Efficacy and safety of fibrin glue and tranexamic acid to prevent postoperative blood loss in total knee arthroplasty: a randomized controlled clinical trial

Strategies for the Management of Postoperative Anemia in Elective Orthopedic Surgery

Objective: To assess the use of oral iron, intravenous (IV) iron, and erythropoiesis-stimulating agents (ESAs) for the prevention and management of perioperative anemia in elective orthopedic surgery patients, and to provide a clinical algorithm for use. Data Sources: A PubMed and MEDLINE search was conducted from 1964 through March 2016 using the following search terms alone or in combination: orthopedic, surgery, elective, anemia, blood transfusion, iron, erythropoiesis-stimulating agents, and erythropoietin.Study Selection and Data Extraction: All English-language prospective and retrospective human studies and meta-analyses evaluating oral iron, IV iron, or ESA alone or in combination in elective orthopedic surgery patients were evaluated, provided they reported blood transfusion outcomes. Data Synthesis: A total of 9 prospective and retrospective studies and 1 meta-analysis were identified and included. In the preoperative setting, administration of oral iron, IV iron, or ESA alone or in combination to correct underlying anemia led to significantly reduced transfusion rates. Transfusion requirements were generally less with combination therapy (ESA + oral or IV iron). In the short-term perioperative or postoperative period, use of oral or IV iron led to conflicting results, with some reporting a statistically significant reduction in blood transfusions, whereas others reported none. Conclusions: In elective orthopedic surgery, IV or oral iron with or without an ESA may provide benefit in prevention of postoperative anemia and results in blood transfusion reduction without significantly increasing the risk of adverse events. These agents should be considered at the lowest effective dose with emphasis on administration prior to planned surgery.

EFFECT OF TRANEXAMIC ACID ON BLEEDING CONTROL IN TOTAL KNEE ARTHROPLASTY

OBJECTIVES

To analyze the effectiveness of intravenous (IV) tranexamic acid (TA) in reducing blood loss in total knee arthroplasty (TKA).

METHOD

The population sample was composed of patients with a diagnosis of primary knee osteoarthritis. The patients undergoing TKA were divided in two groups. Group A: comprised patients who used IV TA and B group, formed by patients who did not use TA in the intra or post-operative period. For descriptive analysis, quantitative variables were represented by mean and standard deviations when their distribution was normal and interquartile ranges and medians for non-normal variables.

RESULTS

The mean age of patients was 68 years old, most of them were female and with involvement of the left knee. Postoperatively patients who had used IV TA showed less bleeding rate and less hemoglobin rate reduction.

CONCLUSION

The use of IV TA in TKA reduces blood loss in peri- and postoperative periods. Regarding total blood loss reduction, hemoglobin rate and need for blood transfusions, IV TA should be used routinely during TKA since it has been shown to be safe with no increase in side effects as thromboembolic events. Level of Evidence III. Retrospective Comparative Study.

Topical and intravenous tranexamic acid reduce blood loss compared to routine hemostasis in total knee arthroplasty: a multicenter, randomized, controlled trial

INTRODUCTION

Tranexamic acid (TXA) is becoming widely used in orthopedic surgery to reduce blood loss and transfusion requirements, but consensus is lacking regarding the optimal route and dose of administration. The aim of this study was to compare the efficacy and safety of topical and intravenous routes of TXA with routine hemostasis in patients undergoing primary total knee arthroplasty (TKA).

MATERIALS AND METHODS

We performed a randomized, multicenter, parallel, open-label clinical trial in adult patients undergoing primary TKA. Patients were divided into three groups of 50 patients each: Group 1 received 1 g topical TXA, Group 2 received 2 g intravenous TXA, and Group 3 (control group) had routine hemostasis. The primary outcome was total blood loss. Secondary outcomes were hidden blood loss, blood collected in drains, transfusion rate, number of blood units transfused, adverse events, and mortality.

RESULTS

One hundred and fifty patients were included. Total blood loss was 1021.57 (481.09) mL in Group 1, 817.54 (324.82) mL in Group 2 and 1415.72 (595.11) mL in Group 3 (control group). Differences in total blood loss between the TXA groups and the control group were clinically and statistically significant (p < 0.001). In an exploratory analysis differences between the two TXA groups were not statistically significant (p = 0.073) Seventeen patients were transfused. Transfusion requirements were significantly higher in Group 3 (p = 0.005). No significant differences were found between groups regarding adverse events.

CONCLUSION

We found that 1 g of topical TXA and 2 g of intravenous TXA were both safe strategies and more effective than routine hemostasis to reduce blood loss and transfusion requirements after primary TKA.

LEVEL OF EVIDENCE

I.

Are Routine Blood Salvage/Preservation Measures Justified in All Patients Undergoing Primary TKA and THA?

A sequential series of 366 primary total knee arthroplasties and 320 total hip arthroplasties was reviewed to determine the incidence of allogeneic transfusion. Surgery was performed under regional anesthesia and all patients had a hemovac drain for 24°. Tourniquet hemostasis in TKA was maintained through wound closure. Coumadin, SCD and TED hose were utilized for DVT prophylaxis. No additional blood conservation measures were employed. The transfusion incidence in primary TKA was 2.2% (males .6%/females 3.5%). The transfusion incidence in THA was 1.9%, (males .8%/females 2.6%). The low incidence of allogeneic transfusion in a contemporary series of primary TKA and THA, especially in males, would question the need for routine blood preservation techniques in this group of patients.

Use of a haemostatic matrix (Floseal®) does not reduce blood loss in minimally invasive total knee arthroplasty performed under continued aspirin

BACKGROUND

Aspirin is being used for primary and secondary cardiovascular prevention. It has been proposed that aspirin should be discontinued 5 to 7 days before surgery. However, discontinuation might increase the risk of cardiac and thrombo-embolic co-morbidity. Aspirin also increases the risk of bleeding during and after total knee arthroplasty. This study evaluated if the intra-articular use of a haemostatic matrix (Floseal®) might decrease blood loss in total knee arthroplasty performed under continued aspirin use.

MATERIALS AND METHODS

We retrospectively compared matched pairs in two groups (80 patients in each group). Patients in both groups were taking aspirin: one group was managed with conventional haemostasis (with bovie electrocoagulation), while the other group was treated with an intra-articular haemostatic matrix as an adjunct to electrocoagulation. The outcomes compared were haemoglobin and haematocrit levels at days 2 and 4 after surgery as surrogates for blood loss, transfusion rate, surgical time, and length of stay in the hospital.

RESULTS

No differences were observed between the two groups for haemoglobin and haematocrit levels on days 2 and 4. There were no differences in transfusion rate, surgical time or length of stay in hospital between the two groups.

DISCUSSION

The present study shows that the use of Floseal® has no effect on reducing either visible or hidden blood loss after total knee arthroplasty with peri-operative continuation of aspirin use, as assessed by a drop in haemoglobin or haematocrit.

The efficacy of fibrin sealant in knee surgery: A meta-analysis

BACKGROUND

Fibrin sealant is frequently used in knee surgery as an adjuvant method for reducing postoperative bleeding, however, there is no consensus regarding the efficacy of fibrin sealant.

HYPOTHESIS

Fibrin sealant achieves better efficacy in terms of blood loss control, transfusion rate and units in knee surgery compared with controls.

METHODS

A search of the Cochrane Collaboration (2013 Issue 09), Embase (1974-2013.09), PubMed (1966-2013.09) and Chinese databases (up to 2013.09) were conducted. The Cochrane Collaboration's tool was used to assess for bias and data were analyzed by RevMan 5.29 software.

RESULTS

This study included nine RCTs and four prospective comparative trials with a total of 1299 patients. Compared to the control, fibrin sealant achieved a decrease in hemoglobin reduction [MD=1.14, 95% CI (0.61-1.67)], transfusion rate [OR=0.36, 95% CI (0.25-0.51)], transfusion units [MD=0.47, 95% CI (0.24-0.71)], hospital stay [MD=2.22, 95% CI (0.56-3.88)] and the incidence of complications [OR=0.56, 95% CI (0.38-0.83)]. And it also reduced total blood loss, while there was no significant difference [MD=155.83, 95% CI (-525.02-213.15)].

CONCLUSION

Patients undergoing knee surgery would benefit from high-dose fibrin sealant with reduced transfusion rate and unit, hospital stay and complications, while they might benefit little from it in total blood loss. However, the effects of a low-dose of fibrin in knee surgery remain inconclusive.

One step closer to sparing total blood loss and transfusion rate in total knee arthroplasty: a meta-analysis of different methods of tranexamic acid administration

BACKGROUND

Tranexamic acid (TXA) in orthopedics has recently been gaining favor due to its efficacy and ease of use, both in intravenous (IV) and intraarticular (IA) usage. However, because of safety concerns with IV administration, there has been a growing interest in the IA use of TXA to prevent bleeding.

MATERIALS AND METHODS

This study conducted a systematic review and meta-analysis that included 31 randomized, controlled trials in which the effect of systemic and topical TXA on total blood loss (TBL), rates of transfusion, and thromboembolic events was investigated.

RESULTS

Compared to the control, the IA administration of TXA led to the significant reduction of mean TBL (p < 0.001), rate of transfusion (p < 0.001), and reduction of rate of thromboembolic events (p = 0.29). Compared to the control group, the IV administration of TXA resulted in significant reduction of mean TBL (p < 0.001), rate of transfusion (p < 0.001), and rate of thromboembolic events (p = 0.66). Although no significant differences in efficacy and safety between the IA and IV administration of TXA were found, the IA method was safer than the IV method in that it reduced rate of transfusion and thromboembolic events.

CONCLUSION

This study showed that TXA leads to significant reductions in TBL and the rate of allogeneic transfusions. Generally, no significant difference was detected between IA and IV administration of TXA; however, more studies with focus on safety and efficacy are warranted.

Use of a haemostatic matrix does not reduce blood loss in minimally invasive total knee arthroplasty

BACKGROUND

Blood loss can increase morbidity and the risk of transfusion after total knee arthroplasty (TKA). This study evaluated the difference in blood loss between minimally invasive TKA performed with and without intra-articular use of a haemostatic matrix (Floseal®).

MATERIALS AND METHODS

We retrospectively compared matched pairs in two groups (76 patients in each group): one group received conventional haemostasis (with bovie electrocoagulation), the other group was treated with an intra-articular haemostatic matrix (HM) as an adjunct to electrocoagulation. The outcomes compared were haemoglobin (Hb) and haematocrit levels at days 2 and 4 after surgery as a surrogate for blood loss, transfusion rate, surgical time, preoperative and postoperative range of motion (ROM) at days 21 and 42 and length of stay (LOS) in hospital.

RESULTS

No differences were observed for Hb levels at day 2 or day 4 between men in the two groups. In women, however, the mean Hb at day 2 was 11.1 g/dL (SD 1.3) for TKA with HM and 12.0 g/dL (SD 0.9) for TKA without HM (p<0.001), while that at day 4 was 10.6 g/dL (SD 1.3) for TKA with HM and 11.4 g/dL (SD 1.2) for TKA without HM (p<0.001). The haematocrit was higher for TKA without HM at day 2 (p=0.001) and day 4 (p=0.008). The transfusion rate for TKA with HM was 2.6% and for TKA without HM 0% (p=0.497), while the mean surgical time was 93 minutes (SD 12) vs 87 minutes (SD 14), respectively (p=0.0055). There were no differences in preoperative or postoperative ROM at days 21 and 42 between the two groups. The LOS was longer for TKA with HM than for TKA without HM (4.5 days and 4 days, respectively, p=0.011) influenced by the longer stay for the transfused patients.

DISCUSSION

The present study showed that the use of Floseal had no effect on reducing either visible or hidden blood loss after TKA, as assessed by a drop in Hb or haematocrit and that hidden blood loss was more important in women treated with the HM.

Optimizing perioperative management of total joint arthroplasty

Clinical pathways for total joint arthroplasty have been shown to reduce costs and significantly impact perioperative outcomes mainly through reducing provider variability. Effective clinical pathways link evidence to individual practice and balance costs with local experience, outcomes, and access to resources for responsible perioperative management. Common components of clinical pathways with major impact on perioperative outcomes are: 1) implementing pathways designed to include multimodal analgesia with regional anesthesia, 2) use of tranexamic acid to reduce blood loss, and 3) preconditioning followed by participation in early, accelerated rehabilitation programs to prevent postoperative complications related to immobility.