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Trentino KM, Lloyd A, Swain SG, Trentino L, Gross I. Data and Metrics for Patient Blood Management: A Narrative Review and Practical Guide. Anesth Analg 2023:00000539-990000000-00615. [PMID: 37553085 DOI: 10.1213/ane.0000000000006557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
Data collection, analysis, and reporting are fundamental for a successful hospital-based patient blood management program; however, very little has been published on the topic. Our aim was to synthesize evidence from a literature review to provide a detailed, practical list of outcome metrics, and the required data collection(s) to inform implementation. Ovid MEDLINE and PubMed were searched for any full-text original research articles published from inception to the year 2020. We included any studies reporting the implementation of interventions or programs study authors defined as "patient blood management" and extracted information on data collected and metrics reported. We included 45 studies describing the implementation of a patient blood management program and/or strategies. The outcomes reported by these studies were grouped into 1 of 36 metrics. We compiled a list of 65 relevant data elements to collect, and their potential source hospital information systems: patient administration, laboratory, transfusion/blood bank, operating room, pharmacy, emergency department, and intensive care unit. We further categorized patient blood management data systems into basic, intermediate, and advanced based on the combination of different information systems sourced. The results of this review can be used to inform patient blood management programs in planning what data collection(s) are needed, where these data can be sourced from, and how they can be analyzed.
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Affiliation(s)
- Kevin M Trentino
- From the Data and Digital Innovation, East Metropolitan Health Service, Perth, Western Australia, Australia
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Adam Lloyd
- From the Data and Digital Innovation, East Metropolitan Health Service, Perth, Western Australia, Australia
| | | | - Laura Trentino
- Data Analysis and Research, Datum Statista, Perth, Western Australia, Australia
| | - Irwin Gross
- Department of Medicine, Emeritus, Northern Light Eastern Maine Medical Center, Bangor, Maine
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Lee WS, Lee HD, Kim YB, Yoon TH, Koh YY, Lee Y. Longer Operative Time and the Use of Anticoagulants Are Associated With Increased Blood Loss in Elderly Patients Undergoing Arthroscopic Rotator Cuff Repair. Arthrosc Sports Med Rehabil 2023; 5:100743. [PMID: 37645391 PMCID: PMC10461132 DOI: 10.1016/j.asmr.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/03/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose To study the effects of rotator cuff tear size, operation time, and the use of anticoagulant on blood loss in elderly patients undergoing arthroscopic rotator cuff surgery. Methods Patients aged older than 65 years who underwent arthroscopic rotator cuff repair with subacromial decompression at our hospital from January 2015 to December 2021 were identified. We measured hemoglobin levels preoperatively, postoperatively, and 7 days after surgery. First, subjects were divided according to the operation time (group I, <90 minutes; group II, <120 minutes; group III <150 minutes; and group IV, >150 minutes). Second, we classified the subjects by the size of the rotator cuff tear (group A, <3 cm; group B, <5 cm; and group C, >5 cm). Lastly, we categorized the subjects into 2 groups according to the use of anticoagulant medication. Results A total of 566 patients were included. The mean hemoglobin (Hgb) levels were 13.8 ± 1.4 g/dL preoperatively, 13.2 ± 1.4 g/dL postoperatively, and 12.8 ± 1.3 g/dL 7 days after surgery, and the differences among them were statistically significant (P < .001). The Hgb level changes 7 days after surgery showed a significant decrease in the group with a longer operation time, and the Hgb loss increased from group 1 to group 4 (P < .001). They did not show any difference in the Hgb levels among the groups according to the size of a cuff tear preoperatively, postoperatively, and 7 days after surgery. The subjects with anticoagulant use showed more decrease in Hgb levels between immediately after the surgery and 7 days after the surgery (P = .031). Still, both groups did not show a statistical difference in the Hgb level 7 days after surgery (P = .115). Conclusions In this study, blood loss after arthroscopic rotator cuff repair in elderly patients was greater than expected. Bleeding increased in elderly patients who had longer surgical times or were taking anticoagulant medications after surgery. Tear size was not associated with a decrease in Hgb levels. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
- Woo-seung Lee
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, Seoul, South Korea
| | - Hee Dong Lee
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, Seoul, South Korea
| | - Youngbae B. Kim
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, Seoul, South Korea
| | - Tae-Hyuck Yoon
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, Seoul, South Korea
| | - Yeong-Yoon Koh
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, Seoul, South Korea
| | - Young Lee
- Veterans Medical Research Institute, Veterans Health Service Medical Center, Seoul, South Korea
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Burbul M, Tomaszewski D, Rogalska A, Gawroński K, Literacki S, Waśko M. Thrombotic activation before and after total hip arthroplasty. A prospective cohort study. BMC Musculoskelet Disord 2021; 22:691. [PMID: 34389001 PMCID: PMC8364023 DOI: 10.1186/s12891-021-04566-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 06/09/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) causes acute blood loss. It may lead to a deficiency in coagulation factors, which, in turn, may lead to increased bleeding during the postoperative period. METHODS Thirty patients (18 women) with a mean age of 67 years (range: 63-72 years) participated in this prospective diagnostic study. THA was performed without tranexamic acid administration in the perioperative period. Activities of clotting factors II, VIII, X, and fibrinogen concentration were evaluated before surgery, 6 hours after the procedure, 2, 4, and 6 days after the operation. All laboratory tests were performed using ACL TOP 500 CTS analyzer. RESULTS No thromboembolic complications were noted during hospitalization. Mean fibrinogen concentration was 366 mg/dL before surgery, which decreased to 311 mg/dL 6 hours after the operation and peaked at 827 mg/dL on the 4th day after the procedure. Activities of factors II and X decreased on the second and fourth days after surgery. Although the activity of factor VIII decreased after the procedure, it remained within the normal range. Increased baseline fibrinogen concentrations were observed in 6 out of 30 (20%) patients. Mean blood loss was 1332 mL (range, 183-2479 mL) and did not correlate with changes in clotting factor activities. CONCLUSIONS In patients undergoing THA, fibrinogen acts as an acute-phase protein. Activities of clotting factors II and X normalize within 6 days, and although the activity of factor VIII decreases, it remains within the normal range. TRIAL REGISTRATION The study was pre-registered May 1st, 2020 on ClinicalTrials.gov.
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Affiliation(s)
- Marta Burbul
- Department of Traumatology and Orthopaedics, Military Institute of Medicine, Warsaw, Poland
| | - Dariusz Tomaszewski
- Department of Anesthesiology and Intensive Therapy, Military Institute of Medicine, Warsaw, Poland
| | - Anna Rogalska
- Department of Health Economics and Health Management, School of Health Sciences in Bytom, Medical University of Silesia in Katowice, Bytom, Poland
| | | | - Sławomir Literacki
- Department of Laboratory Diagnostics, Military Institute of Medicine, Warsaw, Poland
| | - Marcin Waśko
- Department of Radiology and Imaging, The Medical Center of Postgraduate Education, Warsaw, Poland
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Pinsornsak P, Phunphakchit J, Boontanapibul K. Efficacy and Systemic Absorption of Peri-articular Versus Intra-articular Administration of Tranexamic Acid in Total Knee Arthroplasty: A Prospective Randomized Controlled Trial. Arthroplast Today 2021; 11:1-5. [PMID: 34401422 PMCID: PMC8358094 DOI: 10.1016/j.artd.2021.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/14/2021] [Accepted: 06/14/2021] [Indexed: 11/17/2022] Open
Abstract
Background Tranexamic acid (TXA) is widely accepted as an effective method for reducing blood loss after total knee arthroplasty (TKA). As different routes of local TXA administration have been proposed to minimize systemic complications, we aimed to investigate the effectiveness and systemic absorption of peri-articular (PA) and intra-articular (IA) administration of TXA after primary TKA. Methods In a randomized controlled trial of patients scheduled for unilateral primary TKA, 108 were assigned to receive PA-TXA (15 mg/kg), IA-TXA (2 g), or no TXA injection. We assessed total blood loss, blood transfusion rate, and hemoglobin level changes 48 hours after surgery. Postoperative serum TXA levels, complications, and clinical symptoms of venous thromboembolism events were also evaluated. Results Total blood loss, hemoglobin level decreases, and blood transfusion rates in both TXA groups were significantly lower than those in the control group (P < .05), without significant differences between PA and IA groups 48 hours after surgery. Serum TXA levels in the IA group were significantly higher than those in the PA cohort at 2 hours (28.2 mg/L vs 15.6 mg/L, P < .01) and 24 hours (4.4 mg/L vs 1.7 mg/L, P < .01) postoperatively. No wound complications were found in both TXA groups, but 14% of the control group developed subcutaneous ecchymoses. No evidence of venous thromboembolism events was reported. Conclusions PA-TXA is an excellent alternative route of local TXA injection to decrease postoperative blood loss after TKA. PA-TXA demonstrated lower levels of postoperative serum TXA, which may be beneficial for high-risk patients.
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Affiliation(s)
- Piya Pinsornsak
- Department of Orthopedics, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Jakkarin Phunphakchit
- Department of Orthopedics, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Krit Boontanapibul
- Department of Orthopedics, Chulabhorn International College of Medicine, Thammasat University, Klong Luang, Pathum Thani, Thailand
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Zhang S, Wang F, Wang C, Chu P, Shi L, Xue Q. Are The Applications of Tranexamic Acid in Reverse Hybrid Total Knee Arthroplasty (TKA) The Same as Those in Fully Cemented TKA?: A Randomized Controlled Trial. Adv Ther 2021; 38:2542-2557. [PMID: 33830462 DOI: 10.1007/s12325-021-01719-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Traditional fully cemented prosthesis for total knee arthroplasty (TKA) has many disadvantages. Current studies have shown that the effects of mixed fixation TKA are the same as or even better than those of fully cemented TKA. We aimed to compare the total blood loss (TBL) in the two fixation types of TKA and the hemostatic effects of different doses of tranexamic acid (TXA) for reverse hybrid TKA. METHODS From September 2018 to November 2020, 233 patients with knee osteoarthritis undergoing unilateral TKA were randomly divided into four groups: groups 1 and 2: fully cemented TKA + intra-articular injection (IAI) of either 1 g TXA (n = 54) or 2 g TXA (n = 60); groups 3 and 4: reverse hybrid TKA + IAI of either 1 g TXA (n = 56) or 2 g TXA (n = 63). All patients were administered intravenous drip of TXA (20 mg/kg) as the basic drug. Perioperative and follow-up data of all patients were compared. RESULTS The TBL in groups 1, 2, and 3 was higher than that in group 4 (P < 0.0001). The TBL in group 1 was significantly less than that in group 3 (P < 0.05). Although there was no significant difference in blood transfusion demand among the four groups (P > 0.05), the number of anemic patients who did not meet the standard of blood transfusion in group 4 decreased significantly (P < 0.0001). There was no significant difference in pain, function or thrombotic complications among all patients. CONCLUSION The TBL in reverse hybrid TKA is larger than in fully cemented TKA. For reverse hybrid TKA, the hemostatic effect of TXA with 2 g of IAI was significantly better than with 1 g. Although this method does not reduce the need for blood transfusion, it can significantly reduce the incidence of postoperative anemia.
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Affiliation(s)
- Shenqi Zhang
- Department of Orthopedics, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
- Department of Joint and Sports Medicine, Zaozhuang Municipal Hospital Affiliated to Jining Medical University, Shandong, 277100, China
| | - Fengyan Wang
- Department of Joint and Sports Medicine, Zaozhuang Municipal Hospital Affiliated to Jining Medical University, Shandong, 277100, China
| | - Chengbin Wang
- Department of Joint and Sports Medicine, Zaozhuang Municipal Hospital Affiliated to Jining Medical University, Shandong, 277100, China
| | - Pengfei Chu
- Department of Orthopedics, Weishan People's Hospital, Shandong, 277600, China
| | - Lei Shi
- Department of Orthopedics, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Qingyun Xue
- Department of Orthopedics, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China.
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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Yapa S, Lockwood C, Kuster M. Effectiveness of administering tranexamic acid to high-risk hip and knee arthroplasty patients: a systematic review protocol. JBI Evid Synth 2020; 18:1801-1807. [PMID: 32898374 DOI: 10.11124/jbisrir-d-19-00145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review is to assess the safety and effectiveness in administering tranexamic acid in high-risk hip and knee arthroplasty patients. INTRODUCTION Arthroplasty surgery is associated with a significant amount of perioperative blood loss. Tranexamic acid is an antifibrinolytic used to counteract blood loss. Although various studies have demonstrated the effectiveness of tranexamic acid without significant adverse effects, a majority of these studies have excluded high-risk patients. Due to this selection bias there is a lack of clear evidence of the safety of administering tranexamic acid in high-risk patients. INCLUSION CRITERIA This review will consider studies that included high-risk patients aged >18 years who had previous myocardial infarction including cardiac stents, deep vein thrombosis and/or pulmonary embolism, transient ischemic attacks and/or stroke and clotting disorders. No exclusions will be made for the dosing route of tranexamic acid. The outcomes measured will be 1) thromboembolic complications of deep vein thrombosis, pulmonary embolism, transient ischemic attacks, stroke, myocardial infarction and death; 2) requirements of blood transfusion and 3) the amount of blood loss. METHODS A search will be conducted in PubMed, Embase, Scopus and Web of Science databases with the results being reported in a PRISMA flow diagram. Selected studies will be critically appraised by two independent reviewers for methodological quality. Study and outcome quality will be reported using the GRADE approach. Data will be extracted using a standardized data extraction tool. Studies will, where possible, be pooled in statistical meta-analysis. Effect sizes will be expressed as either odds ratios (for dichotomous data) or standardized mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis.
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Affiliation(s)
- Shanil Yapa
- 1JBI, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia 2Hollywood Hospital, Department of Orthopaedics, Monash Ave, Perth, Australia
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Hirose H, Ogawa H, Matsumoto K, Akiyama H. Periarticular injection of tranexamic acid promotes early recovery of the range of knee motion after total knee arthroplasty. J Orthop Surg (Hong Kong) 2020; 27:2309499019864693. [PMID: 31359848 DOI: 10.1177/2309499019864693] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Tranexamic acid (TXA) is a commonly used compound that reduces postoperative blood loss. Periarticular injection of TXA is a recently reported procedure with some advantages such as cost-effectiveness and the ease of performance over an intravenous or topical administration. However, its association with functional recovery remains unclear. This study aimed to examine the effect of periarticular injection of TXA on early postoperative recovery of knee functionality after total knee arthroplasty (TKA). METHODS Eighty-four patients who underwent primary unilateral TKA from February 2013 to August 2016 were classified into two groups based on whether they received TXA injection (44 cases each in the TXA and control groups). Patients in the TXA group received periarticular injection of TXA (1000 mg) just prior to incision closure. Ten-meter walk test (s), pain visual analog scale, knee extension muscle force (N), range of motion (ROM) (maximum flexion angle, maximum extension angle, and motion arc), and blood loss (mL) were assessed. RESULTS The maximum flexion angle and maximal extension angle on postoperative day (POD) 4, POD7, POD10, and POD14 in the TXA group were significantly larger than those in the control group. The postoperative drained blood in the TXA group was significantly less than that of the control group (543.9 ± 464.3 mL and 814.9 ± 481.4 mL, respectively, p < 0.05). No significant difference was observed in the other parameters at any time point. CONCLUSION Periarticular injection of TXA significantly promotes early recovery of knee ROM after TKA. Level of Evidence: Level IV, therapeutic case series.
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Affiliation(s)
- Hitoshi Hirose
- 1 Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hiroyasu Ogawa
- 1 Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan.,2 Department of Advanced Joint Reconstructive Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazu Matsumoto
- 1 Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Haruhiko Akiyama
- 1 Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
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Gianakos AL, Hurley ET, Haring RS, Yoon RS, Liporace FA. Reduction of Blood Loss by Tranexamic Acid Following Total Hip and Knee Arthroplasty: A Meta-Analysis. JBJS Rev 2019; 6:e1. [PMID: 29738409 DOI: 10.2106/jbjs.rvw.17.00103] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND This study involved a meta-analysis of 36 published studies to examine the efficacy of intravenous (IV) and intra-articular (IA) tranexamic acid (TXA) in reducing blood loss, drain output, thromboembolic complications, and hospital stay following total hip and total knee arthroplasty. This study also evaluated whether treatment with a combination of both IA and IV TXA has an effect on these outcomes. Lastly, this study attempted to analyze the method and technique of TXA administration in order to establish a best practice for its use in reducing overall blood loss in arthroplasty procedures. METHODS MEDLINE, Embase, and the Cochrane Library database were screened. Studies comparing IV TXA with IA TXA or with combined IV and IA TXA were included. Data including total blood loss, drain output, thromboembolic complications, and hospital stay, where available, were analyzed using meta-analysis with fixed effects. Results are presented as the standardized mean difference (SMD), and meta-regression was employed to explore plausible demographic contributions to heterogeneity. RESULTS Twenty-eight randomized controlled trials, 3 prospective cohort studies, and 5 retrospective cohort studies with 5,499 patients were included in this review. IA administration during total knee arthroplasty showed a significant advantage in terms of total blood loss (SMD = -0.14, 95% confidence interval [CI] = -0.027 to -0.02, I = 78.2%) and drain output (SMD = -0.30, 95% CI = -0.43 to -0.18). There was no significant difference between IV and IA administration in total hip arthroplasty. Combined IA plus IV TXA was associated with a significant reduction in blood loss versus IV TXA alone in both total knee arthroplasty and total hip arthroplasty. IV TXA dosing varied, as 14 (39%) of the studies used a weight-based approach while 22 (61%) used a standard dose. Twenty-seven (96%) of 28 studies of IA administration used standard dosing while 1 study followed a weight-based protocol. There was no difference in symptomatic thromboembolic complications, with overall rates in total knee arthroplasty and total hip arthroplasty of 1.0% and 1.0% for IV administration and 1.1% and 0.3% for IA administration, respectively. There was no difference in length of hospital stay for IV versus IA TXA administration. CONCLUSIONS IA TXA, either alone or in conjunction with IV TXA, reduces total blood loss and/or drain output in total knee arthroplasty and total hip arthroplasty. Optimal methodology remains to be clarified; however, there are substantial economic benefits of utilizing either IV or IA TXA, with greater cost benefits when using IA TXA. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Arianna L Gianakos
- Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, RWJBarnabas Health - Jersey City Medical Center, Jersey City, New Jersey
| | | | - R Sterling Haring
- Johns Hopkins Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Richard S Yoon
- Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, RWJBarnabas Health - Jersey City Medical Center, Jersey City, New Jersey
| | - Frank A Liporace
- Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, RWJBarnabas Health - Jersey City Medical Center, Jersey City, New Jersey
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Zhang S, Wang C, Shi L, Xue Q. Multi-route applications of tranexamic acid to reduce blood loss after total knee arthroplasty: a randomized controlled trial. Medicine (Baltimore) 2019; 98:e16570. [PMID: 31348286 PMCID: PMC6709093 DOI: 10.1097/md.0000000000016570] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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 Perioperative bleeding during total knee arthroplasty (TKA) is an ongoing problem for surgeons. Intravenous or topical application of tranexamic acid (TXA) can effectively stop bleeding, but there is still no uniform standard for the best method of administration and dose. METHODS From October 2016 to September 2018, 218 patients with unilateral primary knee osteoarthritis requiring knee replacement were enrolled and randomly divided into four groups. Group 1 (n = 55) received intra-articular injection (IAI) of TXA and peri-articular injection (PAI) of placebo, group 2 (n = 55) received IAI of placebo and PAI of TXA, group 3 (n = 51) received IAI of TXA and PAI of TXA, and group 4 (n = 57) received double placebo (IAI of placebo and PAI of placebo). The demographic characteristics, surgical indices, hematological indices, wound healing history, and thromboembolic events were investigated. RESULTS Eight patients were lost to follow-up and 210 patients were included in the analysis. The median TBLs in patients who received IAI of TXA and PAI of placebo and those who received IAI of placebo and PAI of TXA were 470.81 ml and 481.54 ml, respectively. These TBL levels were significantly higher compared to those in patients who received IAI of TXA and PAI of TXA (359.18 ml, P ≤ .001), but significantly lower compared to those in patients who received the double placebo (522.71 ml, P ≤ .001). Compared to other groups, more patients in the double placebo group needed a blood transfusion (P = .013). In the short-term, the double placebo group had higher VAS pain scores and less ROM after surgery (P = .011 and P = .001, respectively). In the long-term (6-month follow-up), there were no significant differences in ROM, VAS, DVT, PE, or wound-related complications. CONCLUSION The combined use of IAI and PAI of TXA can significantly reduce the TBL and the need for blood transfusion without delaying wound healing or increasing the risk of DVT and PE. In the short-term after surgery, this combined method reduces the pain VAS scores and improves the ROM; however, there are no long-term effects on VAS and ROM.
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Affiliation(s)
- Shenqi Zhang
- Department of Orthopedics, Beijing Hospital ,National Center of Gerontology, PR China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing
- The Department of Joint and Sports Medicine, Zaozhuang Municipal Hospital, Shandong, China
| | - Chengbin Wang
- The Department of Joint and Sports Medicine, Zaozhuang Municipal Hospital, Shandong, China
| | - Lei Shi
- Department of Orthopedics, Beijing Hospital ,National Center of Gerontology, PR China
| | - Qingyun Xue
- Department of Orthopedics, Beijing Hospital ,National Center of Gerontology, PR China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing
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Zhou L, Ma J, Bao J. Effect of pharmacist intervention on blood conservation therapy in total knee arthroplasty: A retrospective, observational study. Basic Clin Pharmacol Toxicol 2018; 124:681-690. [PMID: 30472799 DOI: 10.1111/bcpt.13181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 11/20/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is associated with blood loss and an increased risk of transfusion. Guidelines for antifibrinolytic drug tranexamic acid (TXA) treatment in TKA patients are available. We evaluated the effects of anticoagulant pharmacist intervention on perioperative blood conservation treatment in TKA patients. METHODS In a retrospective, observational experimental study, patients admitted for TKA were allocated into the control or pharmacist intervention group. In the intervention phase, multiple interventions of TXA treatment based on guidelines were implemented. The primary endpoint was blood loss. Other outcome included postoperative haemoglobin and haematocrit levels, allogeneic blood transfusion, cost savings and safety. RESULTS A total of 177 patients were included (88 and 89 in the control and intervention group, respectively). In the intervention group, 24.72% orders of TXA dosage, 20.22% orders of drug choice, 26.97% orders of TXA timing and 30.34% orders of TXA administration manner were adjusted. Eighty-nine (100%) patients received blood conservation therapy compared with 21 (23.86%) patients in the control group (P < 0.001). Total blood loss was 1133.31 ± 627.08 mL in the control group compared with 604.34 ± 459.09 mL in the intervention group (P < 0.001). Postoperative drops in haemoglobin and haematocrit in the control group were greater than in the intervention group (P < 0.001). The rate of allogeneic blood transfusion was 40.91% in the control group compared with 21.35% in the intervention group (P = 0.01). Pharmacist intervention was conducted to cost savings resulting from reduced transfusion, but with comparable safety profile. CONCLUSIONS Anticoagulant pharmacist intervention on blood conservation treatment of TKA patients leads to favourable clinical and economic outcome.
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Affiliation(s)
- Ling Zhou
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, China
| | - Jingjing Ma
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, China
| | - Jianan Bao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, China
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Xiong H, Liu Y, Zeng Y, Wu Y, Shen B. The efficacy and safety of combined administration of intravenous and topical tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 2018; 19:321. [PMID: 30193586 PMCID: PMC6129000 DOI: 10.1186/s12891-018-2181-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 07/10/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The combined administration of intravenous (IV) and topical tranexamic acid (TXA) in primary total knee (TKA) knee remains controversial. The purpose of this meta-analysis was to assess the efficacy and safety of combined administration of IV and topical TXA in primary TKA. METHODS PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, Google Search Engine and China National Knowledge Infrastructure databases were searched for randomized controlled trials (RCTs) were comparing the combined administration of IV and topical TXA following primary TKA. The primary outcomes were total blood loss, maximum hemoglobin drop, and deep venous thrombosis (DVT) and/or pulmonary embolism (PE). The second outcomes were drainage volume and transfusion requirements. Data were analyzed using RevMan 5.3. RESULTS A total of 6 RCTs involving 701 patients were included in the meta-analysis. The combined group provided lower total blood loss (MD - 156.34 mL, 95% CI, - 241.51 to - 71.18; P = 0.0003), drainage volume (MD - 43.54 mL, 95% CI, - 67.59 to - 19.48; P = 0.0004), maximum hemoglobin drop (MD - 0.56 g/dl, 95% CI, - 0.93 to - 0.19; P = 0.003) than IV TXA alone. No significant difference were found in terms of transfusion requirements (RR 0.48, 95% CI, 0.16 to 1.44; P = 0.19), DVT (RR 1.01, 95% CI, 0.14 to 7.12; P = 0.99) and PE (RR 0.33, 95% CI, 0.01 to 7.91; P = 0.49) between the two group. Subgroup analyses shows that the combined group was less total blood loss in non-tourniquet (P = 0.0008), topical TXA dose > 1.5 g (P < 0.00001) and number of IV TXA ≥ 2 doses (P = 0.005) of TXA compared with the IV group alone. CONCLUSIONS The available evidence indicates combined group were associated with lower total blood loss, drainage volume, and maximum hemoglobin drop. A similar transfusion requirement was found in both groups. Subgroup analyses demonstrates that total blood loss was less in patients with non-tourniquet, topical TXA dose > 1.5 g and number of IV TXA ≥ 2 doses of TXA. There was no increase the rates of DVT and PE.
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Affiliation(s)
- Huazhang Xiong
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China.,Department of Orthopedic Surgery, The First Affiliated Hospital of Zunyi Medical College, Zunyi, 563003, Guizhou Province, China
| | - Yi Liu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zunyi Medical College, Zunyi, 563003, Guizhou Province, China
| | - Yi Zeng
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China.
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12
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Han YH, Huang HT, Pan JK, Zeng LF, Liang GH, Liang HD, Yang WY, Guo D, Liu J. Is the combined application of both drain-clamping and tranexamic acid superior to the single use of either application in patients with total-knee arthroplasty?: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97:e11573. [PMID: 30200059 PMCID: PMC6133556 DOI: 10.1097/md.0000000000011573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 06/28/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To compare the efficacy and safety of the combined application of both drain-clamping and tranexamic acid (TXA) versus the single use of either application in patients with total-knee arthroplasty (TKA). METHODS Databases (EMBASE, PubMed, Cochrane Library, Web of Sciences, the Google database, and the Ovid database) were searched from their inception through April 2018 for randomized controlled trials (RCTs) comparing the combined application of both drain-clamping and TXA versus single use of either application in patients with TKA. The Cochrane risk of bias (ROB) tool was used to assess the methodologic quality. The primary outcomes were blood loss in drainage, total blood loss, transfusion rate, and hemoglobin decline. The secondary outcomes were postoperative complications, the Knee Society Score (KSS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. The statistical analysis was performed with RevMan 5.3.5 software. RESULTS A total of five RCTs (479 participants) were included in our meta-analysis. The present meta-analysis indicated that significant differences existed in the total blood loss (mean difference [MD] = -145.86, 95% confidence interval [CI]: -228.64 to -63.08, P = .0006), blood loss in drainage (MD = -169.06, 95% CI: -248.56 to -89.57, P < .0001), hemoglobin decline (MD = -0.66, 95% CI: -1.00 to -0.33, P = .0001), and transfusion rate (MD = 0.44, 95% CI: 0.26-0.75, P = .002) between the groups. However, regarding postoperative complications, no significant differences were found between the 2 groups in the KSS and the WOMAC score (P > .05). CONCLUSION Combined application of both drain-clamping and TXA was associated with significant reductions in blood loss in drainage, total blood loss, hemoglobin decline, and the need for transfusion. However, high-quality, well-designed RCTs with long-term follow-up are still required.
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Affiliation(s)
- Yan-hong Han
- Second School of Clinical Medicine, Guangzhou University of Chinese Medicine
| | - He-tao Huang
- Second School of Clinical Medicine, Guangzhou University of Chinese Medicine
| | - Jian-ke Pan
- Department of Orthopaedics, Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine)
| | - Ling-feng Zeng
- Department of Orthopaedics, Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine)
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Gui-hong Liang
- Department of Orthopaedics, Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine)
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Hao-dong Liang
- Second School of Clinical Medicine, Guangzhou University of Chinese Medicine
| | - Wei-yi Yang
- Department of Orthopaedics, Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine)
| | - Da Guo
- Department of Orthopaedics, Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine)
| | - Jun Liu
- Department of Orthopaedics, Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine)
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
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13
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Mistry JB, Gwam CU, Naziri Q, Pivec R, Abraham R, Mont MA, Delanois RE. Are Allogeneic Transfusions Decreasing in Total Knee Arthroplasty Patients? National Inpatient Sample 2009-2013. J Arthroplasty 2018; 33:1705-1712. [PMID: 29352682 DOI: 10.1016/j.arth.2017.12.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 11/23/2017] [Accepted: 12/13/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Allogeneic transfusions are commonly used for substantial blood loss in total knee arthroplasty (TKA), but have been associated with adverse effects and increased costs. The purpose of this study is to provide a detailed description of (1) trends of allogeneic blood transfusion; (2) risk factors and adverse events; and (3) discharge disposition, length-of-stay (LOS), and cost/charge analysis for primary TKA patients who received an allogeneic blood transfusion from 2009-2013. METHODS A cohort of 3,217,056 primary TKA patients was identified from the National Inpatient Sample database from 2009-2013. Demographic, clinical, economic, and discharge data were analyzed for patients who received allogeneic blood products, and for those who did not receive any type of blood transfusion. Other parameters analyzed include risk factors, adverse events, discharge disposition, and costs/charges. RESULTS There was a significant decline in use of allogeneic transfusion from 2009-2013 incidence (13.9%-7.3%; P < .001). All comorbidities examined were associated with significantly increased risk of receiving allogeneic transfusion with exception of patients with AIDS, metastatic cancer, and peptic ulcer disease. Allogeneic transfusion was associated with worse outcomes during hospitalization. Patients also had a greater likelihood of discharge to short-term care, greater LOS, and greater median costs/charges. Among TKA patients who received an allogeneic transfusion, costs varied based on hospital ownership and characteristics, primary-payer, region, and bed-size. CONCLUSION Given the poor outcomes and higher costs associated with allogeneic transfusions, efforts must be undertaken to minimize this risky practice. With the projected increase in demand for TKAs, orthopedists must understand effective blood management strategies.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Arthroplasty, Replacement, Knee/trends
- Blood Loss, Surgical
- Blood Transfusion/economics
- Blood Transfusion/statistics & numerical data
- Blood Transfusion/trends
- Comorbidity
- Databases, Factual
- Female
- Hospitalization
- Hospitals
- Humans
- Length of Stay/statistics & numerical data
- Male
- Middle Aged
- Patient Discharge
- Risk Factors
- Transplantation, Homologous/economics
- Transplantation, Homologous/statistics & numerical data
- Transplantation, Homologous/trends
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Affiliation(s)
- Jaydev B Mistry
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Qais Naziri
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Robert Pivec
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Roby Abraham
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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14
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Lu Q, Peng H, Zhou G, Yin D. Perioperative Blood Management Strategies for Total Knee Arthroplasty. Orthop Surg 2018; 10:8-16. [PMID: 29424017 PMCID: PMC6594499 DOI: 10.1111/os.12361] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 11/24/2017] [Indexed: 01/28/2023] Open
Abstract
Total knee arthroplasty (TKA) often causes a significant amount of blood loss with an accompanying decline in hemoglobin and may increase the frequency of allogeneic blood transfusion rates. Unfortunately, allogeneic blood transfusions have associated risks including postoperative confusion, infection, cardiac arrhythmia, fluid overload, increased length of hospital stay, and increased mortality. Other than reducing the need for blood transfusions, reducing perioperative blood loss in TKA may also minimize intra-articular hemorrhage, limb swelling, and postoperative pain, and increase the range of motion during the early postoperative period. These benefits improve rehabilitation success and increase patients' postoperative satisfaction. Preoperative anemia, coupled with intraoperative and postoperative blood loss, is a major factor associated with higher rates of blood transfusion in TKA. Thus, treatment of preoperative anemia and prevention of perioperative blood loss are the primary strategies for perioperative blood management in TKA. This review, combined with current evidence, analyzes various methods of blood conservation, including preoperative, intraoperative, and postoperative methods, in terms of their effectiveness, safety, and cost. Because many factors can be controlled to reduce blood loss and transfusion rates in TKA, a highly efficient, safe, and cost-effective blood management strategy can be constructed to eliminate the need for transfusions associated with TKA.
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Affiliation(s)
- Qiang Lu
- Department of OrthopaedicsRenmin Hospital of Wuhan UniversityWuhanChina
| | - Hao Peng
- Department of OrthopaedicsRenmin Hospital of Wuhan UniversityWuhanChina
| | - Guan‐jin Zhou
- Department of Orthopaedics, Puai Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Dong Yin
- Department of OrthopaedicsThe People’s Hospital of Guangxi Zhuang Autonomous RegionNanningChina
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15
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Yozawa S, Ogawa H, Matsumoto K, Akiyama H. Periarticular Injection of Tranexamic Acid Reduces Blood Loss and the Necessity for Allogeneic Transfusion After Total Knee Arthroplasty Using Autologous Transfusion: A Retrospective Observational Study. J Arthroplasty 2018; 33:86-89. [PMID: 28927562 DOI: 10.1016/j.arth.2017.08.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/30/2017] [Accepted: 08/14/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study aimed to examine the influence of a periarticular injection of tranexamic acid (TXA) on blood loss after a total knee arthroplasty (TKA) in patients who received an autologous blood transfusion. METHODS We retrospectively reviewed the medical charts of 82 patients (88 consecutive knees) who underwent a primary unilateral TKA with or without a periarticular TXA injection (TXA and control groups, respectively). All patients underwent an autologous blood transfusion. Perioperative parameters related to blood loss were compared between groups. RESULTS Compared to the control group, the decrease in hemoglobin was significantly smaller in the TXA group (1.5 ± 1.2 vs 2.5 ± 1.4 g/dL, P < .001), and blood drainage was significantly lower in the TXA group (387.2 ± 215.7 vs 582.3 ± 272.9 mL, P = .002). Moreover, the estimated blood loss, based on either hemoglobin or hematocrit, was significantly lower in the TXA group (509.8 ± 405.2 and 530.7 ± 418.5 mL, respectively) than in the control group (814.2 ± 543.8 and 809.1 ± 469.6 mL, respectively, both P < .001). No severe complications, including a venous thromboembolic event or infection, or local complications, including skin necrosis or delayed wound healing, were observed in either group. A postoperative allogeneic blood transfusion was performed in 2 cases in the control group and none in the TXA group. CONCLUSION Periarticular TXA injection is effective in reducing postoperative blood loss and hemoglobin and hematocrit drops without increasing the risk of venous thrombosis or the necessity of an allogeneic blood transfusion.
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Affiliation(s)
- Sain Yozawa
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hiroyasu Ogawa
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan; Department of Advanced Joint Reconstructive Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazu Matsumoto
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Haruhiko Akiyama
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
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16
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Nagra NS, Hamilton TW, Strickland L, Murray DW, Pandit H. Enhanced recovery programmes for lower limb arthroplasty in the UK. Ann R Coll Surg Engl 2017; 99:631-636. [PMID: 28768427 PMCID: PMC5696927 DOI: 10.1308/rcsann.2017.0124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Enhanced recovery programmes (ERPs) reduce patient morbidity and mortality, and provide significant cost savings by reducing length of stay. Currently, no uniform ERP guidelines exist for lower limb arthroplasty in the UK. The aim of this study was to identify variations in ERPs and determine adherence to local policy. METHODS Hospitals offering elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) (23 and 22 centres respectively) contributed details of their ERPs, and performed an audit (15 patients per centre) to assess compliance. RESULTS Contrasting content and detail of ERPs was noted across centres. Adherence to ERPs varied significantly (40-100% for TKA, 17-94% for THA). Analysis identified perioperative use of dexamethasone, tranexamic acid and early mobilisation for TKA, and procedures performed in teaching hospitals for THA as being associated with a reduced length of stay. CONCLUSIONS This study highlights variation in practice and poor compliance with local ERPs. Given the proven benefits of ERPs, evidence-based guidelines in the context of local skillsets should be established to optimise the patient care pathway.
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Affiliation(s)
- N S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - T W Hamilton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - L Strickland
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - D W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - H Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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17
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Wang J, Wang Q, Zhang X, Wang Q. Intra-articular Application is More Effective Than Intravenous Application of Tranexamic Acid in Total Knee Arthroplasty: A Prospective Randomized Controlled Trial. J Arthroplasty 2017; 32:3385-3389. [PMID: 28697863 DOI: 10.1016/j.arth.2017.06.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/25/2017] [Accepted: 06/12/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The optimal administration route of tranexamic acid (TXA) in total knee arthroplasty (TKA), and the effect of TXA on hidden blood loss and total blood loss are undetermined. The purpose of this study was to compare the effectiveness of intravenous versus intra-articular application of tranexamic acid in patients undergoing knee arthroplasty. METHODS A total of 150 patients undergoing primary unilateral total knee arthroplasty were randomly distributed to 3 groups (IV, intra-articular, and control group; each 50 patients) and administrated TXA (1 g IV and 50 mL intra-articular saline, 1 g intra-articularly and 50 mL intra-articular saline, and 0 g and 50 mL intra-articular saline, respectively). The amount of total and hidden blood loss (HBL), drainage, transfusion, changes in hemoglobin levels, and complications were recorded. RESULTS Intra-articular use of TXA reduced more total blood loss (P = .011) and reduced more total 48 hours drainage volume than IV use of TXA (P < .001). Two patients received transfusion in IV and control group. No deep venous thrombosis or other severe complications had occurred. The HBL volume had no significant difference among the control, IV, and intra-articular groups (708.6 ± 308.2, 651.7 ± 302.9, and 625.2 ± 252.1 mL, respectively; which was 65.6%, 70.8%, and 81.1% of the total loss). CONCLUSION Intra-articular administration of TXA significantly reduced total blood loss and drainage volume to a greater degree than IV injection in total knee arthroplasty without reduction of HBL.
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Affiliation(s)
- Jin Wang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qiaojie Wang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xianlong Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qi Wang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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18
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Mi B, Liu G, Zhou W, Lv H, Liu Y, Zha K, Wu Q, Liu J. Intra-articular versus intravenous tranexamic acid application in total knee arthroplasty: a meta-analysis of randomized controlled trials. Arch Orthop Trauma Surg 2017; 137:997-1009. [PMID: 28378211 DOI: 10.1007/s00402-017-2683-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND The purpose of this meta-analysis was to compare the blood loss and complications of intra-articular (IA) with intravenous (IV) tranexamic acid (TXA) for total knee arthroplasty (TKA). METHODS A comprehensive search of studies was conducted to identify related articles in Pubmed, Embase, Cochrane central Register of Controlled Trials, springerLink, OVID and the Research published from January 1980 to September 2016. All studies that compared IA TXA with IV TXA application on TKA were included. Main outcomes of the two methods were collected and analyzed by using Review Manager 5.3. RESULTS There were 16 randomized controlled trials with 1308 cases met the criteria. Compared with IV TXA, IA TXA had similar blood volume of drainage, hidden blood loss, transfusion rate and complications (P > 0.05). IA TXA had lower total blood loss than IV TXA, and there was significant difference (P < 0.05). Subgroup analysis of total blood loss based on times of IV TXA administration showed that repeat dose of IV TXA had a higher total blood loss and postoperative hemoglobin drop (P < 0.05) than IA TXA. However, single dose of IV TXA had a similar efficacy on total blood loss and postoperative hemoglobin drop (P > 0.05) when compared with IA TXA. CONCLUSIONS Both IA TXA and single dose of IV TXA are effective in reducing total blood loss and postoperative hemoglobin drop without increasing complications of DVT or PE. The current meta-analysis suggests that 1.5 g TXA by IA administration or 1 g TXA by IV administration 10 min before tourniquet deflation is effective and safe in patients undergoing TKA.
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Affiliation(s)
- Bobin Mi
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Guohui Liu
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China.
| | - Wu Zhou
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Huijuan Lv
- Deparetment of Rheumatology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yi Liu
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Kun Zha
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Qipeng Wu
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Jing Liu
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
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19
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Yang L, Du S, Sun Y. Is combined topical and intravenous tranexamic acid superior to single use of tranexamic acid in total joint arthroplasty?: A meta-analysis from randomized controlled trials. Medicine (Baltimore) 2017; 96:e7609. [PMID: 28746213 PMCID: PMC5627839 DOI: 10.1097/md.0000000000007609] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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 To compare the efficacy and safety of the combined application of both intravenous and topical tranexamic acid (TXA) versus the single use of either application in patients with total knee and hip arthroplasty (TKA and THA). METHODS Potentially relevant studies were identified from electronic databases including Medline, PubMed, Embase, ScienceDirect, and the Cochrane Library. Randomized control trials (RCTs) of patients prepared for total joint arthroplasty that compared combined TXA with placebo were retrieved. The primary endpoint was hemoglobin decline or postoperative hemoglobin level, blood loss, drainage volume, transfusion requirements. The secondary outcomes were length of stay (LOS), and operation time as well as surgery-related adverse effects, such as wound infection, deep vein thrombosis (DVT), and pulmonary embolism (PE). After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects models when necessary. RESULTS Five RCTs that included 604 patients met the inclusion criteria. The present meta-analysis indicated significant differences existed in the total blood loss (mean difference [MD] = -134.65, 95% CI: -191.66 to -77.64, P < .0001), postoperative hemoglobin level (MD = 0.74, 95% CI: 0.39-1.10, P < .0001), drainage volume (MD = -47.44, 95% CI: -64.55 to -30.33, P < .00001), and transfusion rate (risk difference [RD] = -0.06, 95% CI: -0.10 to -0.02, P = .006) between groups. CONCLUSION Combined administration of TXA in TKA and THA was associated with significantly reduced total blood loss, postoperative hemoglobin decline, drainage volume, and transfusion requirements. Well-designed, high-quality RCTs with long-term follow-up are still required.
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20
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Peng Zhang MM, Jifeng Li MM, Xiao Wang MM. Combined versus single application of tranexamic acid in total knee and hip arthroplasty: A meta-analysis of randomized controlled trials. Int J Surg 2017; 43:171-180. [PMID: 28602763 DOI: 10.1016/j.ijsu.2017.05.065] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/07/2017] [Accepted: 05/29/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of the combined application of both intravenous and topical tranexamic acid versus the single use of either application in patients with total knee and hip arthroplasty. METHODS Potentially relevant studies were identified from electronic databases including Medline, PubMed, Embase, ScienceDirect and the Cochrane Library. Patients undergoing primary total knee and hip arthroplasty were included in our studies, with an experimental group that received combined intravenous and topical application of tranexamic acid and a control group that received a single application of tranexamic acid or normal saline. The primary outcomes were total blood loss, hemoglobin decline and transfusion requirements. The secondary outcomes were length of stay, operation time and tranexamic acid-related adverse effects, such as superficial infection, deep vein thrombosis or pulmonary embolism. Modified Jadad scores were used to assess the quality of the included randomized controlled trials (RCTs). The data was pooled using RevMan 5.3. After testing for heterogeneity across studies, the data were aggregated using random-effects modeling when appropriate. We have registered the trial at http://www.researchregistry.com. RESULTS Six RCTs that included 704 patients met the inclusion criteria. The present meta-analysis indicated significant differences existed in the total blood loss (MD = -134.65, 95% CI: -191.66 to -77.64, P < 0.0001), postoperative hemoglobin level (MD = 0.74, 95% CI: 0.39 to 1.10, P < 0.0001), drainage volume (MD = -40.19, 95% CI: -55.95 to -24.43, P < 0.00001) and transfusion rate (RD = -0.07, 95% CI: -0.11 to -0.03, P = 0.0004) between groups. CONCLUSION Combined administration of tranexamic acid in total knee and hip arthroplasty was associated with significantly reduced total blood loss, postoperative hemoglobin decline, drainage volume, and transfusion requirements. Based on the limitations of current meta-analysis, well-designed, high-quality RCTs with long-term follow-up are still required.
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Affiliation(s)
- M M Peng Zhang
- Department of Orthopedics, Huaihe Hospital, Henan University, Henan, China
| | - M M Jifeng Li
- Department of Orthopedics, Huaihe Hospital, Henan University, Henan, China
| | - M M Xiao Wang
- Department of Orthopedics, Huaihe Hospital, Henan University, Henan, China.
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Wu Y, Yang T, Zeng Y, Li C, Shen B, Pei F. Clamping drainage is unnecessary after minimally invasive total knee arthroplasty in patients with tranexamic acid: A randomized, controlled trial. Medicine (Baltimore) 2017; 96:e5804. [PMID: 28207503 PMCID: PMC5319492 DOI: 10.1097/md.0000000000005804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Drainage and tranexamic acid (TXA) have been widely used in total knee arthroplasty (TKA). However, it remains unclear whether it is necessary to clamp the drain after minimally invasive TKA (MIS-TKA) when TXA is used. We therefore conducted a randomized controlled trial to compare the effects of clamping versus not clamping drainage following MIS-TKA in patients in whom TXA was used. METHODS From January 2015 to December 2015, 121 patients undergoing unilateral primary MIS-TKA were enrolled and randomly divided into 2 groups. In the clamping group (N = 60), drainage was clamped for the 1st 4 postoperative hours. In the nonclamping group (N = 61), drainage was not clamped. All patients underwent a minimidvastus approach and received 10 mg/kg TXA intravenously before tourniquet deflation. We recorded the total blood loss, drainage volume, and transfusion requirements in the postoperative period. We also measured the hemoglobin (Hb) and hematocrit (Hct) levels on postoperative days 1, 3, and 5. Other factors, including range of motion (ROM), visual analog scale (VAS), and occurrence of wound-related complications, deep vein thrombosis (DVT), and pulmonary embolism (PE) were recorded at the time of discharge and 1 and 6 months postoperatively. No statistically significant differences were found between the 2 groups with regard to age, gender, weight, BMI, preoperative Hb and Hct levels, preoperative ROM, VAS, duration of surgery, anesthesia method, and the American Society of Anesthesiologists classification. RESULTS The clamping group experienced better drainage volume results than the nonclamping group (P < 0.001). There were no statistically significant differences in TBL and transfusion requirements (P = 0.105 and 0.276, respectively); Hb and Hct levels on postoperative days 1, 3, and 5 were similar between the 2 groups. No significant differences were found for ROM, VAS, DVT, PE, wound-related complications, and hospital length of stay in the postoperative follow-up. CONCLUSION Based on our findings, clamping drainage is unnecessary after routine MIS-TKA using TXA.
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Affiliation(s)
- Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Timin Yang
- Department of Orthopaedic Surgery, People's Hospital of Tibet Autonomous Region, Lasa, China
| | - Yi Zeng
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Canfeng Li
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
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Pinsornsak P, Rojanavijitkul S, Chumchuen S. Peri-articular tranexamic acid injection in total knee arthroplasty: a randomized controlled trial. BMC Musculoskelet Disord 2016; 17:313. [PMID: 27455842 PMCID: PMC4960744 DOI: 10.1186/s12891-016-1176-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 07/20/2016] [Indexed: 11/30/2022] Open
Abstract
Background Intravenous tranexamic acid (IV TXA) is one of the most effective agents in use for reducing blood loss following total knee arthroplasty (TKA) but its safety regarding venous thromboembolic events (VTEs) remains in question. The direct, local application of TXA may reduce systemic toxicity whilst maintaining good or better bleeding control compared to IV TXA. The topical application of TXA via Hemovac drains has been reported previously with good results. However, there are no data on peri-articular TXA injections during TKA. Methods We conducted an open randomized, pilot study of peri-articular vs. IV TXA in 60 patients undergoing TKA. 30 patients received either: (i) 750 mg peri-articular TXA into the medial, lateral capsules and the quadriceps tendon prior to capsular closure and tourniquet deflation (group1), or (ii) 750 mg of IV TXA just before tourniquet deflation. Blood loss in the hemovac drain and hemoglobin (Hb) concentrations were measured at 24 and 48 h (h), and the number of blood transfusions and leg circumference measurements were recorded. Results At 48 h, the total blood loss in the hemovac drain was 445 mL in group 1 vs. 520 mL in group 2 (p = 0.081) and the corresponding declines in Hb were 1.85 g/dL vs. 1.87 g/dL (p = 0.84). 16 patients received blood transfusions: 9 vs. 7 in groups 1 and 2, respectively (p = 0.928). There were no differences in thigh and lower leg circumferences, pain scores, knee flexion at discharge date and lengths of hospital stay. There were no clinically detected venous thromboembolic events. Conclusion This pilot study has shown promising results for peri-articular TXA during TKA. Additional, larger studies are needed to confirm our results and be powered to show differences in efficacy and safety of peri-articular vs. IV TXA. Trial registration ClinicalTrials.gov Identifier NCT02829346. Retrospectively registered: 07/11/2016.
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Affiliation(s)
- P Pinsornsak
- Department of Orthopaedic Surgery, Thammasat University, 99 Moo 18, Khlong Nueng, Khlong Luang, Pathumthani, Thailand, 12120.
| | - S Rojanavijitkul
- Department of Orthopaedic Surgery, Thammasat University, 99 Moo 18, Khlong Nueng, Khlong Luang, Pathumthani, Thailand, 12120
| | - S Chumchuen
- Department of Orthopaedic Surgery, Thammasat University, 99 Moo 18, Khlong Nueng, Khlong Luang, Pathumthani, Thailand, 12120
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