Intra-articular tranexamic acid wash during bilateral total knee arthroplasty

No Difference in Blood Loss and Risk of Transfusion Between Patients Treated with One or Two Doses of Intravenous Tranexamic Acid After Simultaneous Bilateral TKA

BACKGROUND

Tranexamic acid (TXA) is often used to prevent excessive blood loss during bilateral TKA. Although it diminishes blood loss, TXA may have a potentially elevated thrombogenic risk with extra, unnecessary doses of TXA in this high-risk population. To date, the most efficacious dosing protocol in this setting has not yet been ascertained.

QUESTIONS/PURPOSES

We compared one versus two doses of intravenous TXA in the setting of same-day bilateral TKA in terms of (1) perioperative blood loss that occurred during the hospital stay, (2) transfusion usage during the hospital stay, and (3) major complications occurring within 30 days of surgery.

METHODS

Between August 2013 and October 2016, 309 patients underwent simultaneous bilateral TKA performed by one of five attending surgeons. During that time, indications for same-day bilateral TKA included bilateral knee pathology in which each knee was independently indicated for TKA and the patient preferred bilateral simultaneous TKAs versus staged bilateral surgeries. Patients who had cardiac disease or an American Society for Anesthesiologists physical classification score of greater than 2 were not generally indicated for bilateral simultaneous TKAs. After preoperative clearance from the primary physician and/or specialists as necessary, the decision for bilateral TKA was at the judgment of the operating surgeons. Input from anesthesia occurred at the time of the surgery as the procedure was performed in a sequential fashion allowing for the surgery to be restrained to a single limb if anesthesia identified concerns at the completion of the first TKA. The current retrospective, comparative series compared generally sequential groups in terms of TXA usage. Between August 2013 and July 2015, we used two TXA doses. Patients received 1 g of intravenous TXA as a bolus immediately after the last tourniquet release and were given a 1-g intravenous bolus 6 hours after the initial dose. A total of 167 patients were treated with this approach, of whom 96% (161) are fully analyzed here. Between August 2015 and October 2016, our approach changed to a single TXA dose. The dosing regimen change occurred as a group decision for change of practice and occurred mid-year to coincide with the fellowship year cycle. Patients received a 1-g bolus of intravenous TXA immediately after the final tourniquet release. A total of 105 patients were treated with this approach, of whom 89% (93) are fully analyzed here. An additional 37 patients were excluded because they did not receive any TXA because of a medical contraindication such as history of venous thromboembolism, history of thrombotic stroke, cardiac stent in the past 2 years, atrial fibrillation, or long-term anticoagulation therapy. We compared patients who received one versus two doses in terms of blood loss, transfusion usage, and 30-day major complications. The mean age was 65 years for patients receiving one dose and 67 years for patients receiving two doses (p = 0.17). The one-dose group comprised 67% (62 of 93) women and the two-dose group comprised 61% (98 of 161) women (p = 0.36). Blood loss was defined as change in the hemoglobin level (the last recorded value before discharge subtracted from the preoperative value). During the study period, the decision to transfuse was based on a hemoglobin level less than 8.0 g/dL or at higher levels for symptomatic patients, patients with cardiac disease, or at the discretion of the attending surgeon. We defined complications as major medical events that included cerebrovascular accidents, myocardial infarction, deep vein thrombosis, and pulmonary embolism.

RESULTS

With the numbers available, there was no difference in blood loss between patients treated with one and those treated with two doses of TXA (mean hemoglobin decrease -3.5 ± 1.2 g/dL versus -3.5 ± 1.0 g/dL, respectively; mean difference 0.03 g/dL [95% CI -0.2 to 0.3 g/dL]; p = 0.80). No patient in either group received a transfusion. There was no difference in the proportion of patients in either group who experienced a cerebrovascular accident (0% [0 of 93] versus 1% [1 of 161]; p > 0.99), deep vein thrombosis (1% [1 of 93] versus 0% [0 of 161]; p = 0.37), or pulmonary embolism (1% [1 of 93] versus 1% [1 of 161]; p > 0.99). No patient in either the one-dose or two-dose TXA groups experienced a myocardial infarction.

CONCLUSION

The findings of this study suggest that a single dose of intravenous TXA may be adequate to control excessive blood loss and reduce blood transfusion in simultaneous bilateral TKA. Despite its short half-life, TXA still appears to be effective in this demanding procedure without requiring prolonged plasma concentrations obtained from multiple doses. Additional high-quality studies are still needed to determine the most appropriate dosing regimen.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Optimizing Outpatient Total Ankle Replacement from Clinic to Pain Management

Outpatient total ankle arthroplasty is a potential significant source of cost savings. The ability to institute an effective outpatient total ankle program depends on appropriate patient selection, surgeon experience with total ankle replacement, addressing preoperative patient expectations, the involvement of an experienced multidisciplinary care team including experienced anesthesiologists, nurse navigators, recovery room nursing staff and physical therapists, and most importantly, such a program requires complete institutional logistical support.

Optimizing Intraoperative Blood Management for One-Stage Bilateral Total Knee Arthroplasty

BACKGROUND

Effective blood management strategies are a major determinant of successful outcomes after one-stage bilateral total knee arthroplasty (BTKA). Proper patient selection with preoperative optimization and intra- and postoperative interventions can reduce transfusion risk and associated morbidity in these patients.

QUESTIONS/PURPOSES

The purpose of this study was to evaluate intraoperative blood management modalities based on three keystone questions: (1) What is the role of the anesthesiologist?, (2) Which are the surgeon-dependent strategies?, and (3) Is there any place for pharmacologic interventions?

METHODS

We searched the established electronic literature database MEDLINE. After critical appraisal, 94 studies were deemed eligible from which to draw documented evidence.

RESULTS

A number of blood-conserving methods are currently implemented in patients undergoing one-stage BTKA. Among them, regional anesthesia, tourniquet use, and tourniquet deflation after wound closure, femoral canal sparing or femoral canal plugging, avoidance of drains, and tranexamic acid use were the intraoperative strategies with documented efficacy in blood conservation.

CONCLUSION

Combined proper intraoperative anesthesiologic, surgical, and pharmacologic interventions reduce blood loss and need for transfusion in BTKA patients. However, contemporary relevant literature is lacking evidence-based guidelines.

Combined Intravenous and Intra-Articular Tranexamic Acid in Simultaneous Bilateral Total Knee Arthroplasty without Tourniquet Use

Background:

A combined intravenous and intra-articular regimen is one of the most effective administration routes of tranexamic acid (TXA) to reduce perioperative blood loss in unilateral total knee arthroplasty. However, there have been few reports regarding use of the combined regimen for patients undergoing simultaneous bilateral total knee arthroplasty, in which blood-management strategy is more challenging.

Methods:

We compared perioperative blood loss in 30 consecutive patients undergoing simultaneous bilateral total knee arthroplasty who received both 1,000 mg of TXA intravenously and 1,000 mg of intra-articular TXA in each knee (combined TXA group) with that in a consecutive series of 51 patients who only received 1,000 mg of TXA intravenously (intravenous TXA group). Additional intravenous TXA was administered 6 hours after the initial administration in both groups. Except for the intraoperative TXA administration regimen, an identical perioperative blood-management strategy was applied to both groups; this consisted of transfusion of 800 or 400 mL of predeposited autologous blood except for patients with a preoperative hemoglobin level of <11.0 g/dL, who received 4 units of allogenic blood. All surgical procedures were performed with spinal anesthesia and without use of a pneumatic tourniquet. Perioperative blood loss was calculated using the blood volume and change in hemoglobin level from the preoperative measurement to postoperative day 3.

Results:

There was significantly less perioperative blood loss in the combined TXA group compared with the intravenous TXA group (mean and standard deviation, 1,201 ± 347 versus 1,638 ± 400 mL, respectively; mean difference, 437 mL; 95% confidence interval, 263 to 613 mL; p < 0.0001). No patient in the combined TXA group and 1 patient (2%) in the intravenous TXA group required additional allogenic blood transfusion. No thrombotic events occurred in either group.

Conclusions:

In a nonrandomized comparison, combined intra-articular and intravenous TXA significantly reduced the calculated perioperative blood loss in simultaneous bilateral total knee arthroplasty compared with that found in patients treated only with intravenous TXA.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Preoperative haemoglobin cut-off values for the prediction of post-operative transfusion in total knee arthroplasty

PURPOSE

The purpose of this study is to determine preoperative haemoglobin cut-off values that could accurately predict post-operative transfusion outcome in patients undergoing primary unilateral total knee arthroplasty (TKA). This will allow surgeons to provide selective preoperative type and screen to only patients at high risk of transfusion.

METHODS

A total of 1457 patients diagnosed with osteoarthritis and underwent primary unilateral TKA between January 2012 and December 2014 were retrospectively reviewed. Logistic regression analyses were applied to identify factors that could predict transfusion outcome.

RESULTS

A total of 37 patients (2.5 %) were transfused postoperatively. Univariate analysis revealed preoperative haemoglobin (p < 0.001), age (p < 0.001), preoperative haematocrit (p < 0.001), and preoperative creatinine (p < 0.001) to be significant predictors. In the multivariate analysis with patients dichotomised at 70 years of age, preoperative haemoglobin remained significant with adjusted odds ratio of 0.33. Receiver operating characteristic curve identified the preoperative haemoglobin cut-off values to be 12.4 g/dL (AUC = 0.86, sensitivity = 87.5 %, specificity = 77.2 %) and 12.1 g/dL (AUC = 0.85, sensitivity = 69.2 %, specificity = 87.1 %) for age above and below 70, respectively.

CONCLUSIONS

The authors recommend preoperative haemoglobin cut-off values of 12.4 g/dL for age above 70 and 12.1 g/dL for age below 70 to be used to predict post-operative transfusion requirements in TKA. To maximise the utilisation of blood resources, the authors recommend that only patients with haemoglobin level below the cut-off should receive routine preoperative type and screen before TKA.

LEVEL OF EVIDENCE

IV.