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Dang X, Liu M, Yang Q, Jiang J, Liu Y, Sun H, Tian J. Tranexamic acid may benefit patients with preexisting thromboembolic risk undergoing total joint arthroplasty: a systematic review and meta-analysis. EFORT Open Rev 2024; 9:467-478. [PMID: 38828967 PMCID: PMC11195339 DOI: 10.1530/eor-23-0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
Purpose This study sought to determine if the use of tranexamic acid (TXA) in preexisting thromboembolic risk patients undergoing total joint arthroplasty (TJA) was linked to an increased risk of death or postoperative complications. Methods We conducted a comprehensive search for studies up to May 2023 in PubMed, Web of Science, EMBASE, and the Cochrane Library. We included randomized clinical trials, cohort studies, and case-control studies examining the use of TXA during TJA surgeries on high-risk patients. The Cochrane Risk of Bias instrument was used to gauge the excellence of RCTs, while the MINORS index was implemented to evaluate cohort studies. We used mean difference (MD) and relative risk (RR) as effect size indices for continuous and binary data, respectively, along with 95% CIs. Results Our comprehensive study, incorporating data from 11 diverse studies involving 812 993 patients, conducted a meta-analysis demonstrating significant positive outcomes associated with TXA administration. The findings revealed substantial reductions in critical parameters, including overall blood loss (MD = -237.33; 95% CI (-425.44, -49.23)), transfusion rates (RR = 0.45; 95% CI (0.34, 0.60)), and 90-day unplanned readmission rates (RR = 0.86; 95% CI (0.76, 0.97)). Moreover, TXA administration exhibited a protective effect against adverse events, showing decreased risks of pulmonary embolism (RR = 0.73; 95% CI (0.61, 0.87)), myocardial infarction (RR = 0.47; 95% CI (0.40-0.56)), and stroke (RR = 0.73; 95% CI (0.59-0.90)). Importantly, no increased risk was observed for mortality (RR = 0.53; 95% CI (0.24, 1.13)), deep vein thrombosis (RR = 0.69; 95% CI (0.44, 1.09)), or any of the evaluated complications associated with TXA use. Conclusion The results of this study indicate that the use of TXA in TJA patients with preexisting thromboembolic risk does not exacerbate complications, including reducing mortality, deep vein thrombosis, and pulmonary embolism. Existing evidence strongly supports the potential benefits of TXA in TJA patients with thromboembolic risk, including lowering blood loss, transfusion, and readmission rates.
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Affiliation(s)
- Xiangji Dang
- Evidence-based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, P.R. China
- Department of Pharmaceutical, Lanzhou University Second Hospital, Lanzhou, Gansu province, P.R. China
| | - Mei Liu
- The First Clinical Medical School, Gansu University of Chinese Medicine, Gansu, P.R. China
| | - Qiang Yang
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, Gansu province, P.R. China
| | - Jin Jiang
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou, Gansu province, P.R. China
| | - Yan Liu
- Gansu High Throughput Screening and Creation Center for Health Products, School of Pharmacy, Lanzhou University, Lanzhou, P.R. China
| | - Hui Sun
- Cuiying Biomedical Research Center, Lanzhou University Second Hospital, Lanzhou, Gansu province, P.R. China
| | - Jinhui Tian
- Evidence-based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, P.R. China
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Lewis SR, Pritchard MW, Estcourt LJ, Stanworth SJ, Griffin XL. Interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews. Cochrane Database Syst Rev 2023; 6:CD013737. [PMID: 37294864 PMCID: PMC10249061 DOI: 10.1002/14651858.cd013737.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Following hip fracture, people sustain an acute blood loss caused by the injury and subsequent surgery. Because the majority of hip fractures occur in older adults, blood loss may be compounded by pre-existing anaemia. Allogenic blood transfusions (ABT) may be given before, during, and after surgery to correct chronic anaemia or acute blood loss. However, there is uncertainty about the benefit-risk ratio for ABT. This is a potentially scarce resource, with availability of blood products sometimes uncertain. Other strategies from Patient Blood Management may prevent or minimise blood loss and avoid administration of ABT. OBJECTIVES To summarise the evidence from Cochrane Reviews and other systematic reviews of randomised or quasi-randomised trials evaluating the effects of pharmacological and non-pharmacological interventions, administered perioperatively, on reducing blood loss, anaemia, and the need for ABT in adults undergoing hip fracture surgery. METHODS In January 2022, we searched the Cochrane Library, MEDLINE, Embase, and five other databases for systematic reviews of randomised controlled trials (RCTs) of interventions given to prevent or minimise blood loss, treat the effects of anaemia, and reduce the need for ABT, in adults undergoing hip fracture surgery. We searched for pharmacological interventions (fibrinogen, factor VIIa and factor XIII, desmopressin, antifibrinolytics, fibrin and non-fibrin sealants and glue, agents to reverse the effects of anticoagulants, erythropoiesis agents, iron, vitamin B12, and folate replacement therapy) and non-pharmacological interventions (surgical approaches to reduce or manage blood loss, intraoperative cell salvage and autologous blood transfusion, temperature management, and oxygen therapy). We used Cochrane methodology, and assessed the methodological quality of included reviews using AMSTAR 2. We assessed the degree of overlap of RCTs between reviews. Because overlap was very high, we used a hierarchical approach to select reviews from which to report data; we compared the findings of selected reviews with findings from the other reviews. Outcomes were: number of people requiring ABT, volume of transfused blood (measured as units of packed red blood cells (PRC)), postoperative delirium, adverse events, activities of daily living (ADL), health-related quality of life (HRQoL), and mortality. MAIN RESULTS We found 26 systematic reviews including 36 RCTs (3923 participants), which only evaluated tranexamic acid and iron. We found no reviews of other pharmacological interventions or any non-pharmacological interventions. Tranexamic acid (17 reviews, 29 eligible RCTs) We selected reviews with the most recent search date, and which included data for the most outcomes. The methodological quality of these reviews was low. However, the findings were largely consistent across reviews. One review included 24 RCTs, with participants who had internal fixation or arthroplasty for different types of hip fracture. Tranexamic acid was given intravenously or topically during the perioperative period. In this review, based on a control group risk of 451 people per 1000, 194 fewer people per 1000 probably require ABT after receiving tranexamic acid (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.46 to 0.68; 21 studies, 2148 participants; moderate-certainty evidence). We downgraded the certainty for possible publication bias. Review authors found that there was probably little or no difference in the risks of adverse events, reported as deep vein thrombosis (RR 1.16, 95% CI 0.74 to 1.81; 22 studies), pulmonary embolism (RR 1.01, 95% CI 0.36 to 2.86; 9 studies), myocardial infarction (RR 1.00, 95% CI 0.23 to 4.33; 8 studies), cerebrovascular accident (RR 1.45, 95% CI 0.56 to 3.70; 8 studies), or death (RR 1.01, 95% CI 0.70 to 1.46; 10 studies). We judged evidence from these outcomes to be moderate certainty, downgraded for imprecision. Another review, with a similarly broad inclusion criteria, included 10 studies, and found that tranexamic acid probably reduces the volume of transfused PRC (0.53 fewer units, 95% CI 0.27 to 0.80; 7 studies, 813 participants; moderate-certainty evidence). We downgraded the certainty because of unexplained high levels of statistical heterogeneity. No reviews reported outcomes of postoperative delirium, ADL, or HRQoL. Iron (9 reviews, 7 eligible RCTs) Whilst all reviews included studies in hip fracture populations, most also included other surgical populations. The most current, direct evidence was reported in two RCTs, with 403 participants with hip fracture; iron was given intravenously, starting preoperatively. This review did not include evidence for iron with erythropoietin. The methodological quality of this review was low. In this review, there was low-certainty evidence from two studies (403 participants) that there may be little or no difference according to whether intravenous iron was given in: the number of people who required ABT (RR 0.90, 95% CI 0.73 to 1.11), the volume of transfused blood (MD -0.07 units of PRC, 95% CI -0.31 to 0.17), infection (RR 0.99, 95% CI 0.55 to 1.80), or mortality within 30 days (RR 1.06, 95% CI 0.53 to 2.13). There may be little or no difference in delirium (25 events in the iron group compared to 26 events in control group; 1 study, 303 participants; low-certainty evidence). We are very unsure whether there was any difference in HRQoL, since it was reported without an effect estimate. The findings were largely consistent across reviews. We downgraded the evidence for imprecision, because studies included few participants, and the wide CIs indicated possible benefit and harm. No reviews reported outcomes of cognitive dysfunction, ADL, or HRQoL. AUTHORS' CONCLUSIONS Tranexamic acid probably reduces the need for ABT in adults undergoing hip fracture surgery, and there is probably little or no difference in adverse events. For iron, there may be little or no difference in overall clinical effects, but this finding is limited by evidence from only a few small studies. Reviews of these treatments did not adequately include patient-reported outcome measures (PROMS), and evidence for their effectiveness remains incomplete. We were unable to effectively explore the impact of timing and route of administration between reviews. A lack of systematic reviews for other types of pharmacological or any non-pharmacological interventions to reduce the need for ABT indicates a need for further evidence syntheses to explore this. Methodologically sound evidence syntheses should include PROMS within four months of surgery.
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Affiliation(s)
- Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Michael W Pritchard
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Simon J Stanworth
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and University of Oxford, Oxford, UK
| | - Xavier L Griffin
- Trauma & Orthopaedics Surgery Group, Blizard Institute, Queen Mary University of London, London, UK
- The Royal London Hospital Barts Health NHS Trust, London, UK
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Shu H, Huang Z, Bai X, Xia Z, Wang N, Fu X, Cheng X, Zhou B. The Application of Platelet-Rich Plasma for Patients Following Total Joint Replacement: A Meta-Analysis of Randomized Controlled Trials and Systematic Review. Front Surg 2022; 9:922637. [PMID: 35860197 PMCID: PMC9289244 DOI: 10.3389/fsurg.2022.922637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/13/2022] [Indexed: 12/04/2022] Open
Abstract
Background The clinical efficacy of platelet-rich plasma (PRP) in the treatment of total joint replacement (TJR) remains inconclusive. In this paper, systematic review and meta-analysis was adopted to assess the efficacy of using PRP for the treatment of TJR. Methods A comprehensive search of Medline, Embase, and Cochrane library databases for randomized controlled trial (RCT) articles recording data of PRP for TJR was conducted from inception to February 2022. Outcomes concerned were pain, range of motion (ROM), WOMAC score, length of hospital stay (LOS), hemoglobin (Hb) drop, total blood loss, wound healing rate, and wound infection. The methodological quality of the included RCTs was evaluated by using the Cochrane Risk of Bias Tool 2.0 (RoB 2.0). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was utilized to assess the level of evidence for the outcomes. Subgroup analysis was conducted according to the type of TJR. Results Ten RCTs were included in the meta-analysis. In the TKA subgroup, the available data demonstrated that there were significant differences in the outcomes of pain and Hb drop, while it was the opposite of ROM, WOMAC score, LOS, total blood loss, wound healing rate, and wound infection. In the THA subgroup, no significant differences could be seen between two groups in the outcomes of LOS and wound infection. However, the PRP group gained a higher wound healing rate in the THA subgroup. Conclusion The application of PRP did not reduce blood loss but improved the wound healing rate. However, more prospective and multicenter studies are warranted to confirm these results.
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Juraj M, Jaroslav V, Gažová A, Žufková V, Kyselovič J, Šteňo B. Evaluation of efficacy and safety of systemic and topical intra-articular administration of tranexamic acid in primary unilateral total hip arthroplasty. Medicine (Baltimore) 2021; 100:e26565. [PMID: 34190197 PMCID: PMC8257841 DOI: 10.1097/md.0000000000026565] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 06/11/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic agent used to reduce bleeding in major surgical procedures. This study evaluates the efficacy and safety of the systemic and topical intra-articular administration of TXA in total hip arthroplasty (THA). METHODS Patients (N = 123) scheduled for primary unilateral THA were divided into 3 treatment groups: control group; TXA, systemic, repeated 1 g bolus; TXA, topically intra-articularly, 2 g in 50 mL saline. Primary readouts used were intra- and postoperative bleeding, transfusion requirement, postoperative hemoglobin levels and complications. RESULTS Both systemic and topical intra-articular TXA administrations decreased bleeding and transfusion requirements. Topical intra-articular use of TXA led to the reduction in intraoperative and postoperative bleeding and affected hemoglobin levels compared with control. Systemic administration of TXA led to a significant reduction of postoperative bleeding and transfusion rate compared with control and was not different in efficacy and complication incidence when compared to topical administration of TXA. CONCLUSIONS The use of TXA to reduce blood loss and transfusion requirements in THA is an effective and safe concept in practice. The dose of 2 g TXA topically intra-articularly and a repeated bolus of 1 g TXA systematic led to lower intra- and postoperative bleeding and a significantly lower transfusion rate than the control group. Topical intra-articular TXA administration could be a reasonable alternative in high-risk patients.
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Affiliation(s)
- Masaryk Juraj
- Orthopedic Department of the University Hospital Trencin, Legionárska 28, 911 71 Trenčín
| | - Vidan Jaroslav
- Orthopedic Department of the University Hospital Trencin, Legionárska 28, 911 71 Trenčín
| | - Andrea Gažová
- Institute of Pharmacology and Clinical Pharmacology, Faculty of Medicine Comenius University
| | - Viera Žufková
- Department of Languages, Faculty of Pharmacy, Comenius University
| | - Ján Kyselovič
- V. Department of Internal Medicine, Faculty of Medicine Comenius University, Bratislava, Slovakia
| | - Boris Šteňo
- II. Department of Orthopedics and Traumatology, University Hospital and Faculty of Medicine, Comenius University
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McClatchy SG, Cline JT, Rider CM, Pharr ZK, Mihalko WM, Toy PC. Blood Management in Outpatient Total Hip Arthroplasty. Orthop Clin North Am 2021; 52:201-208. [PMID: 34053565 DOI: 10.1016/j.ocl.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Based on a series of 407 outpatient total hip arthroplasties performed by a single surgeon, a standardized protocol for blood loss management in outpatient arthroplasty was developed consisting of a presurgical hematocrit of greater than 36%, administration of tranexamic acid, prophylactic introduction of albumin, hypotensive epidural anesthesia, monopolar electrocautery, and bipolar sealer. This protocol uses techniques that alone are not novel but together create a standardized and reproducible pathway that when implemented can increase the safety of outpatient hip arthroplasty.
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Affiliation(s)
- Samuel Gray McClatchy
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA.
| | - Joseph T Cline
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Carson M Rider
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Zachary K Pharr
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - William M Mihalko
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Patrick C Toy
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
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Pekrul I, Schachtner T, Zwißler B, Möhnle P. [Tranexamic acid for bleeding prophylaxis in orthopedic surgery and trauma-standard or customized therapy?]. Anaesthesist 2021; 70:515-521. [PMID: 33620508 PMCID: PMC8190014 DOI: 10.1007/s00101-021-00928-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 11/23/2022]
Abstract
The use of tranexamic acid (TXA) is established in the treatment of bleeding, especially of bleeding due to hyperfibrinolysis. In recent years the prophylactic use of TXA in trauma and orthopedic surgery has increased leading to open questions regarding potentially associated risks and a possible classification as off label use. The available literature provides a sound basis for the recommendation that TXA can be used in these indications provided that an individual risk assessment is done in patients with increased risks for thromboembolic complications. Although the prophylactic use of TXA in orthopedic surgery and trauma is not explicitly listed in the product characteristics, it should not be regarded as an off label use.
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Affiliation(s)
- Isabell Pekrul
- Klinik für Anaesthesiologie, Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Universität München (LMU), Marchioninistr. 15, 81377, München, Deutschland
| | - Thomas Schachtner
- Anästhesie und Intensivmedizin, Schön Klinik München Harlaching, München, Deutschland
| | - Bernhard Zwißler
- Klinik für Anaesthesiologie, Universität München (LMU), München, Deutschland
| | - Patrick Möhnle
- Klinik für Anaesthesiologie, Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Universität München (LMU), Marchioninistr. 15, 81377, München, Deutschland.
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Tranexamic acid versus aminocapróic acid in multiple doses via the oral route for the reduction of postoperative bleeding in total primary hip arthroplasty: a prospective, randomized, double-blind, controlled study. Blood Coagul Fibrinolysis 2021; 32:132-139. [PMID: 33443925 DOI: 10.1097/mbc.0000000000001005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To compare the effects of oral ε-aminocaproic acid (EACA) as a hemostatic agent versus the use of oral tranexamic acid (TXA) administered in multiple doses pre and postsurgery in patients undergoing elective primary total hip arthroplasty (THA). We enrolled 102 patients that were randomly divided into two groups: received three oral doses of EACA (2000 mg per dose) or three oral doses of TXA (1300 mg per dose). The medication was given according to the following schedule: 2 h before surgery and 6 and 12 h after surgery. The variables analyzed to compare the effectiveness of the hemostatic agents were total blood loss, hidden blood loss, external blood loss, transfusion rate, intraoperative blood loss, decreases in hemoglobin and hematocrit values, surgical drainage output, visual analog scale, and surgical complications. There were no significant differences between any of the study variables for the group receiving oral TXA and the group receiving oral EACA (P > 0.05). Our study showed that the use of oral EACA was similar to its counterpart TXA regarding the evaluated parameters. TXA did not have superior blood conservation effects, safety profile, or differences in functional scales compared with EACA in THA. We consider the use of multiple oral doses of aminocaproic acid at the selected dose to be effective as a standard protocol to achieve less blood loss and a lower rate of transfusion and adverse events related to the medication in patients undergoing a THA.
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Tandogan RN, Polat M, Beyzadeoglu T, Karabulut E, Yildirim K, Kayaalp A. Topical co-delivery of platelet rich fibrin and tranexamic acid does not decrease blood loss in primary total knee arthroplasty compared to the standard of care: a prospective, randomized, controlled trial. Knee Surg Sports Traumatol Arthrosc 2021; 29:519-528. [PMID: 32170355 DOI: 10.1007/s00167-020-05938-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/03/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the efficacy of intra-operative co-administration of tranexamic acid (TA) and platelet rich fibrin (PRF) using a proprietary co-delivery system on the amount of blood loss, early functional outcomes and wound complications after primary total knee arthroplasty (TKA). The intervention was compared to the standard of care (combined intravenous & topical TA) in a prospective, randomized, blinded setting. METHODS 80 patients undergoing primary cemented TKA without tourniquet were prospectively randomized into control (combined intravenous and topical TA) and PRF (intra-venous TA and co-delivery of topical PRF and TA) groups after informed consent. Total blood loss, drainage blood loss, knee range of motion, VAS pain scores, length of stay and wound complications were analysed. Data collection was performed in a double blind manner on days 1, 3 and 21. RESULTS There was no statistically significant difference in drainage blood loss (550 ml vs. 525 ml, p = 0.643), calculated total blood loss on day 1 (401 ml vs. 407 ml, p = 0.722), day 3 (467 ml vs 471 ml, p = 0.471) and day 21 (265 ml vs. 219 ml, p = 0.082) between the PRF and control groups respectively. The PRF group had a small but statistically significant increase in median knee extension in the early post-operative period, however this difference evened out at 3 weeks. No significant difference could be demonstrated between the PRF and control groups in length of stay, VAS pain scores, narcotic usage, wound complications and knee flexion at all time points. CONCLUSIONS The topical co-delivery of PRF and TA does not significantly decrease blood loss in primary TKA compared to the standard of care. Slightly better active knee extension in the first 3 postoperative days can be achieved, however this benefit is not clinically relevant. LEVEL OF EVIDENCE I, Therapeutic study.
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Affiliation(s)
- Reha N Tandogan
- Ortoklinik and Cankaya Orthopedics, Cinnah caddesi 51/4, Cankaya, 06680, Ankara, Turkey.
| | - Metin Polat
- Ortoklinik and Cankaya Orthopedics, Cinnah caddesi 51/4, Cankaya, 06680, Ankara, Turkey
| | - Tahsin Beyzadeoglu
- Orthopaedics and Traumatology, Halic University and Beyzadeoglu Clinic, Bagdat Cad. No: 333 Erenkoy, 34738, Istanbul, Turkey
| | - Erdem Karabulut
- Department of Biostatistics, Hacettepe University, Sihhiye Campus, Ankara, Turkey
| | - Kerem Yildirim
- Orthopaedics and Traumatology, Istanbul Gelisim University and Beyzadeoglu Clinic, Bagdat Cad. No: 333 Erenkoy, 34738, Istanbul, Turkey
| | - Asim Kayaalp
- Ortoklinik and Cankaya Orthopedics, Cinnah caddesi 51/4, Cankaya, 06680, Ankara, Turkey
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Sun C, Zhang X, Chen L, Deng J, Ma Q, Cai X, Yang H. Comparison of oral versus intravenous tranexamic acid in total knee and hip arthroplasty: A GRADE analysis and meta-analysis. Medicine (Baltimore) 2020; 99:e22999. [PMID: 33126380 PMCID: PMC7598783 DOI: 10.1097/md.0000000000022999] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The efficacy and safety of oral tranexamic acid (TXA) remain controversial because of the small number of clinical studies. The aim of the present study was to compare the efficacy and safety of oral TXA with intravenous TXA in patients undergoing total hip arthroplasty and total knee arthroplasty in a systematic review and meta-analysis. METHODS We conducted a meta-analysis to identify randomized controlled trials (RCTs) involving oral and intravenous TXA in total hip arthroplasty and total knee arthroplasty up to December 2019 by searching databases including PubMed, Web of Science, Embase, the Cochrane Controlled Trials Register, the Cochrane Library China Biology Medicine, China National Knowledge Infrastructure, China Science and Technology Journal Database and Wanfang. The mean difference or standard mean difference was used to assess continuous outcomes such as hemoglobin (Hb) drop, total blood loss, drain blood loss, and length of hospital stay, with a 95% confidence interval. Relative risks with a 95% confidence interval were used to assess dichotomous outcomes such as transfusion rate and the incidence of deep venous thrombosis and calf muscular vein thrombosis. Review Manager was used for the meta-analysis. RESULTS Ten RCTs containing 1080 participants met the inclusion criteria. We found no significant differences in terms of the average Hb drop (P = .60), total blood loss (P = .60), transfusion rate (P = .99), drain blood loss (P = .91), length of hospital stay (P = .95), and the incidence of deep venous thrombosis (P = .55) and calf muscular vein thrombosis (P = .19) between oral and IV TXA. CONCLUSIONS Compared with the IV TXA, oral TXA has similar effects on reducing the Hb drop, total blood loss, transfusion rate, drain blood loss, and length of hospital stay without increasing the risk of calf muscular vein thrombosis and deep venous thrombosis. Furthermore, oral TXA is easy to access and administer, which decreases the workload of nurses and even delivers cost-saving benefits to the health care system. We thus conclude that oral TXA may be an optimal approach in total joint arthroplasty. However, more high-quality and multicenter RCTs are still needed to confirm our conclusions. REGISTRATION The current meta-analysis was registered on PROSPERO (International Prospective Register of Systematic Reviews), and the registration number was CRD42018111291.
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Affiliation(s)
| | - Xiaofei Zhang
- Department of Clinical Epidemiology and Biostatistics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Changping District, Beijing, China
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Zhang Y, Xiong K, Li R, Yang L. Postoperative outcomes after total hip arthroplasty in patients with Parkinson disease: A protocol of case control study. Medicine (Baltimore) 2020; 99:e20018. [PMID: 32384460 PMCID: PMC7220782 DOI: 10.1097/md.0000000000020018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Parkinson disease (PD) is a progressive neuromuscular disease associated with bradykinesia, tremor, and postural instability. We aimed to compare outcomes and complications of total hip arthroplasty (THA) between patients with PD and those without. METHODS A single institution retrospective cohort from 2000 to 2018 was reviewed. PD patients were matched 1:2 with non-PD control patients for age, gender, American Society of Anesthesiologists score, and body mass index using a propensity score matching procedure. The primary outcome measures were postoperative complications and revision between PD and cohort groups. Secondary outcome measures were Harris Hip Score, hip range of motion, patient satisfaction, and surgery time. Univariable and multivariable logistic regression were used to determine the relationship between PD and surgical outcomes in the matched cohort. RESULTS Using prospectively collated data, we identified 35 PD patients after primary THA. A control cohort of 70 primary THA patients was matched. CONCLUSION Our hypothesis was that PD would have adverse impact on complication rates, range of movement, or improvement in functional outcome after subsequent THA. TRIAL REGISTRATION This study protocol was registered in Research Registry (researchregistry5446).
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Affiliation(s)
| | | | | | - Li Yang
- Department of Ophthalmology, People's Hospital of Dujiangyan, Sichuan Province, China
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Xu Y, Sun S, Feng Q, Zhang G, Dong B, Wang X, Guo M. The efficiency and safety of oral tranexamic acid in total hip arthroplasty: A meta-analysis. Medicine (Baltimore) 2019; 98:e17796. [PMID: 31725622 PMCID: PMC6867752 DOI: 10.1097/md.0000000000017796] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Intravenous (IV), topical and combination of both application of tranexamic acid (TXA) can reduce blood loss, hemoglobin drop, and transfusion rate in patients following total hip arthroplasty (THA). Lately, published articles reported that oral TXA had as similar blood-saving as IV and topical TXA in THA. The purpose of this meta-analysis is to investigate the efficiency and safety of oral TXA in THA. METHODS We systematically searched articles about oral administration of TXA in THA from PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and the Chinese Wanfang database. STUDY ELIGIBILITY CRITERIA The outcomes were collected and analyzed by the Review Manager 5.3. RESULTS Nine RCTs and 1 CCT, containing 1305 patients, were ultimately included according to the inclusion criteria and exclusion criteria in the meta-analysis. The effectiveness of oral TXA was as similar as the IV or topical TXA in regard to hemoglobin drop (SMD = -0.14; 95% CI, [-0.28, 0.01]; P = .06), total blood loss (SMD = 0.01; 95% CI, [-0.13, 0.16]; P = .84), transfusion rate (OR = 0.76; 95% CI, [0.38, 1.55]; P = .37). Compared with single oral TXA or blank group, multiple oral TXA effectively reduced hemoglobin drop (SMD = -1.06; 95% CI, [-1.36, -0.77]; P < .05), total blood loss (SMD = -1.30; 95% CI, [-1.66, -0.94]; P < .05), transfusion rate (OR = 0.53; 95% CI, [0.29, 0.95]; P = .03). There were no significant difference in terms of length of stay and complication among all of enrolled studies. CONCLUSION Oral TXA has favorable effect of blood-saving and do not increase risk of complication in patients following THA. Oral TXA may have no effect in the length of stay. More high quality RCTs are necessary.
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Affiliation(s)
| | - Shaoting Sun
- Department of Nephrology, the People's Hospital of Cangzhou, Cangzhou, Hebei, China
| | | | | | - Bin Dong
- Department of Orthopedics Surgery
| | | | - Ming Guo
- Department of Orthopedics Surgery
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Farley KX, Anastasio AT, Premkumar A, Boden SD, Gottschalk MB, Bradbury TL. The Influence of Modifiable, Postoperative Patient Variables on the Length of Stay After Total Hip Arthroplasty. J Arthroplasty 2019; 34:901-906. [PMID: 30691932 DOI: 10.1016/j.arth.2018.12.041] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 12/25/2018] [Accepted: 12/31/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Many studies have examined strategies to reduce length of stay (LOS) after total hip arthroplasty (THA), but few have focused on modifiable patient-specific information in the acute postoperative period. This study investigates the determinants of LOS after THA, with a focus on potentially modifiable factors. METHODS A total of 1278 patients undergoing elective THA from 2012 to 2014 were extracted from our institutional data warehouse at our academic orthopedic specialty hospital. Data were collected on patient demographics, comorbidities, inpatient opioid use, hypotensive events, and abnormalities in laboratory values, all occurring on postoperative day 0 or 1. The main outcome was hospital LOS. Multivariate regression analysis was performed to identify independent risk factors for LOS over 3 days. RESULTS The average age of patients undergoing primary total hip arthroplasty in our cohort was 62.3 (standard deviation 10.7) years, and 52.7% were women. Eighty-one (6.3%) of 1278 patients had a LOS more than 3 days. Multivariate regression analysis demonstrated several statistically significant nonmodifiable and modifiable risk factors that influence LOS after THA. Nonmodifiable risk factors included nonwhite race (odds ratio [OR], 1.497), single marital status (OR, 1.724), increasing age (OR, 1.330), and increasing Charlson Comorbidity Index (OR, 1.411). Potentially modifiable risk factors included every 10 mg oral morphine equivalent consumption (1.069), every 5 postoperative hypotensive events (OR, 1.232), low hemoglobin (OR, 3.265), high glucose levels (OR, 1.887), and a high creatinine (OR, 2.874). CONCLUSION This study identifies potentially modifiable factors that are associated with increased LOS after THA, including postoperative opioid use and hypotensive events. Efforts to control narcotic use and initiatives aimed to reduce early postoperative hypotension could aid in reducing LOS. Furthermore, attempts should be made to correct postoperative anemia, high glucose levels, and a high creatinine level when possible.
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Affiliation(s)
- Kevin X Farley
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Albert T Anastasio
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Ajay Premkumar
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Scott D Boden
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Michael B Gottschalk
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Thomas L Bradbury
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
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