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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: 47] [Impact Index Per Article: 11.8] [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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Basora M, Colomina MJ. Tranexamic acid in orthopaedic surgery: A paradigm shift in transfusion. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019; 64:1-3. [PMID: 31780399 DOI: 10.1016/j.recot.2019.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/02/2019] [Accepted: 09/14/2019] [Indexed: 11/18/2022] Open
Affiliation(s)
- M Basora
- Servicio de Anestesiología y Reanimación, Hospital Clínic, Barcelona, España.
| | - M J Colomina
- Servicio de Anestesiología y Cuidados Críticos de Anestesiología, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat, Barcelona, España; Universitat de Barcelona, Barcelona, España
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Schiavone A, Bisaccia M, Inkov I, Rinonapoli G, Manni M, Rollo G, Meccariello L, Vicente CI, Ceccarini P, Ruggiero C, Caraffa A. Tranexamic Acid in Pertrochanteric Femoral Fracture: Is it a Safe Drug or Not? Folia Med (Plovdiv) 2019; 60:67-78. [PMID: 29668448 DOI: 10.1515/folmed-2017-0070] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 08/01/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND There is a high incidence of blood transfusion following hip fractures in elderly patients. AIM The aim of this study is to evaluate the effectiveness and complications of use of tranexamic acid in proximal femur nailing surgery. MATERIALS AND METHODS Our sample group consisted of 90 patients suffering from pertrochanteric fractures surgically treated with osteosynthesis with SupernailGT(LimaCorporate). The classification system AO/OTA was used to divide the fractures into 31A1 (n=45) and 31A2 (n=45). The patients were divided into two groups: 47 patients were administered 15 mg of tranexamic acid per kg (group A) and 43 patients were administered placebo (group B). Blood counts were monitored daily to evaluate the rate of anemia. As a safety criterion, we monitored the possible occurrence of vascular events, symptomatic or not, over the 8 weeks post-surgery. Markers predicting mortality and deep venous thrombosis (DVE) were also monitored (fibrinogen D-dimer). RESULTS Blood loss occurring post-surgery can be influenced by numerous factors that are not linked to the use or non-use of tranexamic acid. While closely monitoring hemoglobin levels daily, we observed that 42% of the patients in group A required blood transfusion as opposed to 60% in group B. The results of the markers predicting mortality (alpha1-acid glycoprotein; albumin LDL) and those of DVE were not statistically significant between the two groups in this study (p>0.05). CONCLUSION Based on this study, the use of tranexamic acid was statistically significant in reducing post-surgery blood loss.
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Affiliation(s)
- Andrea Schiavone
- Division of Orthopedics and Trauma Surgery, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Michele Bisaccia
- Division of Orthopedics and Trauma Surgery, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Ivan Inkov
- Department of Thoracic Surgery, Military Medical Academy, Sofia, Bulgaria
| | - Giuseppe Rinonapoli
- Division of Orthopedics and Trauma Surgery, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Mattia Manni
- Division of Orthopedics and Trauma Surgery, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Giuseppe Rollo
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
| | - Luigi Meccariello
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
| | - Cristina Ibáñez Vicente
- Division of Orthopedics and Trauma Surgery, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Paolo Ceccarini
- Division of Orthopedics and Trauma Surgery, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy
| | | | - Auro Caraffa
- Division of Orthopedics and Trauma Surgery, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy
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Moppett IK, Rowlands M, Mannings AM, Marufu TC, Sahota O, Yeung J. The effect of intravenous iron on erythropoiesis in older people with hip fracture. Age Ageing 2019; 48:751-755. [PMID: 31127269 DOI: 10.1093/ageing/afz049] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/26/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND anaemia following hip fracture is common and associated with worse outcomes. Intravenous iron is a potential non-transfusion treatment for this anaemia and has been found to reduce transfusion rates in previous observational studies. There is good evidence for its use in elective surgical populations. OBJECTIVE to examine the impact of intravenous iron on erythropoiesis following hip fracture. DESIGN two-centre, assessor-blinded, randomised, controlled trial of patients with primary hip fracture and no contra-indications to intravenous iron. METHOD the intervention group received three doses of 200 mg iron sucrose over 30 min (Venofer, Vifor Pharma, Bagshot Park, UK) on three separate days. Primary outcome was reticulocyte count at day 7 after randomisation. Secondary outcomes included haemoglobin concentration, complications and discharge destination. Eighty participants were randomised. RESULTS there was a statistically significantly greater absolute final reticulocyte count in the iron group (89.4 (78.9-101.3) × 109 cells l-1 (n = 39) vs. the control (72.2 (63.9-86.4)) × 109 cells l-1 (n = 41); P = 0.019; (mean (95% confidence intervals) of log-transformed data). There were no differences in final haemoglobin concentration (99.9 (95.7-104.2) vs. 102.0 (98.7-105.3) P = 0.454) or transfusion requirements in the first week (11 (28%) vs. 12 (29%); P = 0.899). Functional and safety outcomes were not different between the groups. CONCLUSIONS although intravenous iron does stimulate erythropoiesis following hip fracture in older people, the effect is too small and too late to affect transfusion rates. Trial Registry Numbers: ISRCTN:76424792; EuDRACT: 2011-003233-34.
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Affiliation(s)
- I K Moppett
- Anaesthesia and Critical Care Research Group, Division of Clinical Neuroscience, Queen’s Medical Centre, University of Nottingham, Nottingham, UK
| | - M Rowlands
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - A M Mannings
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - T C Marufu
- Department of Healthcare of Older Life, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - O Sahota
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J Yeung
- Warwick Medical School, University of Warwick, Warwick, UK
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Abstract
PURPOSE OF REVIEW Hip fracture is common in the elderly population, painful and costly. The present investigation was undertaken to review epidemiology, socio-economic and medical implications, relevant anatomy, and anesthetic and pain modalities of hip fracture. RECENT FINDINGS A literature search of PubMed, Ovid Medline, and Cochrane databases was conducted in December 2018 to identify relevant published clinical trials, review articles, and meta-analyses studies related to anesthetic and pain modalities of hip fracture. The acute pain management in these situations is often challenging. Common issues associated with morbidity and mortality include patients' physiological decrease in function, medical comorbidities, and cognitive impairment, which all can confound and complicate pain assessment and treatment. Perioperative multidisciplinary and multimodal approaches require medical, surgical, and anesthesiology teams employing adequate preoperative optimization. Reduction in pain and disability utilizing opioid and non-opioid therapies, regional anesthesia, patient-tailored anesthetic approach, and delirium prevention strategies seems to ensure best outcomes.
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Xiao C, Zhang S, Long N, Yu W, Jiang Y. Is intravenous tranexamic acid effective and safe during hip fracture surgery? An updated meta-analysis of randomized controlled trials. Arch Orthop Trauma Surg 2019; 139:893-902. [PMID: 30637503 DOI: 10.1007/s00402-019-03118-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The efficacy and safety of intravenous (IV) tranexamic acid (TXA) during hip fracture surgery remain controversial. This meta-analysis aimed to assess the efficacy of IV-TXA administration during hip fracture surgery for reducing the transfusion requirement and blood loss as well as its safety regarding the risk of thrombolysis. MATERIALS AND METHODS PubMed, EMBASE, Web of Science, and the Cochrane Library Database were systematically searched for randomized controlled trials (RCTs) that focused on the efficacy and safety of IV-TXA in patients during hip fracture surgery. The primary outcome was the transfusion requirement. Secondary outcomes included total blood loss (TBL), deep vein thrombosis (DVT), and total thromboembolic events (TTEs). Risk ratio (RR), risk difference (RD), and mean difference (MD) for dichotomous and continuous data outcomes were determined from the meta-analysis. Data were analyzed using Rev Man 5.3. RESULTS Altogether, 11 RCTs were included (total sample size 892 patients). IV-TXA significantly reduced the transfusion requirement [RR 0.60, 95% confidence interval (CI) 0.38-0.93, P = 0.02] and TBL (MD 326.64 ml, 95% CI - 462.23 to - 191.06, P < 0.00001) vs. cosntrol group. IV-TXA caused no increased risk of DVT (RD 0.02, 95% CI - 0.01 to 0.04, P = 0.13) or TTEs (RD 0.02, 95% CI - 0.01 to 0.05, P = 0.12). CONCLUSION Available evidence indicates that IV-TXA efficaciously reduces TBL and transfusion requirements during hip fracture surgery without significantly increasing the risk of TTEs including DVT.
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Affiliation(s)
- Cong Xiao
- Department of Orthopedics, The Third Hospital of Mianyang (Sichuan Mental Health Center), No. 190 The East Jiannan Road, Mianyang, 621000, China
| | - Shaoyun Zhang
- Department of Orthopedics, The Third Hospital of Mianyang (Sichuan Mental Health Center), No. 190 The East Jiannan Road, Mianyang, 621000, China
| | - Nengji Long
- Department of Orthopedics, The Third Hospital of Mianyang (Sichuan Mental Health Center), No. 190 The East Jiannan Road, Mianyang, 621000, China
| | - Wei Yu
- Department of Orthopedics, The Third Hospital of Mianyang (Sichuan Mental Health Center), No. 190 The East Jiannan Road, Mianyang, 621000, China
| | - Yishan Jiang
- Department of Orthopedics, The Third Hospital of Mianyang (Sichuan Mental Health Center), No. 190 The East Jiannan Road, Mianyang, 621000, China.
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Soffin EM, Gibbons MM, Wick EC, Kates SL, Cannesson M, Scott MJ, Grant MC, Ko SS, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery. Anesth Analg 2019; 128:1107-1117. [PMID: 31094775 DOI: 10.1213/ane.0000000000003925] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.
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Affiliation(s)
- Ellen M Soffin
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Melinda M Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Maxime Cannesson
- Department of Anesthesiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Samantha S Ko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher L Wu
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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Luo X, He S, Lin Z, Li Z, Huang C, Li Q. Efficacy and Safety of Tranexamic Acid for Controlling Bleeding During Surgical Treatment of Intertrochanteric Fragility Fracture with Proximal Femoral Nail Anti-rotation: A Randomized Controlled Trial. Indian J Orthop 2019; 53:263-269. [PMID: 30967695 PMCID: PMC6415572 DOI: 10.4103/ortho.ijortho_401_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Intertrochanteric fragility fracture (IFF) treated with proximal femoral nail anti-rotation (PFNA) is associated with significant hidden blood loss and high blood transfusion rate. The purpose of the present study was to evaluate the efficacy and safety of tranexamic acid (TXA) in reducing blood loss in these patients. MATERIALS AND METHODS Consecutive eligible patients were recruited and randomly assigned to a TXA group or a control group. The TXA group received 15 mg/kg body weight of TXA intravenously 15 min before incision and the same dose 3 h later. The control group received 100 mL of saline intravenously 15 min before incision. The efficacy outcomes included the total perioperative blood loss, postoperative transfusion rate, postoperative hemoglobin level, and length of the hospital stay. The safety outcomes were the incidence of thrombotic events and the mortality rate within 6 weeks after surgery. RESULTS We had 44 patients in the TXA group and 46 patients in the control group for the final analysis. The TXA group had significantly lower total perioperative blood loss than the control group (384.5 ± 366.3 mL vs. 566.2 ± 361.5 mL; P < 0.020). Postoperative transfusion rate was 15.9% in the TXA group versus 36.9% in the control group (P = 0.024). Each group had one patient with postoperative deep venous thrombosis. In the control group, three patients had cerebral infarction, and one patient died within 6 weeks after the operation. CONCLUSION Intravenous TXA is effective in reducing total perioperative blood loss and transfusion rate in IFF treated with PFNA. No increased risk of thrombotic events was observed with the use of TXA; however, this study was underpowered for detecting this outcome. Further research is necessary before TXA can be recommended for high-risk patients.
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Affiliation(s)
- Xiangping Luo
- Department of Orthopaedic, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shunqing He
- Department of Orthopaedic, People's Hospital of Leiyang, Hunan, China
| | - Zhaowei Lin
- Department of Orthopaedic, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Zhian Li
- Department of Orthopaedic, People's Hospital of Leiyang, Hunan, China
| | - Chao Huang
- Department of Orthopaedic, People's Hospital of Leiyang, Hunan, China
| | - Qi Li
- Department of Orthopaedic, Zhujiang Hospital, Southern Medical University, Guangzhou, China,Address for correspondence: Dr. Qi Li, Department of Orthopaedic, Zhujiang Hospital, Southern Medical University, Guangzhou, China. E-mail:
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Goldstein M, Feldmann C, Wulf H, Wiesmann T. Tranexamic Acid Prophylaxis in Hip and Knee Joint Replacement. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:824-830. [PMID: 29249226 DOI: 10.3238/arztebl.2017.0824] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 02/22/2017] [Accepted: 09/13/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND The antifibrinolytic agent tranexamic acid (TXA) is widely used for the prevention and treatment of hyperfibrinolytic states, such as in severe polytrauma. It can also be used for the systemic prevention of hemorrhage in elective orthopedic procedures. In this review, we assess the efficacy and risks of the prophylactic administration of tranexamic acid before major endoprosthetic surgery of the hip and knee. METHODS This review is based on pertinent articles retrieved by a selective literature search in the PubMed and Cochrane Library databases. RESULTS Endoprosthetic surgery of the hip and knee is often associated with perioperative blood losses exceeding 500 mL. The prophylactic administration of tranexamic acid immediately before such procedures has been shown in randomized, controlled trials to lessen the quantity of intra- and postoperative bleeding and to reduce the likelihood of blood transfusion (number needed to treat [NNT] 3.7-5.7 for knee replacement and 4.1-8.2 for hip replacement). The rate of thromboembolic events did not differ significantly from the rate in the placebo groups. No reliable data are available on the frequency of epileptic seizures as a complication of TXA use in knee and hip endoprosthetic surgery. On the basis of data from other types of surgery, one may reasonably conclude that the doses of TXA used for knee and hip endoprosthetic procedures are unlikely to cause this problem. CONCLUSION The prophylactic intravenous administration of tranexamic acid lessens the amount of bleeding in endoprosthetic knee and hip procedures and reduces the likelihood of blood transfusion. According to the current state of the evidence, complications are rare. Nonetheless, consideration of the risks and benefits implies that tranexamic acid should not be given for this purpose to patients who have recently had urogenital bleeding, pulmonary embolism, or a myocardial infarction, who have recently undergone percutaneous transluminal coronary angioplasty or stenting, or who are known to have epilepsy.
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Zhu Q, Yu C, Chen X, Xu X, Chen Y, Liu C, Lin P. Efficacy and Safety of Tranexamic Acid for Blood Salvage in Intertrochanteric Fracture Surgery: A Meta-Analysis. Clin Appl Thromb Hemost 2018; 24:1189-1198. [PMID: 29929380 PMCID: PMC6714773 DOI: 10.1177/1076029618783258] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The use of tranexamic acid (TXA) for reducing blood loss in intertrochanteric fracture (IF) surgery remains controversial. We therefore performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of TXA in reducing transfusion requirements and blood loss for IF surgery. Databases, including PubMED, Cochrane, and Embase, were searched for RCTs that were published before February 2018 and that addressed the efficacy and safety of TXA in patients who underwent IF surgery. A total of 746 patients from 7 RCTs were subjected to meta-analysis. The results showed that TXA group had reduced surgical blood loss (weighted mean difference [WMD] = −37.24, 95% confidence interval [CI]: −48.70 to −25.77, P <.00001), reduced total blood loss (WMD = −199.08, 95% CI: −305.16 to −93.01, P = .0002), higher postoperative hemoglobin (WMD = 0.46, 95% CI: 0.12 to 0.79, P = .007), and hematocrit levels (WMD = 1.55, 95% CI: 0.64 to 2.47, P = .008) compared to control group, while no significant differences were found in transfusion rates (relative risk [RR] = 0.75, 95% CI: 0.50 to 1.11, P = .15), postoperative drainage (WMD = −38.82, 95% CI: −86.87 to 9.22, P = .11), and thromboembolic events (RR = 0.94, 95% CI: 0.41 to 2.19, P = .89). In patients undergoing IF surgery, the administration of TXA significantly reduced surgical blood loss and total blood loss, while it had no significant effect on transfusion rate, postoperative drainage, and the risk of thromboembolic events. Nevertheless, due to the variations in the included studies, additional RCTs are required to further validate these conclusions.
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Affiliation(s)
- Qianzheng Zhu
- 1 Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China
| | - Caixia Yu
- 1 Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China
| | - Xingzuo Chen
- 1 Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China
| | - Xiaodong Xu
- 1 Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China
| | - Ying Chen
- 1 Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China
| | - Chenggang Liu
- 1 Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China
| | - Peng Lin
- 1 Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China
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Gulati V, Newman S, Porter KJ, Franco LCS, Wainwright T, Ugoigwe C, Middleton R. Implications of anticoagulant and antiplatelet therapy in patients presenting with hip fractures: a current concepts review. Hip Int 2018; 28:227-233. [PMID: 30165764 DOI: 10.1177/1120700018759300] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The increasing use of anticoagulant and antiplatelet therapy for the prevention of thromboembolic disease poses a significant challenge to orthopaedic surgeons treating elderly patients presenting with proximal femoral fractures. Early surgical intervention is known to be beneficial from a clinical perspective and has been encouraged in the UK through the introduction of best practice tariffs providing increased remuneration for prompt treatment. An understanding of the necessary delay to surgery or reversal options for each type of antiplatelet or anticoagulant agent is therefore important. A number of professional bodies have recently produced guidelines that help clinicians manage these patients during the peri-operative period. We review the guidelines relating to antiplatelet and anticoagulant agents during the perioperative period with respect to hip fracture surgery. Antiplatelet agents should not interfere with timing of surgery, but may affect the choice of anaesthetic performed. The action of warfarin should be reversed to expedite surgery. Newer direct oral anticoagulants are more problematic and surgical delay may be necessary, though reversal agents are becoming available.
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Affiliation(s)
- Vivek Gulati
- 1 Orthopaedic Research Institute, Bournemouth University, Bournemouth UK.,2 Homerton University Hospital, London, UK
| | - Simon Newman
- 1 Orthopaedic Research Institute, Bournemouth University, Bournemouth UK
| | | | | | - Tom Wainwright
- 1 Orthopaedic Research Institute, Bournemouth University, Bournemouth UK
| | | | - Robert Middleton
- 1 Orthopaedic Research Institute, Bournemouth University, Bournemouth UK
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Liao L, Chen Y, Tang Q, Chen YY, Wang WC. Tranexamic acid plus drain-clamping can reduce blood loss in total knee arthroplasty: A systematic review and meta-analysis. Int J Surg 2018; 52:334-341. [PMID: 29408472 DOI: 10.1016/j.ijsu.2018.01.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 01/08/2018] [Accepted: 01/29/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND The efficacy of tranexamic acid (TXA) plus drain-clamping in reducing blood loss after total knee arthroplasty (TKA) is controversial. This meta-analysis aimed to identify whether combined tranexamic acid and drain-clamping was superior to TXA alone, drain clamping alone and control treatments. METHODS We searched the PubMed, EMBASE, Web of Science and Google databases and the Cochrane Database of Systematic Reviews. Patients prepared for primary TKA and who underwent TXA plus drain-clamping for blood loss were included in this meta-analysis. Outcomes included the need for transfusion, total blood loss, blood loss in drainage, a decrease in hemoglobin and the occurrence of deep venous thrombosis (DVT). Stata 12.0 was used for meta-analysis. RESULTS Finally, 7 clinical studies with 839 patients were included in this meta-analysis. Compared with the control group, TXA group and drain clamping group treatments, TXA plus drain-clamping could reduce the need for transfusion, total blood loss, blood loss in drainage and the decrease in hemoglobin with statistically significance. CONCLUSIONS TXA plus drain-clamping is an efficient method for controlling blood loss after TKA, and more studies should focus on the optimal clamping duration.
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MESH Headings
- Administration, Intravenous
- Aged
- Antifibrinolytic Agents/adverse effects
- Antifibrinolytic Agents/therapeutic use
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Blood Loss, Surgical/prevention & control
- Blood Loss, Surgical/statistics & numerical data
- Blood Transfusion/statistics & numerical data
- Constriction
- Databases, Factual
- Drainage/methods
- Hemoglobins/analysis
- Hemostasis, Surgical/adverse effects
- Hemostasis, Surgical/methods
- Humans
- Middle Aged
- Tranexamic Acid/adverse effects
- Tranexamic Acid/therapeutic use
- Venous Thrombosis/epidemiology
- Venous Thrombosis/etiology
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Affiliation(s)
- Lele Liao
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - You Chen
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Qi Tang
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Yi-Yue Chen
- Department of Rheumatology and Immunology, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Wan-Chun Wang
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China.
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63
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Effect of tranexamic acid use on blood loss and thromboembolic risk in hip fracture surgery: systematic review and meta-analysis. Hip Int 2018; 28:3-10. [PMID: 28983887 DOI: 10.5301/hipint.5000556] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Intravenous tranexamic acid (IV TXA) is a recognised pharmaceutical intervention utilised to minimise blood loss and allogenic blood transfusion. However, the use of IV TXA in hip fracture surgery remains inconclusive. We conducted a meta-analysis to investigate the role of TXA in operative hip fracture management on operative and total blood loss, allogenic blood transfusion requirements and impact on venous thromboembolic (VTE) event incidence. METHODS A systematic computerised literature search of PubMed, Medline, Embase, Ovid, The Cochrane Controlled Trials Register, Trip and Google was conducted. We reviewed the efficacy of IV TXA on perioperative blood loss, total blood loss, pre- and postoperative haemoglobin differences, duration of surgery, allogenic blood transfusion requirements and VTE events. RESULTS 8 studies were eligible including 6 randomised control trials and 2 cohort studies. Patients receiving IV TXA had reduced mean total blood loss of 442.9 mls (95% CI, 426.5-459.3; p<0.00001), reduced operative blood loss of 88.5 mls (95% CI, 59.9-117.2; p<0.00001), a decrease in the need for allogenic blood transfusion (OR 0.37; 95% CI, 0.26-0.53; p<0.00001) and a reduction in pre- and postoperative haemoglobin difference (p = 0.013.) There was no significant increase in VTE risk (OR 1.59; 95% CI 0.67-3.75; p>0.29) or significant difference on duration of surgery seen with IV TXA usage (p>0.06). CONCLUSIONS Our review demonstrated the efficacy of IV TXA in minimising perioperative, reducing total blood loss and lowering the necessity for allogenic blood transfusions with no significant increased risk in VTE events.
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64
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Gerstein NS, Brierley JK, Windsor J, Panikkath PV, Ram H, Gelfenbeyn KM, Jinkins LJ, Nguyen LC, Gerstein WH. Antifibrinolytic Agents in Cardiac and Noncardiac Surgery: A Comprehensive Overview and Update. J Cardiothorac Vasc Anesth 2017; 31:2183-2205. [DOI: 10.1053/j.jvca.2017.02.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Indexed: 12/19/2022]
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65
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Scharman CD, Burger D, Shatzel JJ, Kim E, DeLoughery TG. Treatment of individuals who cannot receive blood products for religious or other reasons. Am J Hematol 2017; 92:1370-1381. [PMID: 28815690 DOI: 10.1002/ajh.24889] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 08/12/2017] [Accepted: 08/14/2017] [Indexed: 01/04/2023]
Abstract
By virtue of their religious principles, Jehovah's Witnesses (JWs) generally object to receiving blood products, raising numerous ethical, legal, and medical challenges for providers who care for these patients, especially in the emergent setting. In this review, we discuss several areas relevant to the care of JWs, including the current literature on "bloodless" medical care in the setting of perioperative and intraoperative management, acute blood loss, trauma, pregnancy, and malignancy. We have found that medical and administrative efforts in the form of bloodless medicine and surgery programs can be instrumental in helping to reduce risks of morbidity and mortality in these patients. Planning prior to an anticipated event associated with blood loss or anemia (such as elective surgery, pregnancy, and chemotherapy) is critical. Specifically, bloodless medicine programs should prioritize vigilant early screening and management of anemias, early establishment of patient wishes regarding transfusion, and the incorporation of those wishes into multidisciplinary medical and surgical care. Although there are now a variety of human-based and nonhuman-based products available as transfusion alternatives, the degree and quality of evidence to support their use varies significantly between products and is also largely dependent on the clinical setting.
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Affiliation(s)
- Carlton D. Scharman
- Department of Internal Medicine; Oregon Health and Science University; Portland Oregon
| | - Debora Burger
- Patient Blood Management Program; Oregon Health and Science University; Portland Oregon
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology; Oregon Health and Science University, Knight Cancer Institute; Portland Oregon
| | - Edward Kim
- School of Medicine; Oregon Health and Science University; Portland Oregon
| | - Thomas G. DeLoughery
- Division of Hematology and Medical Oncology; Oregon Health and Science University, Knight Cancer Institute; Portland Oregon
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66
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Abstract
Old age is a risk factor for poor outcome in trauma patients, as a result of undertriage and the presence of occult life-threatening injuries. The mechanisms of injury for geriatric trauma differ from those in younger patients, with a much higher incidence of low-impact trauma, especially falls from a low height. Frailty is a risk factor for severe injury after minor trauma, and caring for these patients require a multidisciplinary team with both trauma and geriatric expertise. With early recognition and aggressive management, severe injuries can still be associated with good outcomes, even in very elderly patients.
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Affiliation(s)
- Katrin Hruska
- Department of Emergency Medicine, Karolinska University Hospital, Huddinge, Sweden.
| | - Toralph Ruge
- Department of Emergency Medicine, Karolinska University Hospital, Huddinge, Sweden; Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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67
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Gausden EB, Qudsi R, Boone MD, OʼGara B, Ruzbarsky JJ, Lorich DG. Tranexamic Acid in Orthopaedic Trauma Surgery: A Meta-Analysis. J Orthop Trauma 2017; 31:513-519. [PMID: 28938281 PMCID: PMC6827340 DOI: 10.1097/bot.0000000000000913] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIM To systematically review and quantify the efficacy of tranexamic acid (TXA) use in reducing the risk of receiving a blood transfusion in patients undergoing orthopaedic trauma surgery, in reducing blood loss, and risk of thromboembolic events. METHODS A systematic literature search was performed using MEDLINE, Embase, ClinicalTrials.gov, and conference proceeding abstracts from 2014 to 2016. A minimum of 2 reviewers screened each study and graded quality. The primary outcome measure was the risk of receiving a blood transfusion in the TXA group versus control. A meta-analysis was performed to construct a combined odds ratio (OR) of receiving a blood transfusion, mean difference (MD) of blood loss, and OR of thromboembolic events. RESULTS Twelve studies were included in the quantitative analysis (1,333 patients). The risk of blood transfusion was significantly less in patients who were administered TXA compared with controls [OR 0.407; 95% confidence interval (CI) 0.278-0.594, I = 34, Q = 17, P ≤ 0.001]. There was significantly less blood loss in the TXA group compared with controls, as the mean difference was 304 mL (95% CI, 142-467 mL) (I = 94, Q value = 103, P < 0.001). There was no significant difference in risk of symptomatic thromboembolic events (OR 0.968; 95% CI, 0.530-1.766, I = 0, Q value = 5, P = 0.684). CONCLUSIONS In patients with orthopaedic trauma, TXA reduces the risk of blood transfusion, reduces perioperative blood loss, and has no significant effect on the risk of symptomatic thromboembolic events. More high-quality studies are needed to ensure the safety of the drug in these patients. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Elizabeth B Gausden
- *Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY; †Harvard Combined Orthopaedic Residency Program, Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA; ‡Department of Anesthesiology and Critical Care, Beth Israel Deaconess, Boston, MA; and §Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY
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68
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Lei J, Zhang B, Cong Y, Zhuang Y, Wei X, Fu Y, Wei W, Wang P, Wen S, Huang H, Wang H, Han S, Liu S, Zhang K. Tranexamic acid reduces hidden blood loss in the treatment of intertrochanteric fractures with PFNA: a single-center randomized controlled trial. J Orthop Surg Res 2017; 12:124. [PMID: 28810918 PMCID: PMC5558747 DOI: 10.1186/s13018-017-0625-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 08/05/2017] [Indexed: 01/21/2023] Open
Abstract
Background Hidden blood loss is a major concern for patients undergoing hip surgery for intertrochanteric fracture. The objective of this study was to investigate whether tranexamic acid (TXA) could reduce postoperative hidden blood loss in patients undergoing hip surgery for intertrochanteric fracture. Methods A total of 77 patients with intertrochanteric fracture were enrolled in this randomized controlled study. Patients received either 200 mL (1 g) of TXA (n = 37) or normal-saline (NS) (n = 40) i.v. before hip surgery using proximal femoral nail anti-rotation (PFNA). Hemoglobin and hematocrit levels were measured preoperatively and postoperatively at day 1 and 3. Visible and hidden blood loss volumes were calculated at postoperative day 3. Results On postoperative day 3, the transfusion rate was significantly lower in the TXA group compared to the NS group, although mean hemoglobin and hematocrit levels were not significantly different between the two groups. However, the estimated hidden blood loss volume (210.09 ± 202.14 mL vs. 359.35 ± 290.12 mL; P < 0.05) and total blood loss volume (279.35 ± 209.11 mL vs. 417.89 ± 289.56 mL; P < 0.05) were significantly less in the TXA group compared to the NS group, respectively. Conclusion TXA significantly reduced postoperative hidden blood loss in patients with intertrochanteric fracture who underwent PFNA. (Registration number: ChiCTR-INR-16008134).
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Affiliation(s)
- Jinlai Lei
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China
| | - Binfei Zhang
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China
| | - Yuxuan Cong
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China
| | - Yan Zhuang
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China.
| | - Xing Wei
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China
| | - Yahui Fu
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China
| | - Wei Wei
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China
| | - Pengfei Wang
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China
| | - Shiming Wen
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China
| | - Hai Huang
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China
| | - Hu Wang
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China
| | - Shuang Han
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China
| | - Shuguang Liu
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China
| | - Kun Zhang
- Department of Orthopaedic Trauma, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No 555, Youyi East Road, Xi'an, Shaanxi Province, China.
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70
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71
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Farrow LS, Smith TO, Ashcroft GP, Myint PK. A systematic review of tranexamic acid in hip fracture surgery. Br J Clin Pharmacol 2016; 82:1458-1470. [PMID: 27492116 PMCID: PMC5099561 DOI: 10.1111/bcp.13079] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 12/14/2022] Open
Abstract
AIM To systematically examine and quantify the efficacy and safety of tranexamic acid in hip fracture surgery. METHODS A systematic literature search was conducted using Medline, EMBASE, AMED, CiNAHL, and the Cochrane Central Registry of Controlled Trials. Two assessors independently screened search outputs for potentially relevant articles which met the eligibility criteria. The primary outcome measure was requirement of post-operative blood transfusion. Risk of bias assessment was performed using the Cochrane Collaboration's risk of bias tool for randomized controlled trials (RCTs) and the ROBINS-I tool for observational studies. Meta-analysis was performed to estimate risk ratio (RR), risk difference (RD) and mean difference (MD) values for dichotomous and continuous data outcomes, respectively. The interpretation of each outcome was made using the GRADE approach. RESULTS Of 102 studies identified, seven met the inclusion criteria including a total of 770 participants (TXA: 341; Control: 429). On meta-analysis, intravenous TXA resulted in a 46% risk reduction in blood transfusion requirement compared to a placebo/control group (RR: 0.54; 95% CI: 0.35-0.85; I2 : 78%; Inconsistency (χ2 ) P = <0.0001; n = 750). There was also a significantly higher post-operative haemoglobin for TXA versus placebo/control (MD: 0.81; 95% CI: 0.45-1.18; I2 : 46%; Inconsistency (χ2 ) P = 0.10; n = 638). There was no increased risk of thromboembolic events (RD: 0.01; 95% CI: -0.03, 0.05; I2 : 68%; Inconsistency (χ2 ) P = 0.007, n = 683). CONCLUSION There is moderate quality evidence that TXA reduces blood transfusion in hip fracture surgery, with low quality evidence suggesting no increased risk of thrombotic events. These findings are consistent with TXA use in other orthopaedic procedures.
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Affiliation(s)
- Luke S. Farrow
- Institute of Medical SciencesUniversity of AberdeenForesterhillAberdeenAB25 2ZDUK
| | - Toby O. Smith
- School of Health SciencesUniversity of East AngliaQueen's Building, Norwich Research ParkNorwichNR4 7TJUK
| | - George P. Ashcroft
- Institute of Medical SciencesUniversity of AberdeenForesterhillAberdeenAB25 2ZDUK
| | - Phyo K. Myint
- Epidemiology Group, Institute of Applied Health SciencesUniversity of AberdeenForesterhillAberdeenAB25 2ZDUK
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