedics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andreas H Gomoll
- Center for Regenerative Medicine and Cartilage Repair Center, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA.,Department of Orthopedics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Akonjom M, Battenberg A, Beverland D, Choi JH, Fillingham Y, Gallagher N, Han SB, Jang WY, Jiranek W, Manrique J, Mihov K, Molloy R, Mont MA, Nandi S, Parvizi J, Peel T, Pulido L, Sarungi M, Sodhi N, Alberdi MT, Olivan RT, Wallace D, Weng X, Wynn-Jones H, Yeo SJ. General Assembly, Prevention, Blood Conservation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S147-S155. [PMID: 30348569 DOI: 10.1016/j.arth.2018.09.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Clavé A, Gérard R, Lacroix J, Baynat C, Danguy des Déserts M, Gatineau F, Mottier D. A randomized, double-blind, placebo-controlled trial on the efficacy of tranexamic acid combined with rivaroxaban thromboprophylaxis in reducing blood loss after primary cementless total hip arthroplasty. Bone Joint J 2019; 101-B:207-212. [PMID: 30700116 DOI: 10.1302/0301-620x.101b2.bjj-2018-0898.r1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Cementless primary total hip arthroplasty (THA) is associated with risks of bleeding and thromboembolism. Anticoagulants are effective as venous thromboprophylaxis, but with an increased risk of bleeding. Tranexamic acid (TXA) is an efficient antifibrinolytic agent, but the mode and timing of its administration remain controversial. This study aimed to determine whether two intravenous (IV) TXA regimens (a three-hour two-dose (short-TXA) and 11-hour four-dose (long-TXA)) were more effective than placebo in reducing perioperative real blood loss (RBL, between baseline and day 3 postoperatively) in patients undergoing THA who receive rivaroxaban as thromboprophylaxis. The secondary aim was to assess the non-inferiority of the reduction of blood loss of the short protocol versus the long protocol. PATIENTS AND METHODS A multicentre, prospective, randomized, double-blind, placebo-controlled trial was undertaken involving 229 patients undergoing primary cementless THA using a posterior approach, whose extended rivaroxaban thromboprophylaxis started on the day of surgery. There were 98 male and 131 female patients, with a mean age of 65.5 years (32 to 91). The primary outcome, perioperative RBL, was evaluated at 72 hours postoperatively. The efficacy of short- and long-TXA protocols in the reduction of perioperative RBL was compared with a placebo group. RESULTS TXA significantly reduced perioperative blood loss compared with placebo (p < 0.001); the mean differences were 525.3 ml (short-TXA vs placebo) and 550.1 ml (long-TXA vs placebo). No venous or arterial thromboembolic complications were reported. The upper boundary of the 95% confidence interval, when comparing short and long protocols, was below the pre-specified margin of non-inferiority (p = 0.027). CONCLUSION In patients undergoing primary cementless THA, using a posterior approach, who are treated with rivaroxaban for thromboembolic prophylaxis, short- and long-TXA IV protocols are significantly more effective than placebo in reducing perioperative RBL, without any thromboembolic complications. Non-inferiority of a short- versus a long-TXA protocol in reducing perioperative RBL was supported in a secondary analysis.
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Affiliation(s)
- A Clavé
- Department of Orthopedics and Traumatology, Brest University Hospital, Brest, France
| | - R Gérard
- Department of Orthopedics and Traumatology, Polyclinique Keraudren, Brest, France
| | - J Lacroix
- Department of Orthopedics and Traumatology, Morlaix General Hospital, Morlaix, France
| | - C Baynat
- Department of Orthopedics and Traumatology, Clermont-Tonnerre Armed Forces Hospital, Brest, France
| | - M Danguy des Déserts
- Department of Anesthesiology, Clermont Tonnerre Military Hospital, Brest, France; Investigation Network on Venous Thromboembolism (F-Crin Network INNOVTE), Saint-Étienne, France
| | - F Gatineau
- Brest University Hospital, University of Western Brittany, Unité de recherche EA 3878 GETBO, Centre d'Investigation Clinique, and Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 1412, Brest, France
| | - D Mottier
- Brest University Hospital, UBO, and EA 3878, CIC INSERM 1412, Brest, France; Investigation Network on Venous Thromboembolism (F-Crin Network INNOVTE), Saint-Étienne, France
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Sun Q, Li J, Chen J, Zheng C, Liu C, Jia Y. Comparison of intravenous, topical or combined routes of tranexamic acid administration in patients undergoing total knee and hip arthroplasty: a meta-analysis of randomised controlled trials. BMJ Open 2019; 9:e024350. [PMID: 30696680 PMCID: PMC6352808 DOI: 10.1136/bmjopen-2018-024350] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE This study aimed to compare the effects of intravenous, topical and combined routes of tranexamic acid (TXA) administration on blood loss and transfusion requirements in patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). DESIGN This was a meta-analysis of randomised controlled trials (RCT) wherein the weighted mean difference (WMD) and relative risk (RR) were used for data synthesis applied in the random effects model. Stratified analyses based on the surgery type, region, intravenous and topical TXA dose and transfusion protocol were also conducted. The main outcomes included intraoperative and total blood loss volume, transfusion rate, low postoperative haemoglobin (Hb) level and postoperative Hb decline. However, the secondary outcomes included length of hospital stay (LOS) and/or occurrence of venous thromboembolism (VTE). SETTING We searched the PubMed, Embase and Cochrane CENTRAL databases for RCTs that compared different routes of TXA administration. PARTICIPANTS Patients undergoing TKA or THA. INTERVENTIONS Intravenous, topical or combined intravenous and topical TXA. RESULTS Twenty-six RCTs were selected, and the intravenous route did not differ substantially from the topical route with respect to the total blood loss volume (WMD=30.92, p=0.31), drain blood loss (WMD=-34.53, p=0.50), postoperative Hb levels (WMD=-0.01, p=0.96), Hb decline (WMD=-0.39, p=0.08), LOS (WMD=0.15, p=0.38), transfusion rate (RR=1.08, p=0.75) and VTE occurrence (RR=1.89, p=0.15). Compared with the combined-delivery group, the single-route group had significantly increased total blood loss volume (WMD=198.07, p<0.05), greater Hb decline (WMD=0.56, p<0.05) and higher transfusion rates (RR=2.51, p<0.05). However, no significant difference was noted in the drain blood loss, postoperative Hb levels and VTE events between the two groups. The intravenous and topical routes had comparable efficacy and safety profiles. CONCLUSIONS The combination of intravenous and topical TXA was relatively more effective in controlling bleeding without increased risk of VTE.
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Affiliation(s)
- Qi Sun
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jinyu Li
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jiang Chen
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Chenying Zheng
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Chuyin Liu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yusong Jia
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
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Desai BD, Taylor DG, Chen CJ, Buell TJ, Mullin JP, Naik BI, Smith JS, Shaffrey CI. Utility of topical tranexamic acid for adult patients with spinal deformity and contraindications to systemic tranexamic acid: initial experience and report of 2 cases. J Neurosurg Spine 2019; 30:500-505. [PMID: 30684936 DOI: 10.3171/2018.9.spine18204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 09/26/2018] [Indexed: 01/09/2023]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic agent with demonstrated efficacy in reducing blood loss when administered systemically. However, in patients with contraindications to systemic or intravenous TXA, topical TXA (tTXA) has been shown to reduce perioperative blood loss, with some studies suggesting equivalence compared to systemic TXA. However, these studies have been conducted in healthy cohorts without contraindications to systemic TXA. In the surgical management of adult spinal deformity (ASD), comorbid disease is commonly encountered and may preclude use of systemic TXA. In this subset of patients with ASD who have contraindications for systemic TXA, use of tTXA has not been reported.The primary objective of this study was to conduct a systematic review on the use of tTXA in spine surgery and to present the authors' initial experience with tTXA as a novel hemostatic technique for 2 patients with medically complex ASD. Both patients had contraindications to systemic TXA use and underwent high-risk, long-segment fusion operations for correction of ASD. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to obtain studies related to spine surgery and tTXA from the National Institutes of Health PubMed (www.pubmed.gov) database. Criteria for final selection included a demonstration of quantitative data regarding operative or postoperative blood loss with the use of tTXA, and selection criteria were met by 6 articles.Topical TXA may offer a potential therapeutic role in reducing intra- and postoperative blood loss following long-segment spinal fusion surgeries, particularly for medically complex patients with contraindications to systemic TXA. It is reasonable to consider the use of tTXA as a salvage technique in complex high-risk patients with contraindications to systemic TXA, although further research is needed to delineate safety, magnitude of benefit, and optimization of dosing.
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Affiliation(s)
| | | | | | | | | | - Bhiken I Naik
- Departments of1Neurosurgery and
- 2Anesthesiology, University of Virginia Health System, Charlottesville, Virginia
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Felli L, Revello S, Burastero G, Gatto P, Carletti A, Formica M, Alessio-Mazzola M. Single Intravenous Administration of Tranexamic Acid in Anterior Cruciate Ligament Reconstruction to Reduce Postoperative Hemarthrosis and Increase Functional Outcomes in the Early Phase of Postoperative Rehabilitation: A Randomized Controlled Trial. Arthroscopy 2019; 35:149-157. [PMID: 30611343 DOI: 10.1016/j.arthro.2018.07.050] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the effect of tranexamic acid (TXA) in patients undergoing anterior cruciate ligament (ACL) reconstruction in reducing intra-articular effusion and affecting clinical outcomes 3 months after surgery. METHODS Eighty consecutive patients undergoing ACL reconstruction were prospectively assessed from 2014 to 2016. Patients were randomly allocated to 1 of 2 groups: The test group received an intravenous infusion of 15 mg/kg of TXA, and the control group did not receive TXA. The patellar circumference, range of motion (ROM), Coupens and Yates (CY) value, visual analog scale score for pain assessment, and quadriceps strength (QS) were considered on postoperative day (PD) 1, PD 7, and PD 15 and at 1 month and 3 months after surgery. Blood volume in the intra-articular drainage was recorded on PD 1. Any adverse effect, such as fever onset (>37.5°C), hemarthrosis, or infection, was also considered. RESULTS We found a statistically significant reduction in drainage blood volume (P < .001) and CY value (P = .0044) on PD 1 in patients in the test group compared with those in the control group. On PD 7, a significant improvement was found for mean CY values (P = .0057), ROM (P = .0031), and QS (P = .015). On PD 15, we noted significant improvements in CY values (P < .001), patellar circumference (P = .0019), QS (P = .0089), and visual analog scale values (P = .0032) in the test group. We noted 13 fever episodes in the control group and 2 fever episodes in the study group (P = .047). No differences for any outcomes or complications were found at 3 months. CONCLUSION TXA administration reduced hemarthrosis and the amount of suction drainage blood volume, improved ROM and QS, and reduced fever episodes during the first 2 weeks after surgery. TXA use improved early-phase outcomes in the postoperative period after ACL reconstruction. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Lamberto Felli
- Orthopaedic Clinic, Department of Surgical Sciences, Policlinico San Martino IST, Genoa, Italy
| | - Stefano Revello
- Orthopaedic Clinic, Department of Surgical Sciences, Policlinico San Martino IST, Genoa, Italy
| | - Giorgio Burastero
- Orthopedic and Traumatology Unit 2, Santa Corona Hospital, Pietra Ligure, Italy
| | - Pietro Gatto
- Orthopaedic Clinic, Department of Surgical Sciences, Policlinico San Martino IST, Genoa, Italy
| | - Antonio Carletti
- HAN, Anesthesiology Service, Department of Emergency and Acceptance, Policlinico San Martino IST, Genoa, Italy
| | - Matteo Formica
- Orthopaedic Clinic, Department of Surgical Sciences, Policlinico San Martino IST, Genoa, Italy
| | - Mattia Alessio-Mazzola
- Orthopaedic Clinic, Department of Surgical Sciences, Policlinico San Martino IST, Genoa, Italy.
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Safety of intravenous tranexamic acid in patients undergoing majororthopaedic surgery: a meta-analysis of randomised controlled trials. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018. [PMID: 29337665 DOI: 10.2450//2017.0219-17] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Among the various pharmacological options to decrease peri-operative bleeding, tranexamic acid appears to be one of the most interesting. Several trials have consistently documented the efficacy of this synthetic drug in reducing the risk of blood loss and the need for allogeneic blood transfusion in patients undergoing total hip and knee arthroplasty. The safety of intravenous tranexamic acid in major orthopaedic surgery, particularly regarding the risk of venous thromboembolism, was systematically analysed in this review. A systematic search of the literature identified 73 randomised controlled trials involving 4,174 patients and 2,779 controls. The raw overall incidence of venous thromboembolism was 2.1% in patients who received intravenous tranexamic acid and 2.0% in controls. A meta-analytic pooling showed that the risk of venous thromboembolism in tranexamic acid-treated patients was not significantly different from that of controls (risk difference: 0.01%, 95% confidence interval [CI]: -0.05%, 0.07%; risk ratio: 1.067, 95% CI: 0.760-1.496). Other severe drug-related adverse events occurred very rarely (0.1%). In conclusion, the results of this systematic review and meta-analysis show that intravenous tranexamic acid is a safe pharmacological treatment to reduce blood loss and transfusion requirements in patients undergoing major orthopaedic surgery.
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Xie J, Hu Q, Huang Z, Zhou Z, Pei F. Comparison of three routes of administration of tranexamic acid in primary unilateral total knee arthroplasty: Analysis of a national database. Thromb Res 2018; 173:96-101. [PMID: 30500676 DOI: 10.1016/j.thromres.2018.11.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 11/11/2018] [Accepted: 11/22/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The ideal route for the administration of tranexamic acid (TXA) remains undecided. This study aimed to compare the efficacy and safety of three routes of TXA following primary total knee arthroplasty (TKA). MATERIALS AND METHODS We prospectively collected patients' data through the National Health Database from January 2013 to September 2017. The patients were divided into a control group, intravenous group, topical group, and combined group according to the different routes of TXA. The primary outcome was the incidence of transfusion, and secondary outcomes were total blood loss, hemoglobin level and extent of hemoglobin decrease on postoperative day 3, and incidence of complications. RESULTS Of the total of 7133 primary TKA procedures collected, 4201 employed TXA and 2932 did not. The transfusion rate was 19.8% in the control group and 7.5% in the topical group, significantly higher than that in the intravenous (4.0%, p < 0.001) and combined (4.2%, p < 0.01) groups. The topical group had higher blood loss (0.97 ± 0.47 L), greater reduction in hemoglobin level (31.2 ± 10.1 g/L), and lower hemoglobin level (102.6 ± 12.7 g/L) on postoperative day 3, compared with the intravenous and combined groups (p < 0.05 for all). The differences between the intravenous and combined groups were not significant (p > 0.05). The incidence of deep vein thrombosis in the topical group (1.1%) was significantly higher than that in the control (0.4%, p = 0.007) and intravenous groups (0.3%, p = 0.003). CONCLUSION Intravenous and combined administration of TXA was equivalent in reducing blood loss and transfusion requirement, and superior to topical routes.
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Affiliation(s)
- Jinwei Xie
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Qinsheng Hu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Zeyu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Zongke Zhou
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China.
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China.
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