Are Three Doses of Intravenous Tranexamic Acid more Effective than Single Dose in Reducing Blood Loss During Bilateral Total Knee Arthroplasty?

The efficacy and safety of tranexamic acid in rheumatoid arthritis patients undergoing simultaneous bilateral total knee arthroplasty: a multicenter retrospective study

BACKGROUND

The efficacy and safety of tranexamic acid (TXA) in reducing blood loss following total knee arthroplasty (TKA) in patients with osteoarthritis have been widely confirmed. However, there is still a paucity of the evidences regarding the effectiveness of TXA in patients with rheumatoid arthritis (RA). The purpose of the study is to explore the efficacy and safety of intravenous TXA on blood loss and transfusion risk following simultaneous bilateral TKA (SBTKA) in patients with RA.

METHODS

As a multicenter retrospective study, a total of 74 patients diagnosed with RA who underwent SBTKA were assigned into TXA group (15 mg/kg intravenous TXA before skin incision, n = 50) and control group (no TXA use, n = 24). The primary outcomes were total blood loss (TBL) and intraoperative blood loss (IBL). The secondary outcomes were hemoglobin (Hb) and hematocrit (Hct) drop on postoperative day 3, transfusion rate and volume, ambulation time, length of stay, hospitalization expenses and the incidence of complications.

RESULTS

The mean TBL, IBL and transfusion volume in TXA group were significantly lower than those in control group. The Hb and Hct drop on postoperative day 3 in control group were higher than those in TXA group (p<0.05). The similar trend was detected on transfusion rate, ambulation time and length of stay. The incidence of complications and hospitalization expenses did not differ significantly between the two groups (p>0.05).

CONCLUSIONS

TXA could effectively reduce blood loss, decrease transfusion risk, shorten ambulation time and length of stay following SBTKA in patients with RA, without increasing the risk of complications.

Perioperative Management in Shoulder Arthroplasty: A Review of Current Practice

Perioperative management for patients undergoing shoulder arthroplasty has evolved significantly over the years to reduce overt complications and improve patient outcomes. The groundwork for perioperative care encompasses initial patient selection and education strategies for achieving successful outcome. Multimodal pain management strategies have advanced patient care with the increased use of new regional/local anesthetics. In addition, complications resulting from blood loss and transfusions have been curtailed with the use of synthetic antifibrinolytic agents. It remains critical for shoulder arthroplasty surgeons to optimize patients during the perioperative period through various modalities to maximize functional progression, outcomes, and patient's satisfaction following shoulder arthroplasty.

No Difference in Blood Loss and Risk of Transfusion Between Patients Treated with One or Two Doses of Intravenous Tranexamic Acid After Simultaneous Bilateral TKA

BACKGROUND

Tranexamic acid (TXA) is often used to prevent excessive blood loss during bilateral TKA. Although it diminishes blood loss, TXA may have a potentially elevated thrombogenic risk with extra, unnecessary doses of TXA in this high-risk population. To date, the most efficacious dosing protocol in this setting has not yet been ascertained.

QUESTIONS/PURPOSES

We compared one versus two doses of intravenous TXA in the setting of same-day bilateral TKA in terms of (1) perioperative blood loss that occurred during the hospital stay, (2) transfusion usage during the hospital stay, and (3) major complications occurring within 30 days of surgery.

METHODS

Between August 2013 and October 2016, 309 patients underwent simultaneous bilateral TKA performed by one of five attending surgeons. During that time, indications for same-day bilateral TKA included bilateral knee pathology in which each knee was independently indicated for TKA and the patient preferred bilateral simultaneous TKAs versus staged bilateral surgeries. Patients who had cardiac disease or an American Society for Anesthesiologists physical classification score of greater than 2 were not generally indicated for bilateral simultaneous TKAs. After preoperative clearance from the primary physician and/or specialists as necessary, the decision for bilateral TKA was at the judgment of the operating surgeons. Input from anesthesia occurred at the time of the surgery as the procedure was performed in a sequential fashion allowing for the surgery to be restrained to a single limb if anesthesia identified concerns at the completion of the first TKA. The current retrospective, comparative series compared generally sequential groups in terms of TXA usage. Between August 2013 and July 2015, we used two TXA doses. Patients received 1 g of intravenous TXA as a bolus immediately after the last tourniquet release and were given a 1-g intravenous bolus 6 hours after the initial dose. A total of 167 patients were treated with this approach, of whom 96% (161) are fully analyzed here. Between August 2015 and October 2016, our approach changed to a single TXA dose. The dosing regimen change occurred as a group decision for change of practice and occurred mid-year to coincide with the fellowship year cycle. Patients received a 1-g bolus of intravenous TXA immediately after the final tourniquet release. A total of 105 patients were treated with this approach, of whom 89% (93) are fully analyzed here. An additional 37 patients were excluded because they did not receive any TXA because of a medical contraindication such as history of venous thromboembolism, history of thrombotic stroke, cardiac stent in the past 2 years, atrial fibrillation, or long-term anticoagulation therapy. We compared patients who received one versus two doses in terms of blood loss, transfusion usage, and 30-day major complications. The mean age was 65 years for patients receiving one dose and 67 years for patients receiving two doses (p = 0.17). The one-dose group comprised 67% (62 of 93) women and the two-dose group comprised 61% (98 of 161) women (p = 0.36). Blood loss was defined as change in the hemoglobin level (the last recorded value before discharge subtracted from the preoperative value). During the study period, the decision to transfuse was based on a hemoglobin level less than 8.0 g/dL or at higher levels for symptomatic patients, patients with cardiac disease, or at the discretion of the attending surgeon. We defined complications as major medical events that included cerebrovascular accidents, myocardial infarction, deep vein thrombosis, and pulmonary embolism.

RESULTS

With the numbers available, there was no difference in blood loss between patients treated with one and those treated with two doses of TXA (mean hemoglobin decrease -3.5 ± 1.2 g/dL versus -3.5 ± 1.0 g/dL, respectively; mean difference 0.03 g/dL [95% CI -0.2 to 0.3 g/dL]; p = 0.80). No patient in either group received a transfusion. There was no difference in the proportion of patients in either group who experienced a cerebrovascular accident (0% [0 of 93] versus 1% [1 of 161]; p > 0.99), deep vein thrombosis (1% [1 of 93] versus 0% [0 of 161]; p = 0.37), or pulmonary embolism (1% [1 of 93] versus 1% [1 of 161]; p > 0.99). No patient in either the one-dose or two-dose TXA groups experienced a myocardial infarction.

CONCLUSION

The findings of this study suggest that a single dose of intravenous TXA may be adequate to control excessive blood loss and reduce blood transfusion in simultaneous bilateral TKA. Despite its short half-life, TXA still appears to be effective in this demanding procedure without requiring prolonged plasma concentrations obtained from multiple doses. Additional high-quality studies are still needed to determine the most appropriate dosing regimen.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Tranexamic acid achieves less blood loss volume of in primary shoulder arthroplasty: a systematic review and meta-analysis of level I randomized controlled trials

Background

Tranexamic acid (TXA) reduces blood loss in knee and hip arthroplasty, but the effectiveness in shoulder arthroplasty is unknown. This study aimed to evaluate current level I randomized controlled trials examining the efficacy of TXA in primary shoulder arthroplasty.

Methods

A protocol for the study was designed and registered with PROSPERO (CRD42021230398). The PubMed, Embase, and Cochrane Library databases were searched using the following search strategy: "shoulder replacement" OR "shoulder arthroplasty" OR "reverse shoulder arthroplasty" AND "tranexamic acid." All randomized controlled trials were included in this study. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was followed. Outcomes include blood loss, drain output, hemoglobin, thromboembolic complications, and blood transfusion.

Results

Five randomized controlled trials of 435 patients (219 patients in the TXA group and 216 patients in the non-TXA group) were included in the systematic review. The results indicated that the group using TXA had less total blood loss (MD, -249.56 mL; 95% confidence interval [CI] -347.60 to -151.52), less drainage output (MD, -113.72 mL; -155.92 to -71.52 95% CI), and less of a change in hemoglobin (MD, -0.68 g/dl; -0.94 to -0.42 g/dl 95% CI). No significant differences in blood transfusion (risk ratio 0.40; -0.11 to 1.45 95% CI) or thromboembolic events (risk ratio 0.13, 0.02 to 1.12 95% CI) were observed. Subgroup analyses showed that there was no significant difference in total blood loss, drainage output, or change in hemoglobin between single dose and multiple doses.

Conclusions

TXA in primary shoulder arthroplasty can reduce blood loss, drain output, and hemoglobin changes. Subgroup analysis showed that multiple TXA doses have similar results compared with single dose in primary shoulder arthroplasty. More randomized controlled trials comparing different administration routes of TXA in primary and revision shoulder arthroplasty are required.

The efficacy and safety of tranexamic acid in high tibial osteotomy: a systematic review and meta-analysis

Objective

The present meta-analysis was conducted to evaluate the efficacy and safety of the application of tranexamic acid (TXA) in patients undergoing high tibial osteotomy (HTO).

Methods

PubMed (MEDLINE), EMBASE, and Cochrane Library were systematically searched for relevant literature from inception until 1 February 2021. A combined searching strategy of subject words and random words was adopted. After testing for potential publication bias and/or heterogeneity, we aggregated variables by using the random-effect model. The primary comparison outcome measures were total blood loss, hemoglobin decrease, drain output, wound complications, thrombotic events, and blood transfusion rate of the TXA group versus control. The meta-analysis was performed using the RevMan 5.3 software.

Results

A total of 5 studies were included involving 532 patients. The results showed that there were significant differences in the two groups concerning total blood loss (95% confidence interval [CI] − 332.74 to − 146.46, P < 0.00001), hemoglobin decrease on postoperative day (POD) 1, 2, and 5 (POD 1 95% CI − 1.34 to − 0.63, P < 0.00001; POD 2 95% CI − 1.07 to − 0.68, P < 0.00001; POD 5 95% CI − 1.46 to − 0.84, P < 0.00001), drain output (POD total 95% CI − 195.86 to − 69.41, P < 0.00001) and wound complications (RR = 0.34, 95% CI 0.12 to 0.97, P = 0.04). Nonsignificant differences were found in the incidence of thromboembolic events (RR = 0.46, 95% CI 0.09 to 2.41, P = 0.36) and blood transfusion rate (RR = 0.25, 95% CI 0.03 to 2.27, P = 0.22).

Conclusions

This meta-analysis of the available evidence demonstrated that TXA could reduce total blood loss, hemoglobin decrease, drain output, and wound complications without increasing the incidence of thromboembolic events in patients undergoing HTO. But there is no obvious evidence that TXA could reduce blood transfusion rates. Further studies, including more large-scale and well-designed randomized controlled trials, are warranted to assess the efficacy and safety issues of routine TXA use in HTO patients.