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B H PP, Diskina D, Lin HM, Vulcano E, Lai YH. Use of tranexamic acid does not influence perioperative outcomes in ambulatory foot and ankle surgery-a prospective triple blinded randomized controlled trial. INTERNATIONAL ORTHOPAEDICS 2021; 45:2277-2284. [PMID: 34324042 DOI: 10.1007/s00264-021-05131-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/23/2021] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVE TXA is an antifibrinolytic medication widely used to reduce perioperative blood loss, but it has been seldom used during foot and ankle surgery. Our study evaluates the impact of TXA use on blood loss, post-operative pain, peri-operative opioid consumption, and wound healing in ambulatory outpatient foot and ankle procedures. DESIGN Prospective, triple-blinded, randomized controlled trial. SETTING Peri-operative environment of a major academic health centre in New York City. PATIENTS A total of 100 participants who were scheduled for ambulatory foot and ankle surgery with a single surgeon. INTERVENTIONS Patients receive either 10 mg/kg TXA (TXA group) or 10 ml/kg of normal saline (placebo group) intravenously prior to skin incision. MEASUREMENTS Primary outcome was intra-operative blood loss. Secondary outcomes were peri-operative opioid consumption and wound complications between post-operative days 14 and 21. MAIN RESULTS We found no difference between TXA and placebo groups in terms of intra-operative blood loss, p value 0.71, 95% CI (63.13-19.80). There was no difference between the two groups in terms of post-operative morphine milliequivalents (MME). The incidence of wound complications was 16.3% in the TXA group compared to 15.7% in the placebo group with OR 1.04, p value 0.93, 95% CI (0.32-2.77). No adverse events associated with TXA were reported. CONCLUSIONS The use of TXA during foot and ankle surgery was not associated with any benefits in perioperative outcomes in our outpatient ambulatory surgical population. Considering potential risks, we do not support the routine use of TXA in this surgical model.
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Affiliation(s)
| | | | - Hung Mo Lin
- Mount Sinai Health System, New York, NY, USA
| | - Ettore Vulcano
- Mount Sinai Medical Center, Columbia University, Miami, FL, USA
| | - Yan H Lai
- Department of Anesthesiology, Mount Sinai Health System, 1000 Tenth Avenue, New York, NY, 10019, USA.
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Mikhail C, Pennington Z, Arnold PM, Brodke DS, Chapman JR, Chutkan N, Daubs MD, DeVine JG, Fehlings MG, Gelb DE, Ghobrial GM, Harrop JS, Hoelscher C, Jiang F, Knightly JJ, Kwon BK, Mroz TE, Nassr A, Riew KD, Sekhon LH, Smith JS, Traynelis VC, Wang JC, Weber MH, Wilson JR, Witiw CD, Sciubba DM, Cho SK. Minimizing Blood Loss in Spine Surgery. Global Spine J 2020; 10:71S-83S. [PMID: 31934525 PMCID: PMC6947684 DOI: 10.1177/2192568219868475] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
STUDY DESIGN Broad narrative review. OBJECTIVE To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery. METHODS A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery. RESULTS There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements. CONCLUSION As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.
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Affiliation(s)
| | | | - Paul M. Arnold
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Norman Chutkan
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - John G. DeVine
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Daniel E. Gelb
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Fan Jiang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Brian K. Kwon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas E. Mroz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmad Nassr
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K. Daniel Riew
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lali H. Sekhon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | | | | | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, USA.
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The Use of Tranexamic Acid to Reduce Surgical Blood Loss: A Review Basic Science, Subspecialty Studies, and The Evolution of Use in Spine Deformity Surgery. Clin Spine Surg 2019; 32:46-50. [PMID: 30789494 DOI: 10.1097/bsd.0000000000000808] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Significant blood loss is often seen in orthopedic surgeries, especially complex spinal procedures that constitute long surgical times, large incisions, and rich blood supplies. Tranexamic acid (TXA), a synthetic analog of the amino acid lysine, has proven to be a cost-effective method in decreasing transfusion rates and avoiding complications associated with low blood volume. Recent data on TXA's use in spine surgery suggest that TXA remains both efficacious and safe, although the ideal dosing and timing of administration is still a point of disagreement. The purpose of this study is to review the literature for the use of TXA in spine surgery to better understand its safety profile and ideal dosage. This narrative review on TXA was conducted on prospective orthopedic studies that used TXA in spine deformity surgery. TXA in adult and pediatric spine surgery has decreased intraoperative and postoperative blood loss, decreasing the need for blood transfusions. The most common dose in the literature is a 10 mg/kg loading dose, followed by 1 mg/kg per hour. Although the proper dosing of TXA for spine surgery remains debatable, studies have proven that TXA is effective at reducing blood loss without increasing the risk of thrombotic events.
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Saleh AN, Mostafa RH. Increased Nociception Following Administration of Different Doses of Tranexamic Acid in Adolescent Idiopathic Scoliosis Surgery. ACTA ACUST UNITED AC 2018. [DOI: 10.2174/2589645801812010061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:The inhibitory effect of Tranexamic Acid (TXA) on γ-aminobutyric acid and glycine receptors of spinal dorsal horn neurons which leads to pain arousal, has been highlighted recently in animal studies. Such findings would elicit concerns about adverse effects of TXA as a routine agent used to reduce perioperative blood loss.Objectives:This study aimed to evaluate the effect of different doses of TXA on analgesic requirements in adolescent patients undergoing elective single-stage posterior spine fusion surgery for idiopathic scoliosis.Patients and Methods:This prospective, randomized, double-blinded study comprised 75 patients who were randomly allocated to one of three groups. Each group comprised 25 patients. In group C (Control), patients received normal saline. While in group HD (High Dose), patients received TXA with a loading dose of 50 mg/kg and maintenance dose of 20 mg/kg/h and patients in group LD (Low Dose) received TXA with a loading dose of 10 mg/kg and maintenance dose of 1 mg/kg/h. The total intraoperative fentanyl dose was calculated for each patient which we used as a measure of the patients’ nociception level.Results:Group HD patients’ required the highest dose of fentanyl compared to those in LD group (mean of 60µgversus27µg). Patients in group C received no extra intraoperative narcotic doses and experienced the longest duration of surgical procedure. These results showed high statistically significant difference (p< 0.001).Conclusion:Intraoperative administration of TXA increases the analgesic requirement during elective single stage posterior spine fusion surgery which likely reflects an increase in patients’ intraoperative nociception.
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Daniels AH, Bess S, Line B, Eltorai AE, Reid DB, Lafage V, Akbarnia BA, Ames CP, Boachie-Adjei O, Burton DC, Deviren V, Kim HJ, Hart RA, Kebaish KM, Klineberg EO, Gupta M, Mundis GM, Hostin RA, O'Brien M, Schwab FJ, Shaffrey CI, Smith JS. Peak Timing for Complications After Adult Spinal Deformity Surgery. World Neurosurg 2018; 115:e509-e515. [DOI: 10.1016/j.wneu.2018.04.084] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/11/2018] [Accepted: 04/13/2018] [Indexed: 11/30/2022]
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Carabini LM, Moreland NC, Vealey RJ, Bebawy JF, Koski TR, Koht A, Gupta DK, Avram MJ, Zeeni C, Gould RW, Hemmer LB, Sugrue PA, McClendon J. A Randomized Controlled Trial of Low-Dose Tranexamic Acid versus Placebo to Reduce Red Blood Cell Transfusion During Complex Multilevel Spine Fusion Surgery. World Neurosurg 2018; 110:e572-e579. [DOI: 10.1016/j.wneu.2017.11.070] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/10/2017] [Accepted: 11/11/2017] [Indexed: 11/29/2022]
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Abstract
Spine procedures are associated with high rates of blood loss which can result in a greater need for transfusions. Repeated exposure to blood products is associated with risks and adverse reactions such as transfusion-related acute lung injury, fluid shifting, and infections. With the higher number of spine procedures and the increasing open surgery times associated with difficult procedures, excessive blood loss has become more prevalent. Perioperative methods have been established to combat the excessive blood loss and decrease the need for blood products. Preoperatively, anemia and coagulopathy screening is standard at least 4 weeks before elective procedures. Erythropoietin, iron loading or transfusions are used to decrease preoperative anemia, a predisposing factor for blood loss. Autologous predonation of blood has been shown to be ineffective and decreases preoperative hemoglobin levels. Intraoperatively, antifibrinolytics such as tranexamic acid and aminocaproic acid are used to decrease blood loss. In addition, fibrinogen concentrates, thromboelastometry, acute normovolemic hemodilution, controlled hypotension, and temperature regulation are some of the techniques used to decrease blood loss and the need for transfusions. Postoperatively, fibrin sealants, shed blood salvage, and erythropoietin or intravenous iron are used in management of blood loss, especially in instances when the patient refuses blood products.
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