Tranexamic acid and the reduction of blood loss in total knee and hip arthroplasty: a meta-analysis

Is there a need for routine post-operative hemoglobin level estimation in total knee arthroplasty with tranexamic acid use?

BACKGROUND

Total knee arthroplasty (TKA) can result in significant blood loss, leading to a need for blood transfusion. The major indication of transfusion is post-operative hemoglobin (Hb) levels in association with symptomatic anemia. The aim of this study was to determine the possibility of eliminating routine post-operative Hb tests in patients undergoing TKA with intra-articular tranexamic acid (TXA) use based on the predictability of pre-operative factors.

METHODS

We conducted a retrospective analysis of 487 patients who underwent TKA with intra-articular TXA use. Statistical analysis was done to predict the transfusion risk based on multiple pre-operative parameters.

RESULTS

Post-operative blood transfusions were required in 2.5% of all patients. Pre-operative-Hb was the only significant predictor of post-operative transfusion (p<0.0001). Age, sex, weight, height and body mass index (BMI) were not related to post-operative transfusion risk. Transfusions were needed in 4.2% of patients with pre-operative Hb levels <14 g/dl. No patient with a pre-operative Hb >14 g/dl required a transfusion (p<0.0001).

CONCLUSIONS

Pre-operative Hb is a strong predictor of post-operative blood transfusion risk. Patients who receive TXA in TKA, with a pre-operative Hb >14 g/dl do not require routine post-operative Hb evaluation.

LEVEL OF EVIDENCE

IV.

Cost Analysis of Tranexamic Acid in Anemic Total Joint Arthroplasty Patients

BACKGROUND

Preoperative anemia is present in 20% of total joint arthroplasty patients. Current preoperative treatment options, including iron supplementation (FE) and erythropoietin (EPO), are expensive. Tranexamic acid (TXA) has been adopted as an intraoperative adjunct to decrease blood loss. Our hypothesis is that TXA is a cost-effective treatment compared to FE and EPO in anemic patients.

METHODS

In this study, a cost analysis was performed, comparing the material costs of TXA and packed red blood cells (PRBCs) to the theoretical administration and material costs of FE and EPO per standard preoperative anemia protocol.

RESULTS

A total of 243 patients were included in the study. Of this group, 18.5% (45/243) had preoperative anemia. The rate of transfusion was 6.7% (3/45), and 5 units of PRBCs was transfused. The combined cost of TXA and PRBCs was $5317.08. Even assuming a best-case scenario with FE or EPO treatment without a postoperative PRBC requirement, the cost of treatment would range from 2 to 17 times more than treatment with TXA. An additional 50 units of PRBC (1.1 units per patient) would need to be transfused for the cost of TXA treatment to be equivalent to FE or EPO treatment.

CONCLUSION

Tranexamic acid is significantly less expensive than FE or EPO as a treatment option for total joint arthroplasty patients presenting with preoperative anemia. It is a cost-effective adjunct for limiting transfusion rates in this patient population. We recommend that new preoperative anemia levels that necessitate preoperative intervention be established.

Antifibrinolytic therapy for preventing oral bleeding in patients with haemophilia or Von Willebrand disease undergoing minor oral surgery or dental extractions

BACKGROUND

Minor oral surgery or dental extractions (oral or dental procedures) are widely performed and can be complicated by hazardous oral bleeding, especially in people with an inherited bleeding disorder such as haemophilia or Von Willebrand disease. The amount and severity of singular bleedings depend on disease-related factors, such as the severity of the haemophilia, both local and systemic patient factors (such as periodontal inflammation, vasculopathy or platelet dysfunction) and intervention-related factors (such as the type and number of teeth extracted or the dimension of the wound surface). Similar to local haemostatic measures and suturing, antifibrinolytic therapy is a cheap, safe and potentially effective treatment to prevent bleeding complications in individuals with bleeding disorders undergoing oral or dental procedures. However, a systematic review of trials reporting outcomes after oral surgery or a dental procedure in people with an inherited bleeding disorder, with or without, the use of antifibrinolytic agents has not been performed to date.

OBJECTIVES

The primary objective was to assess the efficacy of local or systemic use of antifibrinolytic agents to prevent bleeding complications in people with haemophilia or Von Willebrand disease undergoing oral or dental procedures. Secondary objectives were to assess if antifibrinolytic agents can replace or reduce the need for clotting factor concentrate therapy in people with haemophilia or Von Willebrand disease and to further establish the effects of these agents on bleeding in oral or dental procedures for each of these populations.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches of the Cochrane Central Register of Controlled Trials (CENTRAL), of MEDLINE and from handsearching of journals and conference abstract books. We additionally searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and The Cochrane Library. Additional searches were performed in ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP).Date of last search of the Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register: 14 December 2015.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials in people with haemophilia or Von Willebrand disease undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained for potentially relevant abstracts and two authors independently assessed these for inclusion based on the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms.

MAIN RESULTS

While there were no eligible trials in people with Von Willebrand disease identified, two randomised, double-blind, placebo-controlled trials (total of 59 participants) in people with haemophilia undergoing dental extraction were included. One trial of tranexamic acid published in 1972 included 28 participants with mild, moderate or severe haemophilia A and B and one of epsilon aminocaproic acid published in 1971 included 31 people with haemophilia with factor VIII or factor IX levels less than 15%. Overall, the two included trials showed a beneficial effect of tranexamic acid and EACA, administered systemically, in reducing the number of bleedings, the amount of blood loss and the need for therapeutic clotting factor concentrates. Regarding postoperative bleeding, the tranexamic acid trial showed a risk difference of -0.64 (95% confidence interval -0.93 to - 0.36) and the EACA trial a risk difference of -0.50 (95% confidence interval 0.77 to -0.22). The combined risk difference of both trials was -0.57 (95% confidence interval -0.76 to -0.37), with the quality of the evidence (GRADE) for this outcome is rated as moderate. Side effects occurred once and required stopping epsilon aminocaproic acid (combined risk difference of -0.03 (95% CI -0.08 to 0.13). There was heterogeneity between the two trials regarding the proportion of people with severe haemophilia included, the concomitant standard therapy and fibrinolytic agent treatment regimens used. We cannot exclude that a selection bias has occurred in the epsilon aminocaproic acid trial, but overall the risk of bias appeared to be low for both trials.

AUTHORS' CONCLUSIONS

Despite the discovery of a beneficial effect of systemically administered tranexamic acid and epsilon aminocaproic acid in preventing postoperative bleeding in people with haemophilia undergoing dental extraction, the limited number of randomised controlled trials identified, in combination with the small sample sizes and heterogeneity regarding standard therapy and treatment regimens between the two trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in oral or dental procedures in people with haemophilia. No trials were identified in people with Von Willebrand disease.

Absence of a Tourniquet Does Not Affect Fixation of Cemented TKA: A Randomized RSA Study of 70 Patients

We aimed to determine whether not using a tourniquet in cemented TKA would affect migration of the tibial component measured by radiosterometric analysis (RSA). Seventy patients were randomized into a tourniquet group and a non-tourniquet group and using model-based RSA, the migration of the tibial component was analyzed. Primary and secondary outcome measures were maximum total point motion (MTPM) and translations and rotations. Follow-up period was 2 years. The tibial component was well fixated in both groups and no significant difference in migration between the two groups was detected (P=0.632). Mean MTPM (SD) was 0.47 mm (0.16) in the tourniquet group and 0.45 mm (0.21) in the non-tourniquet group. Absence of tourniquet indicates that stable fixation of the tibial component can be achieved in cemented TKA.

Efficacy and Safety of Tranexamic Acid in Bilateral Total Knee Replacement: A Meta-Analysis and Systematic Review

Background

Tranexamic acid (TXA) has been well documented to reduce blood loss and transfusion requirements in patients undergoing unilateral total knee arthroplasty (TKA). However, the efficacy and safety of TXA in simultaneous bilateral TKA have not been clearly defined. The aim of our study was to systematically review the existing evidence regarding the role of TXA in patients undergoing simultaneous bilateral TKA.

Material/Methods

A systematic search of all studies published through June 2014 was performed using Medline, EMBASE, OVID, and other databases. All studies that compared the efficacy and safety of TXA administration in simultaneous bilateral TKA patients were identified. The data from the included trials were extracted and analyzed regarding blood loss and transfusion rates. The evidence quality levels of the selected articles were evaluated using a grading system.

Results

Six studies were included, in which a total of 245 patients received TXA and 271 patients were controls. Overall, the results demonstrated that the use of TXA significantly reduced total blood loss by a mean of 371.1 ml (95% confidence interval (CI)=−412.12 to −330.09; p<0.001) and reduced the number of patients requiring blood transfusion (risk ratio (RR)=0.16; 95% CI=0.10 to 0.28; p<0.001). No significant differences in adverse effects such as deep vein thrombosis (DVT) or pulmonary embolism (PE) were noted in any group.

Conclusions

The intravenous use of TXA in patients undergoing simultaneous bilateral TKA is effective and safe and results in significantly reduced estimated blood loss and transfusion rates. No significant difference was observed in the incidence of side effects. Due to the limitations in the evidence quality of current meta-analyses, well-conducted, larger, high-quality randomized controlled trials (RCTs) are required.

Tranexamic acid: from trauma to routine perioperative use

PURPOSE OF REVIEW

Optimizing hemostasis with antifibrinolytics is becoming a common surgical practice. Large clinical studies have demonstrated efficacy and safety of tranexamic acid (TXA) in the trauma population to reduce blood loss and transfusions. Its use in patients without pre-existing coagulopathies is debated, as thromboembolic events are a concern. In this review, perioperative administration of TXA is examined in nontrauma surgical populations. Additionally, risk of thromboembolism, dosing regimens, and timing of dosing are assessed.

RECENT FINDINGS

Perioperative use of TXA is associated with reduced blood loss and transfusions. Thromboembolic effects do not appear to be increased. However, optimal dosing and timing of TXA administration is still under investigation for nontrauma surgical populations.

SUMMARY

As part of a perioperative blood management programme, TXA can be used to help reduce blood loss and mitigate exposure to blood transfusion.

Universal tranexamic acid therapy to minimize transfusion for major joint arthroplasty: a retrospective analysis of protocol implementation

PURPOSE

Tranexamic acid (TXA) therapy can reduce red blood cell (RBC) transfusion; however, this therapy remains underutilized in many surgical patient populations. We assessed whether implementation of a protocol to facilitate universal administration of TXA in patients undergoing total hip or knee arthroplasty would reduce the incidence of RBC transfusion without increasing adverse clinical outcomes.

METHODS

We implemented a quality of care policy to provide universal administration of intravenous TXA at a dose of 20 mg·kg(-1) iv to all eligible patients undergoing total hip or knee arthroplasty from October 21, 2013 to April 30, 2014. We compared data from an equal number of patients before and after protocol implementation (n = 422 per group). The primary outcome was RBC transfusion with secondary outcomes including postoperative hemoglobin concentration (Hb) and length of hospital stay. Adverse events were identified from the electronic medical records. Data were analyzed by a Chi square test and adjusted logistic and linear regression analysis.

RESULTS

Implementation of the protocol resulted in an increase in TXA utilization from 45.8% to 95.3% [change 49.5%; 95% confidence interval (CI), 44.1 to 54.5; P < 0.001]. This change was associated with a reduction in the rate of RBC transfusion from 8.8% to 5.2%, (change -3.6%; 95% CI, -0.1 to -7.0; P = 0.043). Pre- and post-protocol mean [standard deviation (SD)] Hb values were similar, including the nadir Hb prior to RBC transfusion [72 (8) g·L(-1) vs 70 (8) g·L(-1), respectively; mean difference -1 g·L(-1); 95% CI, -3 to 5; P = 0.569]. Length of stay was not altered, and no increase in adverse events was observed.

CONCLUSIONS

Implementation of a perioperative TXA protocol was associated with both an increase in TXA use and a reduction in RBC transfusion following hip or knee arthroplasty. Adverse events and length of hospital stay were not influenced by the protocol.

Tranexamic acid for the prevention and management of orthopedic surgical hemorrhage: current evidence

Total joint arthroplasty can be associated with major blood loss and require subsequent blood transfusions for postoperative anemia. Measures to effectively and safely decrease blood loss and reduce the need for blood transfusions would help improve patient safety and lower health care costs. A possible pharmacological option to reduce surgical blood loss in total joint arthroplasty is the use of tranexamic acid. Abundant literature has shown that intravenous and/or topical administration of tranexamic acid is effective in reducing blood loss and blood transfusions, with no increased risk of venous thromboembolic events or other complications.

Can tranexamic acid change preoperative anemia management during total joint arthroplasty?

AIM: To investigate the postoperative transfusion and complication rates of anemic and nonanemic total joint arthroplasty patients given tranexamic acid (TXA).

METHODS: A cross-sectional prospective study was conducted of primary hip and knee arthroplasty cases performed from 11/2012 to 6/2014. Exclusion criteria included revision arthroplasty, bilateral arthroplasty, acute arthroplasty after fracture, and contraindication to TXA. Patients were screened prior to surgery, with anemia was defined as hemoglobin of less than 12 g/dL for females and of less than 13 g/dL for males. Patients were divided into four different groups, based on the type of arthroplasty (total hip or total knee) and hemoglobin status (anemic or nonanemic). Intraoperatively, all patients received 2 g of intravenous TXA during surgery. Postoperatively, allogeneic blood transfusion (ABT) was directed by both clinical symptoms and relative hemoglobin change. Complications were recorded within the first two weeks after surgery and included thromboembolism, infection, and wound breakdown. The differences in transfusion and complication rates, as well as the relative hemoglobin change, were compared between anemic and nonanemic groups.

RESULTS: A total of 232 patients undergoing primary joint arthroplasty were included in the study. For the total hip arthroplasty cohort, 21% (18/84) of patients presented with preoperative anemia. Two patients in the anemic group and two patients in the nonanemic group needed ABTs; this was not significantly different (P = 0.20). One patient in the anemic group presented with a deep venous thromboembolism while no patients in the nonanemic group had an acute complication; this was not significantly different (P = 0.21). For nonanemic patients, the average change in hemoglobin was 2.73 ± 1.17 g/dL. For anemic patients, the average change in hemoglobin was 2.28 ± 0.96 g/dL. Between the two groups, the hemoglobin difference of 0.45 g/dL was not significant (P = 0.13). For the total knee arthroplasty cohort, 18% (26/148) of patients presented with preoperative anemia. No patients in either group required a blood transfusion or had an acute postoperative complication. For nonanemic patients, the average change in hemoglobin was 1.85 ± 0.79 g/dL. For anemic patients, the average change in hemoglobin was 1.09 ± 0.58 g/dL. Between the two groups, the hemoglobin difference of 0.76 g/dL was significant (P < 0.001).

CONCLUSION: TXA administration results in low transfusion and complication rates and may be a useful adjunct for TJA patients with preoperative anemia.

Topical Administration of Tranexamic Acid Plus Diluted-Epinephrine in Primary Total Knee Arthroplasty: A Randomized Double-Blinded Controlled Trial

The aim of this trial was to evaluate the efficacy and safety of intra-articular administration of tranexamic acid (TXA) plus diluted-epinephrine (DEP) on perioperative blood loss and transfusion in primary unilateral total knee arthroplasty (TKA) without drainage. One hundred patients scheduled to undergo TKA were randomized into two groups: 50 patients received intra-articular 3g TXA plus 0.25mg DEP (1:200,000), and 50 patients received 3g topical TXA alone. The results showed that topical combined administration significantly reduced total blood loss (P=0.006), hidden blood loss (P=0.000) and transfusion rate (0% vs. 4%), without increasing the risk of thromboembolic and hemodynamic complications (P>0.05). Therefore, topical TXA plus DEP was effective and safe in reducing blood loss and transfusion following TKA, without substantial complications.

Tranexamic acid for preventing postpartum haemorrhage

BACKGROUND

Postpartum haemorrhage (PPH) is a common and potentially life-threatening complication of labour. Several options for preventing PPH are available, but further advances in this field are important, especially the identification of safe, easy to use and cost-effective regimens. Tranexamic acid (TA), which is an antifibrinolytic agent that is used widely to prevent and treat haemorrhage, merits evaluation to assess whether it meets these criteria.

OBJECTIVES

To determine, from the best available evidence, whether TA is effective and safe for preventing PPH in comparison to placebo or no treatment (with or without uterotonic co-treatment), or to uterotonic agents.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

All published, unpublished and ongoing randomised controlled trials (RCTs) evaluating the use of TA alone or in addition to uterotonics in the third stage of labour or during caesarean section (CS) to prevent PPH.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed for inclusion all the potential studies identified as a result of the search strategy. We entered the data into Review Manager software and checked for accuracy.

MAIN RESULTS

Twelve trials involving 3285 healthy women at low risk of excessive bleeding undergoing elective CS (nine trials, 2453 participants) or spontaneous birth (three trials, 832 participants) satisfied inclusion criteria and contributed data to the analysis. All participants received routine prophylactic uterotonics in accordance with the local guideline in addition to TA or placebo or no intervention. Overall, included studies had moderate risk of bias for random sequence generation, allocation concealment, blinding, selective reporting and low risk of bias for incomplete data. The quality of evidence was also as assessed using GRADE.Blood loss greater than 400 mL or 500 mL, and more than 1000 mL was less common in women who received TA versus placebo or no intervention (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.42 to 0.63, six trials, 1398 women; moderate quality evidence) and (RR 0.40, 95% CI 0.23 to 0.71, six trials, 2093 women; moderate quality evidence), respectively. TA was effective in decreasing the incidence of blood loss greater than 1000 mL in women who had undergone CS (RR 0.43, 95% CI 0.23, 0.78, four trials, 1534 women), but not vaginal birth (RR 0.28, 95% CI 0.06, 1.36, two trials 559 women). The effect of TA on blood loss greater than 500 mL or 400 mL was more pronounced in the group of women having vaginal birth than in women who had CS. Mean blood loss (from delivery until two hours postpartum) was lower in women who received TA versus placebo or no intervention (mean difference MD - 77.79 mL, 95% CI -97.95, -57.64, five trials, 1186 women) and this effect was similar following vaginal birth and CS.Additional medical interventions (moderate quality evidence) and blood transfusions were less frequent in women receiving TA versus placebo or no interventions. Mild side effects such as nausea, vomiting, dizziness were more common with the use of TA (moderate quality evidence). The effect of TA on maternal mortality, severe morbidity and thromboembolic events is uncertain (low quality evidence).

AUTHORS' CONCLUSIONS

TA (in addition to uterotonic medications) decreases postpartum blood loss and prevents PPH and blood transfusions following vaginal birth and CS in women at low risk of PPH based on studies of mixed quality. There is insufficient evidence to draw conclusions about serious side effects, but there is an increase in the incidence of minor side effects with the use of TA. Effects of TA on thromboembolic events and mortality as well as its use in high-risk women should be investigated further.

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.

Does tranexamic acid alter the risk of thromboembolism after total hip arthroplasty in the absence of routine chemical thromboprophylaxis?

Tranexamic acid (TXA) has been used to reduce blood loss during total hip arthroplasty (THA), but its use could increase the risk of venous thromboembolic disease (VTE). Several studies have reported that TXA does not increase the prevalence of deep vein thrombosis (DVT), but most of those used routine chemical thromboprophylaxis, thereby masking the potential increased risk of TXA on VTE. We wished to ascertain whether TXA increases the prevalence of VTE in patients undergoing THA without routine chemical thromboprophylaxis. We carried out a retrospective case-control study in 254 patients who underwent a primary THA, 127 of whom received TXA (1 g given pre-operatively) and a control group of 127 who did not. All patients had mechanical but no chemical thomboprophylaxis. Each patient was examined for DVT by bilateral ultrasonography pre-operatively and on post-operative days 1 and 7. TXA was found to statistically significantly increase the incidence of total DVT on post-operative day 7 compared with the control group (24 (18.9%) and 12 (9.4%), respectively; p < 0.05) but most cases of DVT were isolated distal DVT, with the exception of one patient with proximal DVT in each group. One patient in the control group developed a non-fatal symptomatic pulmonary embolism (PE). The use of TXA did not appear to affect the prevalence of either proximal DVT or PE.

Cite this article: Bone Joint J 2015; 97-B:458–62.

Topical tranexamic Acid does not affect electrophysiologic or neurovascular sciatic nerve markers in an animal model

BACKGROUND

Tranexamic acid is a safe and effective antifibrinolytic agent used systemically and topically to reduce blood loss and transfusion rate in patients having TKA or THA. As the hip does not have a defined capsule, topical application of tranexamic acid may entirely envelop the sciatic nerve during THA. Accidental application of tranexamic acid onto the spinal cord in spinal anesthesia has been shown to produce seizures; therefore, we sought to investigate if topical application of tranexamic acid on the sciatic nerve has a deleterious effect.

QUESTIONS/PURPOSES

We explored whether there were any short- or long-term alterations in (1) electrophysiologic measures, (2) macrophage recruitment, or (3) blood-nerve barrier permeability. Our hypothesis was that local application of tranexamic acid would have a transient effect or no effect on histologic features and function of the sciatic nerve.

METHODS

We used a rat protocol to model sciatic nerve exposure in THA to determine the effects of tranexamic acid on neural histologic features and function. We evaluated 35 rats by the dorsal gluteal splitting approach to expose the sciatic nerve for topical use of control and tranexamic acid. We evaluated EMG changes (distal latency, amplitude, nerve conduction velocity), histologic signs of nerve injury via macrophage recruitment, and changes in blood-nerve barrier permeability at early (4 days) and late (1 month) times after surgery, after application of subtherapeutic (1 mg/kg body weight [1.6 mg]), therapeutic (10 mg/kg [16 mg]), and supratherapeutic (100 mg/kg [160 mg]) concentrations of tranexamic acid. Differences in blood-nerve barrier permeability, macrophage recruitment, and EMG between normal and tranexamic acid-treated nerves were calculated using one-way ANOVA, with Newman-Keuls post hoc analyses, at each time. A post hoc power calculation showed that with the numbers available, we had 16% power to detect a 50% difference in EMG changes between the control, 1 mg/kg group, 10 mg/kg group, and 100 mg/kg group.

RESULTS

At the early and late times, with the numbers available, there were no differences in EMG except for distal latency at 4 days, macrophage recruitment, or changes in blood-nerve barrier between control rats and those with tranexamic acid-treated nerves. The distal latency in the 1 mg tranexamic acid-treated animals at 4 days was 1.06 ± 0.15 ms (p = 0.0036 versus all other groups, 95% CI, 0.89-1.25), whereas the distal latencies in the control, the 10 mg/kg, and 100 mg/kg tranexamic acid-treated animals were 0.83 ± 0.11, 0.89 ± 0.05, and 0.87 ± 0.13, respectively. Distal latencies were not increased in any of the groups at 1 month with the numbers available (0.81 ± 0.10, 0.89 ± 0.03, 0.81 ± 0.06, and 0.83 ± 0.08 ms, respectively, for controls; 1 mg/kg, 10 mg/kg, and 100 mg/kg for the tranexamic acid-treated groups).

CONCLUSION

In our in vivo rat model study, tranexamic acid did not appear to have any clinically relevant effect on the sciatic nerve resulting from topical administration up to 1 month. However, because our statistical power was low, these data should be considered hypothesis-generating pilot data for larger, more-definitive studies.

CLINICAL RELEVANCE

Topical tranexamic acid is effective in decreasing patient blood loss during THA, and results from our in vivo rat model study suggest there may be no electrophysiologic and histologic effects on the sciatic nerve, with the numbers available, up to 1 month.

Effectiveness and safety of tranexamic acid for total knee arthroplasty: a prospective randomized controlled trial

Background

Total knee arthroplasty (TKA) is associated with significant perioperative blood loss and need for transfusion. This study aimed to evaluate the effectiveness and safety of tranexamic acid (TXA) to reduce perioperative blood loss in patients receiving TKA.

Material/Methods

A total of 92 patients who accepted unilateral TKA from May 2012 to May 2013 randomly received either 15 mg/kg TXA in 100 mL normal saline solution (TXA group, n=46) or the same amount of normal saline solution (placebo group, n=46) at 15 min before the tourniquet was loosened. The following data were recorded: intraoperative blood loss; post-operative drainage at 12 h; total drainage amount; hidden blood loss; total blood loss; transfusion volumes; number of transfusions; post-operative hemoglobin at 1, 3, and 5 days; D-dimer; number of lower limb ecchymoses; and deep vein thrombosis (DVT).

Results

A total of 81 patients were available for analysis (TXA group, n=41; placebo group, n=40). Post-operative12-h drainage, post-operative 24-h D-dimer values, total drainage volume, hidden blood loss, total blood loss, and the rate of postoperative ecchymosis were lower in the TXA group than in the placebo group (p<0.05). The post-operative 3-day Hgb was higher in the TXA group than in the placebo group (p=0.000). The rate of transfusion and DVT was similar in both groups (n.s.).

Conclusions

Perioperative blood loss could be reduced after TKA by intravenously injecting 15 mg/kg TXA at 15 min before the tourniquet was loosened. The application of TXA is not associated with increased risk of DVT.

Patient blood management in orthopaedic surgery: a four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland

BACKGROUND

The aim of this study was to investigate the impact of the introduction of a Patient Blood Management (PBM) programme in elective orthopaedic surgery on immediate pre-operative anaemia, red blood cell (RBC) mass loss, and transfusion.

MATERIALS AND METHODS

Orthopaedic operations (hip, n=3,062; knee, n=2,953; and spine, n=2,856) performed between 2008 and 2011 were analysed. Period 1 (2008), was before the introduction of the PBM programme and period 2 (2009 to 2011) the time after its introduction. Immediate pre-operative anaemia, RBC mass loss, and transfusion rates in the two periods were compared.

RESULTS

In hip surgery, the percentage of patients with immediate pre-operative anaemia decreased from 17.6% to 12.9% (p<0.001) and RBC mass loss was unchanged, being 626±434 vs 635±450 mL (p=0.974). Transfusion rate was significantly reduced from 21.8% to 15.7% (p<0.001). The number of RBC units transfused remained unchanged (p=0.761). In knee surgery the prevalence of immediate pre-operative anaemia decreased from 15.5% to 7.8% (p<0.001) and RBC mass loss reduced from 573±355 to 476±365 mL (p<0.001). The transfusion rate dropped from 19.3% to 4.9% (p<0.001). RBC transfusions decreased from 0.53±1.27 to 0.16±0.90 units (p<0.001). In spine surgery the prevalence of immediate pre-operative anaemia remained unchanged (p=0.113), RBC mass loss dropped from 551±421 to 404±337 mL (p<0.001), the transfusion rate was reduced from 18.6 to 8.6% (p<0.001) and RBC transfusions decreased from 0.66±1.80 to 0.22±0.89 units (p=0.008).

DISCUSSION

Detection and treatment of pre-operative anaemia, meticulous surgical technique, optimal surgical blood-saving techniques, and standardised transfusion triggers in the context of PBM programme resulted in a lower incidence of immediate pre-operative anaemia, reduction in RBC mass loss, and a lower transfusion rate.

Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial

BACKGROUND

Abundant literature regarding the use of intravenous tranexamic acid (TXA) in primary total knee replacement is available. Randomized controlled trials have confirmed the efficacy of topical TXA compared with placebo, but the comparison between topical and intravenous TXA is unclear. The present study was designed to verify noninferior efficacy and safety of topical intra-articular TXA compared with intravenous TXA in primary total knee replacement with cemented implants.

METHODS

A Phase-III, single-center, double-blind, randomized, controlled clinical trial was performed to compare topical intra-articular TXA (3 g of TXA in 100 mL of physiological saline solution) with two intravenous doses of TXA (15 mg/kg in 100 mL of physiological saline solution, one dose before tourniquet release and another three hours after surgery) in a multimodal protocol for blood loss prevention. The primary outcome was the blood transfusion rate, and the secondary outcomes included visible blood loss (as measured in the drain) at twenty-four hours postoperatively and invisible blood loss (as estimated from the Nadler formula) at forty-eight hours postoperatively. The sample size of seventy-eight patients was calculated to give a statistical power of 99% for demonstrating noninferiority. Thirty-nine patients each were allocated to receive topical intra-articular TXA (the experimental group) and intravenous TXA (the control group); there were no significant differences in demographics or preoperative laboratory values between the groups. Noninferiority was estimated by comparing the confidence intervals with a delta of 10%. Student t and Mann-Whitney tests were used to assess the significance of any differences.

RESULTS

The transfusion rate was zero in both groups; thus, noninferiority was demonstrated for the primary efficacy end point, suggesting equivalence. Noninferiority was also demonstrated for the secondary efficacy end points. Drain blood loss at twenty-four hours was 315.6 mL (95% confidence interval [CI], 248.5 to 382.7 mL) in the experimental group and 308.1 mL (95% CI, 247.6 to 368.5 mL) in the control group (p = 0.948, Mann-Whitney). Also, estimated blood loss at forty-eight hours was 1259.0 mL (95% CI, 1115.6 to 1402.3 mL) in the experimental group and 1317.9 mL (95% CI, 1175.4 to 1460.4 mL) in the control group (p = 0.837, Mann-Whitney). No significant safety differences were seen between groups.

CONCLUSIONS

Topical administration of TXA according to the described protocol demonstrated noninferiority compared with intravenous TXA, with no safety concerns. This randomized controlled trial supports the topical intra-articular administration of TXA in primary total knee replacement with cemented implants.

LEVEL OF EVIDENCE

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

Prophylactic tranexamic acid in parturients at low risk for post-partum haemorrhage: systematic review and meta-analysis

Tranexamic acid is effective in reducing blood loss during various types of surgery and after trauma. No compelling evidence has yet been presented for post-partum haemorrhage. A systematic literature search of relevant databases was performed to identify trials that assessed blood loss and transfusion incidence after tranexamic acid administration for post-partum haemorrhage. The random effects model was used for meta-analysis. Risk ratios (RRs) and weighted mean differences (WMDs) were calculated with 95% confidence intervals (CIs). Seven trials with a low risk of bias comparing tranexamic acid vs. placebo with a total of 1760 parturients were included in our systematic review and meta-analysis. Blood loss was significantly lower after tranexamic acid use (WMD -140.29 ml, 95% CI -189.64 to -90.93 ml; P<0.00001). Tranexamic acid reduced the risk for blood transfusions (RR 0.34, 95% CI 0.20-0.60, P=0.0001). The incidence of transfusions in the placebo group varied between 1.4% and 33%. When omitting the two trials with the highest incidence of transfusions, the RR was no longer significant. Additional uterotonics were necessary in the placebo groups; gastrointestinal adverse events were more common after tranexamic acid use. Only four cases of thrombosis were found, two each in the tranexamic acid and control groups. Tranexamic acid effectively reduced post-partum blood loss; the effect on the incidence of blood transfusions requires further studies. Only few trials observed adverse events including thromboembolic complications and seizures.

Weighted versus uniform dose of tranexamic acid in patients undergoing primary, elective knee arthroplasty: a prospective randomized controlled trial

In a prospective, randomized, double-blinded, controlled study (25 controls), TA was infused parenterally before tourniquet release in two study groups. Group 1 (n = 20) received a 1 g dose, and group 2 (n = 20) received a 20 mg/kg dose. There was no significant difference between groups 1 and 2 with intra-operative, post-operative and total blood loss. Both groups 1 and 2 exhibited significant improvements in intra-operative, post-operative, and total blood loss compared to the control group (P < 0.05). Two blood transfusions were given to one patient in the weighted group, compared to 19 transfusions (10 patients) in the control group. This study suggests that a single 1-g dose can be used with the same efficacy as a weighted 20 mg/kg dose.

Topical administration of tranexamic acid in primary total hip and total knee arthroplasty

Major blood loss is a known potential complication in total hip and total knee arthroplasty. We conducted a prospective, stratified, randomized, double-blind, placebo-controlled trial that evaluated 100 patients undergoing total knee or total hip arthroplasty to evaluate the effect on blood loss using the topical application of tranexamic acid. Participants received either 2 g of topical tranexamic acid or the equivalent volume of placebo into the joint prior to surgical closure. Tranexamic acid resulted in a lower mean maximum decline in postoperative hemoglobin levels when compared to placebo (P = 0.013). Patients in the tranexamic acid group demonstrated an improved but non-significant reduction in the units of blood transfused compared to placebo (P = 0.423). There was no clinically significant increase in complications in the tranexamic acid group, including no incidence of venous thromboembolism.

Blood transfusion after primary total knee arthroplasty can be significantly minimised through a multimodal blood-loss prevention approach

PURPOSE

Our aim was to clarify the effective decrease in blood transfusion after primary total knee arthroplasty (TKA) from a multimodal blood-loss prevention approach (MBLPA) and the related risk factors of blood transfusion.

METHODS

We retrospectively compared the rate of postoperative blood transfusion in 418 cases of primary TKA during 2010 from a single institution with two different groups of patients, allocating cases to the group with MBLPA (group 1, study group, N = 71) and controls to the group without MBLPA (group 2, standard group, N = 347). MBLPA procedure included pre-operative haemoglobin (Hb) optimisation; femoral canal obturation; limited incision and release; peri- and intra-articular use of saline with adrenalin, morpheic chloride, tobramycin, betamethasone and ropivacaine; tourniquet release after skin closure; 24 hour drain under atmospheric pressure; and two doses of tranexamic acid (TXA) i.v.. In the control group, surgeons followed the standard procedure without blood-saving techniques. Case-control comparison and blood transfusion risk factors were analysed.

RESULTS

Group 1 had a zero transfusion rate (0/71), whereas 27.4% of patients (95/347) in group 2 received allogenic blood transfusion. Significant transfusion risk factors were pre-operative Hb <12 g/dl), American Society of Anesthesiologists (ASA) status III and nonobese body mass index (BMI); Age and gender were not significant risk factors.

CONCLUSIONS

MBLPA in primary TKA was highly effective, with a zero transfusion rate. Risk factors for transfusion were determined, and eliminating them contributed to the avoidance of allogeneic blood transfusion in our study series.