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Wiktor Ł, Osadnik B, Damps M. Can local infiltration analgesia supplemented with tranexamic acid reduce blood loss during total knee arthroplasty? BMC Musculoskelet Disord 2024; 25:333. [PMID: 38671411 PMCID: PMC11046775 DOI: 10.1186/s12891-024-07451-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
PURPOSE The aim of this study was to investigate the efficacy of TXA supplemented with local infiltration analgesia (LIA) for reducing blood loss in patients undergoing total knee replacement. MATERIALS A retrospective study of 530 individuals with a mean age of 71.44 years was performed after posterior stabilized total knee arthroplasty. Patients were divided into three groups according to the method of bleeding control: I - patients without an additional bleeding protocol (control group); II - patients receiving IV TXA (TXA group); and III - patients receiving the exact TXA protocol plus intraoperative local infiltration analgesia (TXA + LIA group). Blood loss was measured according to the maximal decrease in Hb compared to the preoperative Hb level. RESULTS The mean hospitalization duration was 7.02 (SD 1.34) days in the control group, 6.08 (SD 1.06) days in the TXA group, and 5.56 (SD 0.79) in the TXA + LIA group. The most significant decrease in haemoglobin was found in the control group, which was an average of 30.08%. The average decrease in haemoglobin was 25.17% (p < 0.001) in the TXA group and 23.67% (p < 0.001) in the TXA + LIA group. A decrease in the rate of allogeneic blood transfusions was observed: 24.4% in the control group, 9.9% in the TXA group, and 8% in the TXA + LIA group (p < 0.01). CONCLUSIONS Compared to the separate administration of tranexamic acid, the combination of perioperative administration with local infiltration analgesia significantly reduced blood loss in patients after total knee replacement.
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Affiliation(s)
- Łukasz Wiktor
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children's Health Centre, Katowice, Poland.
- Department of Trauma and Orthopedic Surgery ZSM Hospital, Pokoju street 74, Chorzów, 41-500, Poland.
| | - Bartłomiej Osadnik
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children's Health Centre, Katowice, Poland
- Department of Trauma and Orthopedic Surgery ZSM Hospital, Pokoju street 74, Chorzów, 41-500, Poland
| | - Maria Damps
- Department of Anaesthesiology and Intensive Care, Upper Silesian Children's Health Centre, Katowice, Poland
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Poston JN, Brown SP, Ilich A, Ginsburg AS, Herren H, El Kassar N, Jensen CE, Triulzi DJ, Key NS, May S, Gernsheimer TB. Fewer severe infections with tranexamic acid in patients with hematologic malignancies. Res Pract Thromb Haemost 2024; 8:102358. [PMID: 38666065 PMCID: PMC11043644 DOI: 10.1016/j.rpth.2024.102358] [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: 09/01/2023] [Revised: 01/22/2024] [Accepted: 02/13/2024] [Indexed: 04/28/2024] Open
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic agent that reduces bleeding in a multitude of clinical settings from postpartum hemorrhage to trauma. TXA may have clinical effects unrelated to bleeding; plasminogen, the target of TXA, alters immune responses, and TXA appears to decrease the risk of infection in patients undergoing cardiac surgery, as well as joint arthroplasty. Objectives To address whether TXA alters rates of infection and inflammatory outcomes in patients with hematologic malignancies. Methods We performed a post hoc analysis of outcomes of patients randomized to receive either TXA or placebo in the double-blinded, multicenter American Trial to Evaluate Tranexamic Acid Therapy in Thrombocytopenia (Clinicaltrials.gov identifier: NCT02578901). Results TXA did not change the overall rate of infections, but the rate of severe infections (Common Toxicology Criteria for Adverse Events grade 3+) was lower in patients who received TXA compared with the placebo group. Patients who experienced grade 3+ infections had higher rates of World Health Organization grade 2+ bleeding and red blood cell transfusion requirements than patients who did not experience a grade 3+ infection, irrespective of treatment group. TXA did not impact other inflammatory outcomes such as mucositis, rash, or graft vs host disease. Conclusion Patients with hematologic malignancies who received TXA had less severe infections than those who received placebo with no difference in overall rate of infection or other inflammatory outcomes. Further investigation is needed on the impact of TXA on infections in this population.
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Affiliation(s)
- Jacqueline N. Poston
- Division of Hematology, University of Washington School of Medicine and Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Hematology/Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Siobhan P. Brown
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Anton Ilich
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amy Sarah Ginsburg
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Heather Herren
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Nahed El Kassar
- Division of Blood Diseases and Resources, National Institutes of Health, National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
| | - Christopher E. Jensen
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Darrell J. Triulzi
- Department of Pathology, Division of Transfusion Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nigel S. Key
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Terry B. Gernsheimer
- Division of Hematology, University of Washington School of Medicine and Fred Hutchinson Cancer Center, Seattle, Washington, USA
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Sağlam S, Orhan Z, Arıcan M, Turhan Y, Karaduman ZO, Tekçe Y, Yücel MO. Topical or intravenous administration of tranexamic acid accelerates wound healing. Jt Dis Relat Surg 2024; 35:85-95. [PMID: 38108169 PMCID: PMC10746897 DOI: 10.52312/jdrs.2023.1044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 09/28/2023] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES In this study, we aimed to investigate the morphological and histological effects of tranexamic acid (TA) on wound healing in a rat wound model. MATERIALS AND METHODS A total of 24 adult male Wistar Albino rats were used in this study. All rats were simple randomly divided into three groups including eight rats in each group. A full-thickness skin defect was created on the back of the rats in all groups. Serum physiological (2 mL) was instilled saline drops after wound formation (control group). Wound was created and topical TA (0.12 to 0.15 mL [30 mg/kg]) was applied (local group). Intravenous TA (0.12 to 0.15 mL [30 mg/kg]) was applied intravenously before the wound was created (intravenous group). The wound diameters of the groups were photographed and measured on Days 0, 3, 7, 10, 14 and, at the end of Day 14, the rats were sacrificed and their histopathological results and wound diameters were compared. RESULTS Fibroblast count values of the control group were found to be significantly lower than the local group (p=0.002), and no significant difference was observed between the local and intravenous groups (p>0.05). The collagen density (%) values of the control group were found to be significantly higher than the local and intravenous groups (p=0.016 and p=0.044). Wound diameter values of the control group on Day 10 day were found to be significantly higher than the local and intravenous groups (p=0.001). In addition, the wound diameter values of the control group on Day 14 were found to be significantly higher than the local and intravenous groups (p=0.001 and p=0.0001). The wound diameter changes of the control group on Days 0-10 were found to be significantly lower than the local and intravenous groups (p=0.001). In addition, the wound diameter changes of the control group on Days 0-14 were found to be lower than those of the local and intravenous groups (p=0.001 and p=0.0001). CONCLUSION The use of local or intravenous TA may have positive effects on the fibroblast count and wound contraction in a rat wound model.
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Affiliation(s)
| | | | - Mehmet Arıcan
- Düzce Üniversitesi Tıp Fakültesi Ortopedi ve Travmatoloji Anabilim Dalı, 81000 Düzce, Türkiye.
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Barroso Rosa S, Wilkinson M, McEwen P, Morse L, Grant A, Doma K, Haward C, Rikard-Bell M. Skin sensory alteration and kneeling ability following cruciate retaining total knee arthroplasty are not affected by the incision position: A randomised controlled trial of simultaneous bilateral surgery. J Exp Orthop 2023; 10:145. [PMID: 38135827 PMCID: PMC10746665 DOI: 10.1186/s40634-023-00695-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/13/2023] [Indexed: 12/24/2023] Open
Abstract
PURPOSE The purpose of this randomised controlled trial was to assess the impact of skin incision location on the patients' ability to kneel. METHODS A total of 29 patients undergoing bilateral total knee arthroplasty (58 knees) were randomised to receive a lateral or midline incision, with the contralateral limb receiving the alternative option. Cruciate retaining implants were used in all cases by three experienced arthroplasty surgeons. The primary outcome measures assessed functional ability to kneel using an innovative five-point kneeling scale, preferred knee to kneel on and the area of cutaneous sensory loss around the incision at 6 weeks, 6 months and 12 months. Secondary outcome measures were the OKS, KOOS JR, FJS and EQ5D patient reported outcome measures (PROMS), length of surgical scar, overall knee preference and range of motion (ROM). RESULTS There were no significant differences between the two groups for any primary or secondary outcome measures. Flexion range however, had a significant positive correlation with kneeling score (r = 0.335, p = 0.010). The kneeling score increased at each time point after surgery and was significantly greater at 12 months than preoperatively (2.7 v 3.5, p = 0.015). The area of sensory loss lateral to the incision was significantly less at 6 and 12 months than at 6 weeks (43.6cm2 and 40.1cm2 v 84.1cm2, p < 0.0001). CONCLUSION The ability to kneel following cruciate retaining total knee arthroplasty is not affected by the incision position but by time and flexion range. TKA improves the ability to kneel by 12 months post-surgery. Sensory loss lateral to the incision reduces with time. LEVEL OF EVIDENCE Therapeutic Level 2.
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Affiliation(s)
- Sergio Barroso Rosa
- The Orthopaedic Research Institute of Queensland, Pimlico, QLD, Australia.
- Department of Clinical and Surgical Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Canary Islands, Spain.
| | - Matthew Wilkinson
- The Orthopaedic Research Institute of Queensland, Pimlico, QLD, Australia
- Department of Orthopaedic Surgery, Royal Hobart Hospital and Calvary Care, University of Tasmania, Hobart, TAS, Australia
| | - Peter McEwen
- The Orthopaedic Research Institute of Queensland, Pimlico, QLD, Australia
| | - Levi Morse
- The Orthopaedic Research Institute of Queensland, Pimlico, QLD, Australia
- Department of Orthopaedic Surgery, Townsville University Hospital, James Cook University, Townsville, QLD, Australia
| | - Andrea Grant
- The Orthopaedic Research Institute of Queensland, Pimlico, QLD, Australia
| | - Kenji Doma
- The Orthopaedic Research Institute of Queensland, Pimlico, QLD, Australia
- Department of Sports and Exercise Science, James Cook University, Townsville, QLD, Australia
| | - Charles Haward
- Department of Orthopaedic Surgery, Royal Hobart Hospital and Calvary Care, University of Tasmania, Hobart, TAS, Australia
- Department of Orthopaedic Surgery, Box Hill Hospital, Eastern Health, Melbourne, Vic, Australia
| | - Matthew Rikard-Bell
- The Orthopaedic Research Institute of Queensland, Pimlico, QLD, Australia
- Department of Orthopaedic Surgery, Townsville University Hospital, James Cook University, Townsville, QLD, Australia
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Ghaffari S, Fateh S, Faramarzi F, Rafiei A, Razavipour M, Zafari P. The effect of tranexamic acid on synovium of patients undergoing arthroplasty and anterior cruciate ligament reconstruction surgery. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:3733-3742. [PMID: 37318523 DOI: 10.1007/s00210-023-02555-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 05/26/2023] [Indexed: 06/16/2023]
Abstract
Preoperative hemorrhage can be reduced using anti-fibrinolytic medicine tranexamic acid (TXA). During surgical procedures, local administration is being used more and more frequently, either as an intra-articular infusion or as a perioperative rinse. Serious harm to adult soft tissues can be detrimental to the individual since they possess a weak ability for regeneration. Synovial tissues and primary fibroblast-like synoviocytes (FLS) isolated from patients were examined using TXA treatment in this investigation. FLS is obtained from rheumatoid arthritis (RA), osteoarthritis (OA), and anterior cruciate ligament (ACL)-ruptured patients. The in vitro effect of TXA on primary FLS was investigated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell viability assays for cell death, annexin V/propidium iodide (PI) staining for apoptotic rate, real-time PCR for p65 and MMP-3 expression, and enzyme-linked immunosorbent assay (ELISA) for IL-6 measurement. MTT assays revealed a significant decrease in cell viability in FLS of all groups of patients following treatment with 0.8-60 mg/ml of TXA within 24 h. There was a significant increase in cell apoptosis after 24 h of exposure to TXA (15 mg/ml) in all groups, especially in RA-FLS. TXA increases the expression of MMP-3 and p65 expression. There was no significant change in IL-6 production after TXA treatment. An increase in receptor activator of nuclear factor kappa-Β ligand (RANK-L) production was seen only in RA-FLS. This study demonstrates that TXA caused significant synovial tissue toxicity via the increase in cell death and elevation of inflammatory and invasive gene expression in FLS cells.
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Affiliation(s)
- Salman Ghaffari
- Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Soroosh Fateh
- Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Faramarzi
- Department of Immunology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Alireza Rafiei
- Department of Immunology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mehran Razavipour
- Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Parisa Zafari
- Ramsar Campus, Mazandaran University of Medical Sciences, Ramsar, Iran.
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Huang X, Li F, Shi W, Liu W, Huang W, Yin D. Efficacy of perioperative cryotherapy combined with intra-articular injection of tranexamic acid in total knee arthroplasty. Medicine (Baltimore) 2023; 102:e34381. [PMID: 37478271 PMCID: PMC10662860 DOI: 10.1097/md.0000000000034381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/27/2023] [Indexed: 07/23/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of perioperative cryotherapy combined with intra-articular injection of tranexamic acid (TXA) in total knee arthroplasty (TKA) and explore a new strategy of enhanced recovery after TKA. METHODS We randomly divided 200 patients into 4 groups: normal saline (10 mL) by drainage (Group A, placebo); intra-articular injection of TXA (1 g, 10 mL, Group B); normal saline (10 mL) and continuous cryotherapy postoperatively (Group C) and intra-articular injection of TXA (1 g, 10 mL) and continuous cryotherapy postoperatively (Group D). Primary outcomes were blood loss volume, postoperative pain and circumference variation. We also recorded consumption of analgesics, postoperative length of stay (p-LOS), range of motion (ROM), function score (Hospital for Special Surgery) and severe complications. RESULTS There were statistically significant differences in postoperative drainage volume, total blood loss, hidden blood loss, and visual analogue scale at rest and walking on postoperative day 1 (POD1), POD2, POD3, ROM (POD3, 7, discharge, postoperative month), circumference variation (POD3, 7), p-LOS, Hospital for Special Surgery score (discharge) and drop of hemoglobin on POD3 (P < .05) among 4 groups, but there were no significant differences in intraoperative blood loss, postoperative prothrombin, activated partial thromboplastin time, overall number of patients or total consumption of oxycodone and perioperative complications (e.g., incidence of surgical site infection, deep venous thrombosis, and cold injury) among them (P > .05). CONCLUSION Continuous cryotherapy combined with intra-articular injection of TXA provides short-term advantages in reducing blood loss, pain, postoperative swelling, p-LOS and increasing ROM and joint function in the early postoperative period after TKA without increasing any severe complications.
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Affiliation(s)
- Xiao Huang
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Fulin Li
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Weifa Shi
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Wenhui Liu
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Wenwen Huang
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Dong Yin
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
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Sun W, Mao Y, Xiong Y, Li J. The Clinical Effect of Topical Application of Tranexamic Acid in Arthroscopic Synovectomy of Pigmented Villonodular Synovitis of the Knee. Orthopedics 2023; 46:e179-e185. [PMID: 36779738 DOI: 10.3928/01477447-20230207-01] [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] [Indexed: 02/14/2023]
Abstract
This study investigated the clinical effect of topical application of tranexamic acid (TXA) in arthroscopic synovectomy of pigmented villonodular synovitis (PVNS) of the knee. Eighty patients who were diagnosed with unilateral knee PVNS underwent arthroscopic synovectomies from January 2017 to January 2021 and were retrospectively investigated in this study. Patients were divided into two groups: group A was the control group, whereas patients in group B received an intra-articular injection of 50 mL of TXA (1 g:100 mL) immediately after the synovectomies. The primary outcome measurement was the drainage volume of the affected knee in each postoperative stage, as well as the hematological parameters. Secondary outcomes included visual analog scale score, knee range of motion, and Lysholm score. Postoperative complications were also recorded. A lower volume of drainage was found in group B than in group A on postoperative day (POD) 1, on POD 2, and in total (POD 1, P=.000; POD 2, P=.000; total, P=.000). A lower visual analog scale pain score in group B was noticed on POD 1 (P=.000) and POD 2 (P=.005). Range of motion (P=.019) and Lysholm score (P=.001) were significantly superior in group B compared with group A on POD 14. Regarding complications, 3 patients in group A and 1 patient in group B developed deep venous thrombosis after surgery. Hematomas were found intra-articularly in 5 patients in group A during follow-up. Intraarticular topical application of TXA was effective in reducing postoperative bleeding and early postoperative pain for patients who underwent arthroscopic synovectomy of PVNS. [Orthopedics. 20XX;XX(X):xx-xx.].
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Li F, Huang X, Liu W, Huang W, Wang C, Yin D. Application of dexamethasone combined with tranexamic acid in perioperative period of total hip arthroplasty. Medicine (Baltimore) 2022; 101:e31223. [PMID: 36281151 PMCID: PMC9592332 DOI: 10.1097/md.0000000000031223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of dexamethasone (DEXA) combined with tranexamic acid (TXA) in the perioperative period of total hip arthroplasty. MATERIALS AND METHODS A total of 100 cases were randomly divided into 2 groups (50 cases per group). All patients were given 15 mg/kg TXA before skin incision and 3 hours later. Patients in the intervention group (TXA + DEXA group) were given 20 mg dexamethasone intravenously after the onset of anesthesia, and the same dose of DEXA was administered again 24 hours later. Patients in the placebo group (TXA group) were only given the same dose of normal saline. Postoperative c-reactive protein and interleukin-6, postoperative nausea and vomiting, fatigue visual analogue scale score, postoperative length of stay, range of motion, and consumption of analgesic and antiemetics were statistically analyzed in the 2 groups. RESULTS The levels of c-reactive protein and interleukin-6 in the TXA + DEXA group were lower than those in the TXA group at 24, 48, 72 hours post-operatively (P < .001). Walking pain scores in the TXA + DEXA group were also significantly lower than those in the TXA group at 24 and 48 hours (P < .001); rest pain scores were lower at 24 hours (P < .001). Compared with the TXA group, the incidence of nausea VAS, postoperative nausea and vomiting, fatigue, analgesia and antiemetics consumption, postoperative length of stay, and range of motion were lower in the TXA + DEXA group (all P < .05), while there were no significant differences in postoperative hematocrit, total blood loss, and complications (P > .05). CONCLUSION The combination of TXA (15 mg/kg; before skin incision and 3 hours later) and DEX (20 mg dexamethasone intravenously after the onset of anesthesia, and again 24 hours later) is an effective and safe strategy for patients undergoing total hip arthroplasty.
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Affiliation(s)
- Fulin Li
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Xiao Huang
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Wenhui Liu
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Wenwen Huang
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Chaoqun Wang
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Dong Yin
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
- * Correspondence: Dong Yin, Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China (e-mail: )
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Is ROTEM Diagnostic in Trauma Care Associated with Lower Mortality Rates in Bleeding Patients?—A Retrospective Analysis of 7461 Patients Derived from the TraumaRegister DGU®. J Clin Med 2022; 11:jcm11206150. [PMID: 36294471 PMCID: PMC9605144 DOI: 10.3390/jcm11206150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/08/2022] [Accepted: 10/14/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction: Death from uncontrolled trauma haemorrhage and subsequent trauma-induced coagulopathy (TIC) is potentially preventable. Point-of-care devices such as rotational thromboelastometry (ROTEM®) are advocated to detect haemostatic derangements more rapidly than conventional laboratory diagnostics. Regarding reductions in RBC transfusion, the use of ROTEM has been described as being efficient and associated with positive outcomes in several studies. Objective: The effect of ROTEM use was assessed on three different outcome variables: (i) administration of haemostatics, (ii) rate of RBC transfusions and (iii) mortality in severely injured patients. Methods and Material: A retrospective analysis of a large data set of severely injured patients collected into the TraumaRegister DGU® between 2009 and 2016 was conducted. The data of 7461 patients corresponded to the inclusion criteria and were subdivided into ROTEM-using and ROTEM-non-using groups. Both groups were analysed regarding (i) administration of haemostatics, (ii) rate of RBC transfusions and (iii) mortality. Results: A lower mortality rate in ROTEM-using groups was observed (p = 0.043). Furthermore, more patients received haemostatic medication when ROTEM was used. In ROTEM-using groups, there was a statistically relevant higher application of massive transfusion. Conclusions: In this retrospective study, the use of ROTEM was associated with reduced mortality and an increased application of haemostatics and RBC transfusions. Prospective evidence is needed for further evidence-based recommendations.
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Prudovsky I, Kacer D, Zucco VV, Palmeri M, Falank C, Kramer R, Carter D, Rappold J. Tranexamic acid: Beyond antifibrinolysis. Transfusion 2022; 62 Suppl 1:S301-S312. [PMID: 35834488 DOI: 10.1111/trf.16976] [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: 11/30/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 11/30/2022]
Abstract
Tranexamic acid (TXA) is a popular antifibrinolytic drug widely used in hemorrhagic trauma patients and cardiovascular, orthopedic, and gynecological surgical patients. TXA binds plasminogen and prevents its maturation to the fibrinolytic enzyme plasmin. A number of studies have demonstrated the broad life-saving effects of TXA in trauma, superior to those of other antifibrinolytic agents. Besides preventing fibrinolysis and blood loss, TXA has been reported to suppress posttraumatic inflammation and edema. Although the efficiency of TXA transcends simple inhibition of fibrinolysis, little is known about its mechanisms of action besides the suppression of plasmin maturation. Understanding the broader effects of TXA at the cell, organ, and organism levels are required to elucidate its potential mechanisms of action transcending antifibrinolytic activity. In this article, we provide a brief review of the current clinical use of TXA and then focus on the effects of TXA beyond antifibrinolytics such as its anti-inflammatory activity, protection of the endothelial and epithelial monolayers, stimulation of mitochondrial respiration, and suppression of melanogenesis.
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Affiliation(s)
- Igor Prudovsky
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, USA
| | - Doreen Kacer
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, USA
| | - Victoria Vieira Zucco
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, USA
| | - Monica Palmeri
- Maine Medical Center Cardiovascular Institute, Maine Medical Center, Portland, Maine, USA
| | - Carolyne Falank
- Department of Trauma, Maine Medical Center, Maine Medical Center, Portland, Maine, USA
| | - Robert Kramer
- Maine Medical Center Cardiovascular Institute, Maine Medical Center, Portland, Maine, USA
| | - Damien Carter
- Department of Trauma, Maine Medical Center, Maine Medical Center, Portland, Maine, USA
| | - Joseph Rappold
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, USA.,Department of Trauma, Maine Medical Center, Maine Medical Center, Portland, Maine, USA
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Mamczak CN, Speybroeck J, Stillson JE, Dynako J, Piscoya A, Peck EE, Aboukhaled M, Cancel E, McDonald M, Garcia D, Lovejoy J, Lubin S, Stanton R, Kutcher ME. Viscoelastic Hemostatic Assays for Orthopedic Trauma and Elective Procedures. J Clin Med 2022; 11:jcm11144029. [PMID: 35887803 PMCID: PMC9323142 DOI: 10.3390/jcm11144029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
The application of viscoelastic hemostatic assays (VHAs) (e.g., thromboelastography (TEG) and rotational thromboelastometry (ROTEM)) in orthopedics is in its relative infancy when compared with other surgical fields. Fortunately, several recent studies describe the emerging use of VHAs to quickly and reliably analyze the real-time coagulation and fibrinolytic status in both orthopedic trauma and elective orthopedic surgery. Trauma-induced coagulopathy—a spectrum of abnormal coagulation phenotypes including clotting factor depletion, inadequate thrombin generation, platelet dysfunction, and dysregulated fibrinolysis—remains a potentially fatal complication in severely injured and/or hemorrhaging patients whose timely diagnosis and management are aided by the use of VHAs. Furthermore, VHAs are an invaluable compliment to common coagulation tests by facilitating the detection of hypercoagulable states commonly associated with orthopedic injury and postoperative status. The use of VHAs to identify hypercoagulability allows for an accurate venous thromboembolism (VTE) risk assessment and monitoring of VTE prophylaxis. Until now, the data have been insufficient to permit an individualized approach with regard to dosing and duration for VTE thromboprophylaxis. By incorporating VHAs into routine practice, orthopedic surgeons will be better equipped to diagnose and treat the complete spectrum of coagulation abnormalities faced by orthopedic patients. This work serves as an educational primer and up-to-date review of the current literature on the use of VHAs in orthopedic surgery.
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Affiliation(s)
- Christiaan N. Mamczak
- Department of Orthopaedic Trauma, Florida Orthopaedic Institute, St. Petersburg, FL 33701, USA;
| | - Jacob Speybroeck
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA;
| | - John E. Stillson
- Department of Family Medicine, John Peter Smith Hospital, Fort Worth, TX 76104, USA
- Correspondence:
| | - Joseph Dynako
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Andres Piscoya
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA;
| | - Ethan E. Peck
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Michael Aboukhaled
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Emily Cancel
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Michael McDonald
- Department of Graduate Medical Education, Naval Medical Readiness and Training Command, Portsmouth, VA 23708, USA;
| | - Diego Garcia
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - John Lovejoy
- Department of Orthopaedic Surgery, University of Florida Health Jacksonville, Jacksonville, FL 32209, USA;
| | - Stephanie Lubin
- Department of Orthopaedic Surgery, Hôpital Sacré Coeur, Milot 1230, Haiti;
| | - Robert Stanton
- Department of Pediatric Orthopaedics, Nemours Children’s Health-Florida, Orlando, FL 32827, USA;
| | - Matthew E. Kutcher
- Departments of Surgery and Emergency Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA;
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12
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Wallen TE, Singer KE, Baucom MR, England LG, Schuster RM, Pritts TA, Goodman MD. Effects of antifibrinolytics on systemic and cerebral inflammation after traumatic brain injury. J Trauma Acute Care Surg 2022; 93:30-37. [PMID: 35319541 PMCID: PMC9232970 DOI: 10.1097/ta.0000000000003607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Administration of antifibrinolytic medications, including tranexamic acid (TXA), may reduce head injury-related mortality. The effect of these medications on post-traumatic brain injury (TBI) inflammatory response is unknown. The goal of this study was to investigate the role of available antifibrinolytic medications on both systemic and cerebral inflammation after TBI. METHODS An established murine weight drop model was used to induce a moderate TBI. Mice were administered 1, 10, or 100 mg/kg of TXA, 400 mg/kg of aminocaproic acid (Amicar, Hospira, Lake Forest, IL), 100 kIU/kg of aprotonin, or equivalent volume of normal saline (NS) 10 minutes after recovery. Mice were euthanized at 1, 6, or 24 hours. Serum and cerebral tissue were analyzed for neuron-specific enolase and inflammatory cytokines. Hippocampal histology was evaluated at 30 days for phosphorylated tau accumulation. RESULTS One hour after TBI, mice given TXA displayed decreased cerebral cytokine concentrations of tumor necrosis factor α (TNF-α) and, by 24 hours, displayed decreased concentrations of cerebral TNF-α, interleukin (IL)-6, and monocyte chemoattractant protein 1 compared with TBI-NS. However, serum concentrations of TNF-α and macrophage inflammatory protein 1α (MIP-1α) were significantly elevated from 1 to 24 hours in TBI-TXA groups compared with TBI-NS. The concentration of phosphorylated tau was significantly decreased in a dose-dependent manner in TBI-TXA groups compared with TBI-NS. By contrast, Amicar administration increased cerebral cytokine levels of IL-6 1 hour after TBI, with serum elevations noted in TNF-α, MIP-1α, and monocyte chemoattractant protein 1 at 24 hours compared with TBI-NS. Aprotonin administration increased serum TNF-α, IL-6, and MIP-1α from 1 to 24 hours without differences in cerebral cytokines compared with TBI-NS. CONCLUSION Tranexamic acid administration may provide acute neuroinflammatory protection in a dose-dependent manner. Amicar administration may be detrimental after TBI with increased cerebral and systemic inflammatory effects. Aprotonin administration may increase systemic inflammation without significant contributions to neuroinflammation. While no antifibrinolytic medication improved systemic inflammation, these data suggest that TXA may provide the most beneficial inflammatory modulation after TBI.
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Affiliation(s)
- Taylor E Wallen
- From the Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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13
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Tranexamic Acid and Its Potential Anti-Inflammatory Effect: A Systematic Review. Semin Thromb Hemost 2022; 48:568-595. [PMID: 35636449 DOI: 10.1055/s-0042-1742741] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic drug primarily used for reducing blood loss in patients with major bleedings. Animal and cell studies have shown that TXA might modulate the inflammatory response by either enhancing or inhibiting cytokine levels. Furthermore, recent human studies have found altered inflammatory biomarkers in patients receiving TXA when compared with patients who did not receive TXA. In this systematic review we investigated the effect of TXA on inflammatory biomarkers in different patient groups. A systematic literature search was conducted on the databases PubMed and Embase to identify all original articles that investigated inflammatory biomarkers in patients receiving TXA and compared them to a relevant control group. The review was performed according to the PRISMA guidelines, and the literature search was performed on November 29, 2021. Thirty-three studies were included, among which 14 studies compared patients receiving TXA with patients getting no medication, another 14 studies investigated different dosing regimens of TXA, and finally five studies examined the administration form of TXA. The present review suggests that TXA has an anti-inflammatory effect in patients undergoing orthopaedic surgery illustrated by decreased levels of C-reactive protein and interleukin-6 in patients receiving TXA compared with patients receiving no or lower doses of TXA. However, the anti-inflammatory effect was not found in patients undergoing cardiac surgery, pediatric craniosynostosis patients, or in rheumatoid arthritis patients. The inflammatory response was not affected by administration form of TXA (oral, intravenous, or topical). In conclusion, an anti-inflammatory effect of TXA was consistently found among orthopaedic patients only.
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14
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Draxler DF, Hanafi G, Zahra S, McCutcheon F, Ho H, Keragala CB, Liu Z, Daly D, Painter T, Wallace S, Plebanski M, Myles PS, Medcalf RL. Tranexamic acid alters the immunophenotype of phagocytes after lower limb surgery. Thromb J 2022; 20:17. [PMID: 35410340 PMCID: PMC8996554 DOI: 10.1186/s12959-022-00373-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic agent frequently used in elective surgery to reduce blood loss. We recently found it also acts as a potent immune-modulator in patients undergoing cardiac surgery. Methods Patients undergoing lower limb surgery were enrolled into the “Tranexamic Acid in Lower Limb Arthroplasty” (TALLAS) pilot study. The cellular immune response was characterised longitudinally pre- and post-operatively using full blood examination (FBE) and comprehensive immune cell phenotyping by flowcytometry. Red blood cells and platelets were determined in the FBE and levels of T cell cytokines and the plasmin-antiplasmin complex determined using ELISA. Results TXA administration increased the proportion of circulating CD141+ conventional dendritic cells (cDC) on post-operative day (POD) 3. It also reduced the expression of CD83 and TNFR2 on classical monocytes and levels of circulating IL-10 at the end of surgery (EOS) time point, whilst increasing the expression of CCR4 on natural killer (NK) cells at EOS, and reducing TNFR2 on POD-3 on NK cells. Red blood cells and platelets were decreased to a lower extent at POD-1 in the TXA group, representing reduced blood loss. Conclusion In this investigation we have extended our examination on the immunomodulatory effects of TXA in surgery by also characterising the end of surgery time point and including B cells and neutrophils in our immune analysis, elucidating new immunophenotypic changes in phagocytes as well as NK cells. This study enhances our understanding of TXA-mediated effects on the haemostatic and immune response in surgery, validating changes in important functional immune cell subsets in orthopaedic patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00373-3.
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15
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Morris JL, Letson HL, McEwen P, Biros E, Dlaska C, Hazratwala K, Wilkinson M, Dobson GP. Comparison of intra-articular administration of adenosine, lidocaine and magnesium solution and tranexamic acid for alleviating postoperative inflammation and joint fibrosis in an experimental model of knee arthroplasty. J Orthop Surg Res 2021; 16:726. [PMID: 34930351 PMCID: PMC8686251 DOI: 10.1186/s13018-021-02871-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/05/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Dysregulated inflammatory responses are implicated in the pathogenesis of joint stiffness and arthrofibrosis following total knee arthroplasty (TKA). The purpose of this study was to compare the effects of intra-articular (IA) administration of tranexamic acid (TXA), an anti-fibrinolytic commonly used in TKA, and ALM chondroprotective solution on postoperative inflammation and joint tissue healing in a rat model of knee implant surgery. METHODS Male Sprague-Dawley rats (n = 24) were randomly divided into TXA or ALM treatment groups. The right knee of each rat was implanted with titanium (femur) and polyethylene (tibia) implants. An IA bolus (0.1 ml) of TXA or ALM was administered after implantation and capsule closure, and before skin closure. Postoperative coagulopathy, haematology and systemic inflammatory changes were assessed. Inflammatory and fibrotic markers were assessed in joint tissue, 28 days after surgery. RESULTS Haemostasis was comparable in animals treated with TXA or ALM after knee implant surgery. In contrast to ALM-treated animals, systemic inflammatory markers remained elevated at day 5 (IL-6, IL-12, IL-10, platelet count) and day 28 (IL-1β, IL-10) following surgery in TXA-treated animals. At day 28 following surgery, the extension range of motion of operated knees was 1.7-fold higher for ALM-treated animals compared to the TXA group. Key inflammatory mediators (NF-κB, IL-12, IL-2), immune cell infiltration (CD68+ cells) and markers of fibrosis (α-SMA, TGF-β) were also lower in capsular tissue of ALM-treated knees at day 28. CONCLUSION Data suggest that IA administration of ALM is superior to TXA for reducing postoperative systemic and joint inflammation and promoting restoration of healthy joint tissue architecture in a rat model of TKA. Further studies are warranted to assess the clinical translational potential of ALM IA solution to improve patient outcomes following arthroplasty.
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Affiliation(s)
- Jodie L Morris
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia.
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia.
| | - Hayley L Letson
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia
| | - Peter McEwen
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Erik Biros
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia
| | - Constantin Dlaska
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Kaushik Hazratwala
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Matthew Wilkinson
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Geoffrey P Dobson
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia
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16
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Thammaiah A, Gajapurada S, Nandakumar S, Sastry P, Mruthyunjaya M. O papel do ácido tranexâmico na prevenção e gerenciamento da perda de sangue na artroplastia total de articulação. Rev Bras Ortop 2021; 57:415-421. [PMID: 35785119 PMCID: PMC9246526 DOI: 10.1055/s-0041-1729933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 12/17/2020] [Indexed: 11/24/2022] Open
Abstract
Objective
To collect data on the role played by tranexamic acid in the prevention and management of blood loss in patients undergoing total hip arthroplasty and total knee arthroplasty.
Methods
In the present prospective, comparative study, 30 patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) were randomly allocated into 1 of 2 groups with 15 patients each. Tranexamic acid was administered by intravenous and topical routes in the study group, but it was not administered in the control group. Preoperative blood parameters, intraoperative and postoperative blood loss, and need for blood transfusion were noted. Statistical analysis was performed using the chi-squared test and the independent
t
-test.
Results
The study group had statistically significant higher postoperative hemoglobin values (
p
= 0.03), less difference between pre and postoperative hemoglobin value (
p
= 0.046), less difference between pre and postoperative packed-cell volume (
p
= 0.06), less intraoperative measured blood loss (
p
= 0.015), and less volume of blood collected in the drain (
p
= 0.0291) compared with the control group. There was also reduced frequency of blood transfusions in the study group (
p
= 0.0008).
Conclusion
Tranexamic acid is associated with reduced intra and postoperative blood loss and reduced frequency of blood transfusions in patients undergoing THA/TKA.
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Affiliation(s)
- Adarsh Thammaiah
- Departamento de Ortopedia, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, Índia
| | - Siddalingamurthy Gajapurada
- Departamento de Ortopedia, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, Índia
| | - Sanjana Nandakumar
- Departamento de Ortopedia, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, Índia
| | - Purushotham Sastry
- Departamento de Ortopedia, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, Índia
| | - Mruthyunjaya Mruthyunjaya
- Departamento de Ortopedia, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, Índia
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17
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Ockerman A, Vanassche T, Garip M, Vandenbriele C, Engelen MM, Martens J, Politis C, Jacobs R, Verhamme P. Tranexamic acid for the prevention and treatment of bleeding in surgery, trauma and bleeding disorders: a narrative review. Thromb J 2021; 19:54. [PMID: 34380507 PMCID: PMC8356407 DOI: 10.1186/s12959-021-00303-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We review the evidence for tranexamic acid (TXA) for the treatment and prevention of bleeding caused by surgery, trauma and bleeding disorders. We highlight therapeutic areas where evidence is lacking and discuss safety issues, particularly the concern regarding thrombotic complications. METHODS An electronic search was performed in PubMed and the Cochrane Library to identify clinical trials, safety reports and review articles. FINDINGS TXA reduces bleeding in patients with menorrhagia, and in patients undergoing caesarian section, myomectomy, hysterectomy, orthopedic surgery, cardiac surgery, orthognathic surgery, rhinoplasty, and prostate surgery. For dental extractions in patients with bleeding disorders or taking antithrombotic drugs, as well as in cases of idiopathic epistaxis, tonsillectomy, liver transplantation and resection, nephrolithotomy, skin cancer surgery, burn wounds and skin grafting, there is moderate evidence that TXA is effective for reducing bleeding. TXA was not effective in reducing bleeding in traumatic brain injury and upper and lower gastrointestinal bleeding. TXA reduces mortality in patients suffering from trauma and postpartum hemorrhage. For many of these indications, there is no consensus about the optimal TXA dose. With certain dosages and with certain indications TXA can cause harm, such as an increased risk of seizures after high TXA doses with brain injury and cardiac surgery, and an increased mortality after delayed administration of TXA for trauma events or postpartum hemorrhage. Whereas most trials did not signal an increased risk for thrombotic events, some trials reported an increased rate of thrombotic complications with the use of TXA for gastro-intestinal bleeding and trauma. CONCLUSIONS TXA has well-documented beneficial effects in many clinical indications. Identifying these indications and the optimal dose and timing to minimize risk of seizures or thromboembolic events is work in progress.
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Affiliation(s)
- Anna Ockerman
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium.
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Melisa Garip
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Jeroen Martens
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peter Verhamme
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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18
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Khella CM, Horvath JM, Asgarian R, Rolauffs B, Hart ML. Anti-Inflammatory Therapeutic Approaches to Prevent or Delay Post-Traumatic Osteoarthritis (PTOA) of the Knee Joint with a Focus on Sustained Delivery Approaches. Int J Mol Sci 2021; 22:8005. [PMID: 34360771 PMCID: PMC8347094 DOI: 10.3390/ijms22158005] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 12/11/2022] Open
Abstract
Inflammation plays a central role in the pathogenesis of knee PTOA after knee trauma. While a comprehensive therapy capable of preventing or delaying post-traumatic osteoarthritis (PTOA) progression after knee joint injury does not yet clinically exist, current literature suggests that certain aspects of early post-traumatic pathology of the knee joint may be prevented or delayed by anti-inflammatory therapeutic interventions. We discuss multifaceted therapeutic approaches that may be capable of effectively reducing the continuous cycle of inflammation and concomitant processes that lead to cartilage degradation as well as those that can simultaneously promote intrinsic repair processes. Within this context, we focus on early disease prevention, the optimal timeframe of treatment and possible long-lasting sustained delivery local modes of treatments that could prevent knee joint-associated PTOA symptoms. Specifically, we identify anti-inflammatory candidates that are not only anti-inflammatory but also anti-degenerative, anti-apoptotic and pro-regenerative.
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Affiliation(s)
| | | | | | | | - Melanie L. Hart
- G.E.R.N. Center for Tissue Replacement, Regeneration & Neogenesis, Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center—Albert-Ludwigs—University of Freiburg, 79085 Freiburg im Breisgau, Germany; (C.M.K.); (J.M.H.); (R.A.); (B.R.)
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19
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Fenger‐Eriksen C, Rasmussen M, Juul N, Krog J, Hvas A. Effect of tranexamic acid on markers of inflammation in children undergoing craniofacial surgery. Acta Anaesthesiol Scand 2021; 65:34-39. [PMID: 32905611 DOI: 10.1111/aas.13700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) reduces blood loss and transfusion requirements during craniosynostosis surgery in small children. Possible interaction from TXA on the inflammatory system is unknown. OBJECTIVE To evaluate the effect of TXA on a wide range of inflammatory markers in children receiving TXA in a randomized, blinded, and placebo controlled study design. METHODS Thirty children undergoing craniosynostosis surgery with significant blood loss received TXA (bolus dose of 10 mg kg-1 followed by 8 hours continuous infusion of 3 mg kg-1 h-1 ) or placebo in a randomized, double-blinded study design. Using a new proximity extension assays employing a panel of inflammatory biomarkers samples was used for analysis of blood samples obtained pre-operatively, 4 and 24 hours after operation. RESULTS Ninety-two inflammatory parameters were measured. TXA did not affect any of the measured parameters as compared with placebo. Among 34 of the 92 pro- and antiinflammatory parameters investigated changes were observed between pre-operative, 4 or 24 hours, respectively, reflecting immune activation during surgical stress. CONCLUSION TXA administration in a low-dose regimen including bolus followed by 8 hours infusion during craniosynostosis surgery did not change any of 92 inflammatory markers as compared with placebo.
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Affiliation(s)
| | - Mads Rasmussen
- Department of Anesthesiology Aarhus University Hospital Aarhus Denmark
| | - Niels Juul
- Department of Anesthesiology Aarhus University Hospital Aarhus Denmark
| | - Jan Krog
- Department of Anesthesiology Aarhus University Hospital Aarhus Denmark
| | - Anne‐Mette Hvas
- Department of Clinical Biochemistry Thrombosis and Hemostasis Research Unit Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
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20
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Tranexamic Acid Combined with Compression Bandage Following Total Knee Arthroplasty Promotes Blood Coagulation: A Retrospective Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2739560. [PMID: 33204690 PMCID: PMC7655242 DOI: 10.1155/2020/2739560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/02/2020] [Accepted: 10/20/2020] [Indexed: 01/23/2023]
Abstract
Objective This paper included a retrospective review of the effect of tranexamic acid (TXA) combined with pressure bandaging on hemostasis of patients who received a unilateral total knee arthroplasty (TKA) from 2017 to 2019. Methods A total of 197 patients undergoing TKA were chosen to be classified into 2 groups, the compression bandage control group and compression bandage combined with TXA observation group. The patients received blood routine examination when they were in the 1st, 3rd, and 6th days of before and postoperation. Some parameters, such as hemoglobin (Hb), C-reactive protein (CRP), D-dimer value, fibrinogen, prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), international normalized ratio (INR), and erythrocyte sedimentation rate (ESR), were also investigated. Results In our research, the mean age was 66.54 ± 7.95 years. No difference was found in patient sex (P = 0.876) and age (P = 0.749) between groups. No differences were found in the levels of Hb, fibrinogen, TT, and INR between the 2 groups at each period (P > 0.05). The difference of PT was significantly different on the 1st day (P = 0.011), 3rd day (P = 0.010), and 6th day (P = 0.004) after surgery. Besides, the changes in APTT in observation group were clearly higher compared with the control group on the 3rd day (P = 0.001) and 6th day (P = 0.001). On the 3rd and 6th days after operation, the CRP level of the two groups increased continuously, and the CRP level was significantly higher in the observation group in comparison with the control group (P = 0.008, P = 0.010). On 1st and 3rd days after surgery, compared to the control group, the D-dimer level of patients in the observation group was distinctly fewer (P = 0.001, P = 0.027). Conclusion TXA combined with compression bandage is a potential option for the reduction of bleeding after TKA.
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21
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Daglas M, Galle A, Draxler DF, Ho H, Liu Z, Sashindranath M, Medcalf RL. Sex-dependent effects of tranexamic acid on blood-brain barrier permeability and the immune response following traumatic brain injury in mice. J Thromb Haemost 2020; 18:2658-2671. [PMID: 32668057 DOI: 10.1111/jth.15015] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an anti-fibrinolytic agent used to reduce bleeding in various conditions including traumatic brain injury (TBI). As the fibrinolytic system also influences the central nervous system and the immune response, TXA may also modulate these parameters following TBI. OBJECTIVES To determine the effect of TXA on blood-brain barrier (BBB) integrity and changes in immune and motor function in male and female mice subjected to TBI. METHODS Wild-type and plasminogen deficient (plg-/-) mice were subjected to TBI then administered either TXA/vehicle. The degree of BBB breakdown, intracerebral hemorrhage (ICH), motor dysfunction, and changes in inflammatory subsets in blood and brain were determined. RESULTS AND CONCLUSIONS Tranexamic acid significantly reduced BBB breakdown, and increased blood neutrophils in male mice 3 hours post-TBI. In contrast, TXA treatment of female mice increased BBB permeability and ICH but had no effect on blood neutrophils at the same time-point. TXA improved motor function in male mice but still increased BBB breakdown in female mice 24 hours post-TBI. Brain urokinase-type plasminogen activator (u-PA) antigen and activity levels were significantly higher in injured females compared to males. Because TXA can promote a pro-fibrinolytic effect via u-PA, these sex differences may be related to brain u-PA levels. TXA also increased monocyte subsets and dendritic cells in the injured brain of wild-type male mice 1 week post-TBI. Plg-/- mice of both sexes had reduced BBB damage and were protected from TBI irrespective of treatment indicating that TXA modulation of the BBB is plasmin-dependent. In conclusion, TXA is protective post-TBI but only in male mice.
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Affiliation(s)
- Maria Daglas
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Adam Galle
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Dominik F Draxler
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Heidi Ho
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Zikou Liu
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Maithili Sashindranath
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Spinella PC, Thomas KA, Turnbull IR, Fuchs A, Bochicchio K, Schuerer D, Reese S, Coleoglou Centeno AA, Horn CB, Baty J, Shea SM, Meledeo MA, Pusateri AE, Levy JH, Cap AP, Bochicchio GV. The Immunologic Effect of Early Intravenous Two and Four Gram Bolus Dosing of Tranexamic Acid Compared to Placebo in Patients With Severe Traumatic Bleeding (TAMPITI): A Randomized, Double-Blind, Placebo-Controlled, Single-Center Trial. Front Immunol 2020; 11:2085. [PMID: 33013880 PMCID: PMC7506112 DOI: 10.3389/fimmu.2020.02085] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/30/2020] [Indexed: 01/08/2023] Open
Abstract
Background The hemostatic properties of tranexamic acid (TXA) are well described, but the immunological effects of TXA administration after traumatic injury have not been thoroughly examined. We hypothesized TXA would reduce monocyte activation in bleeding trauma patients with severe injury. Methods This was a single center, double-blinded, randomized controlled trial (RCT) comparing placebo to a 2 g or 4 g intravenous TXA bolus dose in trauma patients with severe injury. Fifty patients were randomized into each study group. The primary outcome was a reduction in monocyte activation as measured by human leukocyte antigen-DR isotype (HLA-DR) expression on monocytes 72 h after TXA administration. Secondary outcomes included kinetic assessment of immune and hemostatic phenotypes within the 72 h window post-TXA administration. Results The trial occurred between March 2016 and September 2017, when data collection ended. 149 patients were analyzed (placebo, n = 50; 2 g TXA, n = 49; 4 g TXA, n = 50). The fold change in HLA-DR expression on monocytes [reported as median (Q1–Q3)] from pre-TXA to 72 h post-TXA was similar between placebo [0.61 (0.51–0.82)], 2 g TXA [0.57 (0.47–0.75)], and 4 g TXA [0.57 (0.44–0.89)] study groups (p = 0.82). Neutrophil CD62L expression was reduced in the 4 g TXA group [fold change: 0.73 (0.63–0.97)] compared to the placebo group [0.97 (0.78–1.10)] at 24 h post-TXA (p = 0.034). The fold decrease in plasma IL-6 was significantly less in the 4 g TXA group [1.36 (0.87–2.42)] compared to the placebo group [0.46 (0.19–1.69)] at 72 h post-TXA (p = 0.028). There were no differences in frequencies of myeloid or lymphoid populations or in classical complement activation at any of the study time points. Conclusion In trauma patients with severe injury, 4 g intravenous bolus dosing of TXA has minimal immunomodulatory effects with respect to leukocyte phenotypes and circulating cytokine levels. Clinical Trial Registration www.ClinicalTrials.gov, identifier NCT02535949.
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Affiliation(s)
- Philip C Spinella
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Kimberly A Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Isaiah R Turnbull
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Anja Fuchs
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Kelly Bochicchio
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Douglas Schuerer
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Stacey Reese
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Adrian A Coleoglou Centeno
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Christopher B Horn
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Jack Baty
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, United States
| | - Susan M Shea
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - M Adam Meledeo
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Anthony E Pusateri
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, United States
| | - Andrew P Cap
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Grant V Bochicchio
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
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Abstract
OBJECTIVE To review the current literature on the use of viscoelastic hemolytic assays, such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM), during the perioperative period of patients and determine the ability of TEG and ROTEM to detect hypercoagulability and identify increased risk of the development of venous thromboembolism (VTE). DATA SOURCES PubMed, EMBASE, and Cochrane online databases were queried through February 11, 2018, by pairing the terms "thromboelastography," "viscoelastic hemostatic assays," and "rotational thromboelastometry" with "venous thromboembolism," "deep vein thrombosis," "pulmonary embolism," and "hypercoagulability." STUDY SELECTION Inclusion and exclusion criteria were established to determine relevance and quality of data, of which 2.54% of initially identified studies met. DATA EXTRACTION AND SYNTHESIS Articles and citations were reviewed for relevance by 2 independent individuals following PRISMA guidelines as well as a quality assessment of data as established by Zaza et al. In studies that separated patients postoperatively by VTE development or no VTE development, data were pooled utilizing a modified DerSimmion and Laird random effects model. RESULTS One thousand eight hundred ninety-three articles were assessed for eligibility, yielding 370 abstracts. Of the 370 abstracts, 35 studies were included, and of these, only 5 were included in the meta-analysis. Studies included postsurgical patients in a variety of surgical fields, encompassing a total of 8939 patients, with 717 thrombotic events reported. Elevated maximum amplitude (MA) was a statistically significant indicator of hypercoagulability across at least 1 perioperative time point in 17 (50%) of the articles reviewed, consisting of 6348 (72%) patients. The pooled mean MA value for defining hypercoagulability was greater than 66.70 mm. Using a prepublished value for hypercoagulability of 65 mm, the combined effect of MA on the development of VTE in postsurgical patients was determined to be 1.31 (95% confidence, 0.74-2.34, P = 0.175) and was 46% sensitive and 62% specific in predicting a postoperative VTE. CONCLUSIONS Only 1 parameter, MA, was consistently used to both define hypercoagulability and be predictive of VTE after traumatic injury and surgical intervention; however, there remains a broad variability in the definition of hypercoagulability as determined by MA and thus limits its predictive ability. In addition, when hypercoagulability was measured throughout the perioperative period, TEG consistently demonstrated hypercoagulability starting on post-op day 1 (POD1). LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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An YZ, Xu MD, An YC, Liu H, Zheng M, Jiang DM. Combined Application of Dexamethasone and Tranexamic Acid to Reduce the Postoperative Inflammatory Response and Improve Functional Outcomes in Total Hip Arthroplasty. Orthop Surg 2020; 12:582-588. [PMID: 32347005 PMCID: PMC7189035 DOI: 10.1111/os.12664] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 02/29/2020] [Indexed: 12/14/2022] Open
Abstract
Objective To evaluate the efficacy and safety of combined use of tranexamic acid (TXA) and dexamethasone (DEX) for anti‐inflammatory and clinical outcomes after total hip arthroplasty (THA). Methods A total of 100 patients were included in this randomized, controlled study. Patients in the TXA + DEX group were administered TXA at a dose of 15 mg/kg, which was repeated 3 h after THA, and received 20 mg DEX. In contrast, patients in the TXA group were administered TXA at a dose of 15 mg/kg, which was repeated at 3 h postoperatively. C‐reactive protein (CRP), interleukin‐6 (IL‐6) and pain levels, incidence of postoperative nausea and vomiting (PONV), total blood loss and transfusion rates, postoperative fatigue, range of motion (ROM), length of hospital stay (LOS), analgesic rescue and antiemetic rescue consumption, and complications were compared in both groups. Results The CRP and IL‐6 levels were lower in the TXA + DEX group than in the TXA group (all P < 0.001) at 24 h, 48 h, and 72 h postoperatively. Patients in the TXA + DEX group had lower pain scores at rest and walking at 24 h postoperatively (all P < 0.001). In the TXA + DEX group, the incidence of PONV was lower (P = 0.005), postoperative fatigue (P < 0.001) was reduced, and analgesia and antiemetic rescue consumption were also reduced. The total blood loss, transfusion rate, LOS and hip ROM were similar in the two groups. There was no thrombosis, infection, or gastrointestinal bleeding in either group. Conclusion Compared to TXA alone, the combination of TXA + DEX can reduce postoperative inflammatory response, relieve pain, and reduce PONV and fatigue, without increasing the risk of complications. Therefore, the present study suggested that the combination of TXA + DEX is an effective and safe accelerated rehabilitation strategy for patients receiving primary unilateral THA.
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Affiliation(s)
- Yu-Zhang An
- Department of Orthopaedic Surgery, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, China
| | - Ming-Deng Xu
- Department of Orthopaedic Surgery, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, China
| | - Yu-Cheng An
- Department of Cardiology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, China
| | - Huan Liu
- Department of Surgical Inpatient, Cai Jia Hospital, Chongqing, 401120, China
| | - Ming Zheng
- Department of Orthopaedic Surgery, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, China
| | - Dian-Ming Jiang
- Department of Orthopaedic Surgery, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, China
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Chan K, Farouji I, Slim J, Shaaban H, Guron G. Tranexamic acid: A potential treatment option for coronavirus disease 2019. J Glob Infect Dis 2020; 12:160-161. [PMID: 33343171 PMCID: PMC7733429 DOI: 10.4103/jgid.jgid_132_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/27/2020] [Accepted: 05/27/2020] [Indexed: 11/04/2022] Open
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Tranexamic Acid Reduces Total Blood Loss and Inflammatory Response in Computer-Assisted Navigation Total Knee Arthroplasty. BIOMED RESEARCH INTERNATIONAL 2019; 2019:5207517. [PMID: 31886224 PMCID: PMC6925782 DOI: 10.1155/2019/5207517] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 09/11/2019] [Indexed: 11/18/2022]
Abstract
Introduction Tranexamic acid (TXA) is an effective blood salvage agent that reduces perioperative blood loss in conventional total knee arthroplasty (TKA). As computer-assisted surgery for TKA (CAS-TKA) results in a lower perioperative blood loss than conventional TKA, the additional effect of blood conservation by TXA might be mitigated. This study aimed to evaluate the efficacy of TXA in CAS-TKA. Methods We retrospectively reviewed 222 consecutive patients who underwent CAS-TKA. Intravenous TXA was administered in 103 patients (TXA group) at a dosage of 20 mg/kg 15 min before deflation of the tourniquet. The other 119 patients did not receive TXA (control group). Patient demographic data including age, gender, BMI, DM, and hypertension were collected. The primary outcomes were the estimated total blood loss (ETBL) and perioperative data, including tourniquet duration, preoperative and postoperative day 1 (POD1) and day 3 (POD3) serum D-dimer, CRP, hemoglobin (Hb), and hematocrit (Hct) levels. Secondary outcomes including transfusion rate and 90-day complications were recorded. Results The ETBL was lower in the TXA group on both POD1 (404.34 ± 234.77 vs. 595.47 ± 279.04, p < 0.001) and POD3 (761.39 ± 260.88 vs. 987.79 ± 326.58, p < 0.001). The TXA group also demonstrated a lower level of CRP on POD1 (p=0.02) and lower levels of CRP and serum D-dimer on POD3 (p=0.008 and p < 0.001). Consumption of fibrinogen was higher in the control group on both POD1 (p=0.013) and POD3 (p < 0.001). Length of hospital stay was lower in the TXA group (5.42 ± 1.21 vs. 6.25 ± 1.49, p < 0.001). The transfusion rate and perioperative complications were not significantly different between the two groups. Conclusion Administration of TXA is not only effective in reducing perioperative blood loss and length of hospital stay but also exerts an anti-inflammatory effect following CAS-TKA without causing major complications.
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Jules-Elysee KM, Tseng A, Sculco TP, Baaklini LR, McLawhorn AS, Pickard AJ, Qin W, Cross JR, Su EP, Fields KG, Mayman DJ. Comparison of Topical and Intravenous Tranexamic Acid for Total Knee Replacement: A Randomized Double-Blinded Controlled Study of Effects on Tranexamic Acid Levels and Thrombogenic and Inflammatory Marker Levels. J Bone Joint Surg Am 2019; 101:2120-2128. [PMID: 31800425 PMCID: PMC7406146 DOI: 10.2106/jbjs.19.00258] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic drug. Topical administration of TXA during total knee arthroplasty (TKA) is favored for certain patients because of concerns about thrombotic complications, despite a lack of supporting literature. We compared local and systemic levels of thrombogenic markers, interleukin (IL)-6, and TXA between patients who received intravenous (IV) TXA and those who received topical TXA. METHODS Seventy-six patients scheduled for TKA were enrolled in this randomized double-blinded study. The IV group received 1.0 g of IV TXA before tourniquet inflation and again 3 hours later; a topical placebo was administered 5 minutes before final tourniquet release. The topical group received an IV placebo before tourniquet inflation and again 3 hours later; 3.0 g of TXA was administered topically 5 minutes before final tourniquet release. Peripheral and wound blood samples were collected to measure levels of plasmin-anti-plasmin (PAP, a measure of fibrinolysis), prothrombin fragment 1.2 (PF1.2, a marker of thrombin generation), IL-6, and TXA. RESULTS At 1 hour after tourniquet release, systemic PAP levels were comparable between the IV group (after a single dose of IV TXA) and the topical group. At 4 hours after tourniquet release, the IV group had lower systemic PAP levels than the topical group (mean and standard deviation, 1,117.8 ± 478.9 µg/L versus 1,280.7 ± 646.5 µg/L; p = 0.049), indicative of higher antifibrinolytic activity after the second dose. There was no difference in PF1.2 levels between groups, indicating that there was no increase in thrombin generation. The IV group had higher TXA levels at all time points (p < 0.001). Four hours after tourniquet release, wound blood IL-6 and TXA levels were higher than systemic levels in both groups (p < 0.001). Therapeutic systemic TXA levels (mean, 7.2 ± 7.4 mg/L) were noted in the topical group. Calculated blood loss and the length of the hospital stay were lower in the IV group (p = 0.026 and p = 0.025). CONCLUSIONS Given that therapeutic levels were reached with topical TXA and the lack of a major difference in the mechanism of action, coagulation, and fibrinolytic profile between topical TXA and a single dose of IV TXA, it may be a simpler protocol for institutions to adopt the use of a single dose of IV TXA when safety is a concern. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kethy M Jules-Elysee
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Audrey Tseng
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
| | - Thomas P Sculco
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
| | - Lila R Baaklini
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Alexander S McLawhorn
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
| | - Amanda J Pickard
- Donald B. and Catherine C. Marron Cancer Metabolism Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - WeiGe Qin
- Donald B. and Catherine C. Marron Cancer Metabolism Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Justin R Cross
- Donald B. and Catherine C. Marron Cancer Metabolism Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Edwin P Su
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
| | - Kara G Fields
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
| | - David J Mayman
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
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McCutchan A, Dobson GP, Stewart N, Letson HL, Grant AL, Jovanovic IA, Hazratwala K, Wilkinson M, McEwen P, Morris J. Absence of cytotoxic and inflammatory effects following in vitro exposure of chondrogenically-differentiated human mesenchymal stem cells to adenosine, lidocaine and Mg 2+ solution. J Exp Orthop 2019; 6:16. [PMID: 30989345 PMCID: PMC6465392 DOI: 10.1186/s40634-019-0185-5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/22/2019] [Indexed: 12/12/2022] Open
Abstract
Background ALM solution, a combination of adenosine, lidocaine and Mg2+, is an emerging small volume therapy that has been shown to prevent and correct coagulopathy and surgery-related inflammation in preclinical models, though its application in orthopaedic surgery is yet to be demonstrated. The effect of ALM solution on chondrocytes is unknown. The aim of this preliminary study was to investigate the effect of ALM solution on viability and inflammatory responses of chondrogenically-differentiated human bone marrow-derived mesenchymal stem cells (chondro-MSC), in vitro. Methods Chondro-MSC were exposed to media only, saline (0.9% NaCl or 1.3% NaCl) only, or saline containing ALM (1 mM adenosine, 3 mM lidocaine, 2.5 mM Mg2+) or tranexamic acid (TXA, 100 mg/ml) for 1 or 4 h. Responses to ALM solutions containing higher lidocaine concentrations were also compared. Chondrocyte viability was determined using WST-8 colorimetric assays and inflammatory cytokine (TNF-α, IL-1β, IL-8) and matrix metalloproteinases (MMP-3, MMP-12, MMP-13) concentrations using multiplex bead arrays. Results The viability of chondro-MSC was significantly greater after 1 h treatment with ALM compared to saline (96.2 ± 7.9 versus 75.6 ± 7.3%). Extension of exposure times to 4 h had no significant adverse effect on cell viability after treatment with ALM (1 h, 85.4 ± 5.6 v 4 h, 74.0 ± 15.2%). Cytotoxicity was evident following exposure to solutions containing lidocaine concentrations greater than 30 mM. There were no significant differences in viability (80 ± 5.4 v 57.3 ± 16.2%) or secretion of IL-8 (60 ± 20 v 160 ± 50 pg/ml), MMP-3 (0.95 ± 0.6 v 3.4 ± 1.6 ng/ml), and MMP-13 (4.2 ± 2.4 v 9.2 ± 4.3 ng/ml) in chondro-MSC exposed to saline, ALM or TXA. Conclusions Short-term, in vitro exposure to clinically-relevant concentrations of ALM solution had no adverse inflammatory or chondrotoxic effects on human chondro-MSC, with responses comparable to saline and TXA. These findings provide support for continued evaluation of ALM solution as a possible therapeutic to improve outcomes following orthopaedic procedures.
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Affiliation(s)
- Andrew McCutchan
- Department of Haematology and Bone Marrow Transplantation, Townsville Hospital, Townsville, Australia
| | - Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Natalie Stewart
- Department of Haematology and Bone Marrow Transplantation, Townsville Hospital, Townsville, Australia
| | - Hayley L Letson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Andrea L Grant
- The Orthopaedic Research Institute of Queensland, 7 Turner St, Pimlico, Townsville, Q 4812, Australia
| | | | - Kaushik Hazratwala
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, Australia.,The Orthopaedic Research Institute of Queensland, 7 Turner St, Pimlico, Townsville, Q 4812, Australia
| | - Matthew Wilkinson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, Australia.,The Orthopaedic Research Institute of Queensland, 7 Turner St, Pimlico, Townsville, Q 4812, Australia
| | - Peter McEwen
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, Australia.,The Orthopaedic Research Institute of Queensland, 7 Turner St, Pimlico, Townsville, Q 4812, Australia
| | - Jodie Morris
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, Australia. .,The Orthopaedic Research Institute of Queensland, 7 Turner St, Pimlico, Townsville, Q 4812, Australia.
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Morris JL, Letson HL, Gillman R, Hazratwala K, Wilkinson M, McEwen P, Dobson GP. The CNS theory of osteoarthritis: Opportunities beyond the joint. Semin Arthritis Rheum 2019; 49:331-336. [PMID: 30982553 DOI: 10.1016/j.semarthrit.2019.03.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/02/2019] [Accepted: 03/14/2019] [Indexed: 01/06/2023]
Abstract
Osteoarthritis (OA) is a leading cause of global disability that affects more than half of the population over 65. It is not a single disease but a progressive, inflammatory- and immune-altering multi-disease that affects the whole joint. OA has many risk factors including age, obesity, gender, lifestyle, joint morphology, metabolic dysfunction and genetic disposition. A major stumbling block in treating clinical OA has been the inability to detect its early onset and disease progression. This gap in understanding may arise from our failure to recognize that the OA patient exhibits a vulnerability to dysregulation of central feedback circuits that control sympathetic tone, inflammation, circadian rhythms (central and peripheral clocks), gut microbiome, metabolic redox and whole joint pathology. Early detection of OA and slowing its progression may come from discoveries outside the joint targeting these potentially modifiable upstream targets. We argue that future treatments may benefit from moving from a knee-centric viewpoint to a more systems-based, whole-body approach. The challenge, however, will be to better characterize these key circuits and apply this knowledge to develop new therapies and interventions.
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Affiliation(s)
- Jodie L Morris
- The Orthopaedic Research Institute of Queensland (ORIQL), Townsville 4812, Queensland, Australia; Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, 4811, Queensland, Australia.
| | - Hayley L Letson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, 4811, Queensland, Australia.
| | - Rhys Gillman
- The Orthopaedic Research Institute of Queensland (ORIQL), Townsville 4812, Queensland, Australia.
| | - Kaushik Hazratwala
- The Orthopaedic Research Institute of Queensland (ORIQL), Townsville 4812, Queensland, Australia.
| | - Matthew Wilkinson
- The Orthopaedic Research Institute of Queensland (ORIQL), Townsville 4812, Queensland, Australia.
| | - Peter McEwen
- The Orthopaedic Research Institute of Queensland (ORIQL), Townsville 4812, Queensland, Australia
| | - Geoffrey P Dobson
- The Orthopaedic Research Institute of Queensland (ORIQL), Townsville 4812, Queensland, Australia; Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, 4811, Queensland, Australia.
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