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Marous CL, Farhat OJ, Cefalu M, Rothschild MI, Alapati S, Wladis EJ. Effects of Preoperative Intravenous Versus Subcutaneous Tranexamic Acid on Postoperative Periorbital Ecchymosis and Edema Following Upper Eyelid Blepharoplasty: A Prospective, Randomized, Double-Blinded, Placebo-Controlled, Comparative Study. Ophthalmic Plast Reconstr Surg 2024; 40:523-532. [PMID: 38687303 DOI: 10.1097/iop.0000000000002633] [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: 05/02/2024]
Abstract
PURPOSE To compare the effects of preoperative tranexamic acid (TXA) administered intravenously (IV) versus subcutaneously on postoperative ecchymosis and edema in patients undergoing bilateral upper eyelid blepharoplasty. METHODS A prospective, double-blinded, placebo-controlled study of patients undergoing bilateral upper eyelid blepharoplasty at a single-center. Eligible participants were randomized to preoperatively receive either (1) 1 g of TXA in 100 ml normal saline IV, (2) 50 µl/ml of TXA in local anesthesia, or (3) no TXA. Primary outcomes included ecchymosis and edema at postoperative day 1 (POD1) and 7 (POD7). Secondary outcomes included operative time, pain, time until resuming activities of daily living, patient satisfaction, and adverse events. RESULTS By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), ecchymosis scores were significantly lower on POD1 (1.31 vs. 1.56 vs. 2.09, p = 0.02) and on POD7 (0.51 vs. 0.66 vs. 0.98, p = 0.04) among those that received TXA. By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), significant reductions in edema scores occurred in those that received TXA on POD1 (1.59 vs. 1.43 vs. 1.91, p = 0.005) and on POD7 (0.85 vs. 0.60 vs. 0.99, p = 0.04). By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA) patients treated with intravenous and local subcutaneous TXA preoperatively were more likely to experience shorter operative times (10.8 vs. 11.8 vs. 12.9 minutes, p = 0.01), reduced time to resuming activities of daily livings (1.6 vs. 1.6 vs. 2.3 days, p < 0.0001), and higher satisfaction scores at POD1 (8.8 vs. 8.7 vs. 7.9, p = 0.0002). No adverse events occurred were reported. CONCLUSION In an analysis of 106 patients, preoperative TXA administered either IV or subcutaneously safely reduced postoperative ecchymosis and edema in patients undergoing upper eyelid blepharoplasty. While statistical superiority between intravenous versus local subcutaneous TXA treatment was not definitively identified, our results suggest clinical superiority with IV dosing.
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Affiliation(s)
- Charlotte L Marous
- Oculoplastic and Orbital Surgery, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
- Ophthalmic Plastic Surgery, Department of Ophthalmology, Albany Medical College
| | - Omar J Farhat
- Ophthalmic Plastic Surgery, Department of Ophthalmology, Albany Medical College
| | - Matthew Cefalu
- Ophthalmic Plastic Surgery, Department of Ophthalmology, Albany Medical College
| | | | | | - Edward J Wladis
- Ophthalmic Plastic Surgery, Department of Ophthalmology, Albany Medical College
- Department of Otolaryngology and Head and Neck Surgery, Albany Medical College, Albany, New York, U.S.A
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Pinsornsak P, Thaveekitikul R, Pinsornsak P, Tanariyakul Y. Comparative effectiveness of combined peri-articular and intra-articular injection versus intravenous and intra-articular injection of tranexamic acid in total knee arthroplasty: a randomized controlled trial study. Arch Orthop Trauma Surg 2024; 144:2753-2759. [PMID: 38662002 DOI: 10.1007/s00402-024-05337-y] [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] [Received: 11/18/2023] [Accepted: 04/14/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Tranexamic acid (TXA) administration is supported by numerous evidence in reducing blood loss after total knee arthroplasty (TKA). The combination of intravenous (IV) and intra-articular (IA) TXA administration revealed good result in blood loss reduction with less evidence of venous thromboembolism event (VTE). Several literature reviews portray that peri-articular (PA) administration yields similar hemostasis in comparison to IV route. However, there is no report on the clinical effect of combining PA + IA TXA in blood loss reduction and its complications, compared to combining IV + IA TXA after TKA. MATERIALS AND METHODS We conducted a double-blind, randomized controlled trial comparing the use of PA + IA TXA administration and IV + IA TXA administration in 70 patients who were scheduled for unilateral primary TKA. Thirty-five patients were assigned for PA + IA injection (Group 1) and anoter 35 patients were assigned for IV + IA injection (Group 2). Primary outcomes included total blood loss at 48 h, and the need for blood transfusion. Secondary outcomes included thigh and leg circumference, degree of knee flexion, and postoperative complications. RESULTS The calculated blood loss at 48 h showed no difference between Groups 1 and 2 (617 ml vs. 632 ml, p = 0.425). The total hemoglobin and hematocrit changes were not different (1.89 g/dL vs. 1.97 g/dL, p = 0.371 and 5.66% vs. 5.87%, p = 0.391). There was no need for blood transfusion in either group. However, lower thigh swelling was significant in Group 1 (2.15 cm vs. 2.79 cm, p = 0.04). Leg circumferences at 48 h was also lower in Group 1 (42.12 cm vs. 42.77 cm, p = 0.04). There was no significant difference in knee flexion decrease between the two groups (38° vs. 37°, p = 0.425). There were no VTE complications or infections found in either group. CONCLUSIONS Combined PA + IA TXA administration had similar efficacy in blood loss reduction and blood transfusion when compared to combined IV + IA TXA. The first group displayed less soft tissue swelling. The combination of PA + IA TXA administration can be used as an alternative regimen to avoid IV TXA administration.
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Affiliation(s)
- Piya Pinsornsak
- Department of Orthopaedic Surgery, Thammasat University, 99 Moo 18 Phaholyothin Rd, Khlong Luang, Pathum Thani, 12120, Thailand
| | - Ranet Thaveekitikul
- Department of Orthopaedic Surgery, Thammasat University, 99 Moo 18 Phaholyothin Rd, Khlong Luang, Pathum Thani, 12120, Thailand
| | - Prem Pinsornsak
- Kasetsart University Laboratory School Center for Educational Research and Development, 50 Ngamwongwan Rd, Chatuchak, Bangkok, 10900, Thailand
| | - Yot Tanariyakul
- Department of Orthopaedic Surgery, Thammasat University, 99 Moo 18 Phaholyothin Rd, Khlong Luang, Pathum Thani, 12120, Thailand.
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Wiktor Ł, Osadnik B, Damps M. Can local infiltration analgesia supplemented with tranexamic acid reduce blood loss during total knee arthroplasty? BMC Musculoskelet Disord 2024; 25:333. [PMID: 38671411 PMCID: PMC11046775 DOI: 10.1186/s12891-024-07451-9] [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] [Received: 09/25/2023] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
PURPOSE The aim of this study was to investigate the efficacy of TXA supplemented with local infiltration analgesia (LIA) for reducing blood loss in patients undergoing total knee replacement. MATERIALS A retrospective study of 530 individuals with a mean age of 71.44 years was performed after posterior stabilized total knee arthroplasty. Patients were divided into three groups according to the method of bleeding control: I - patients without an additional bleeding protocol (control group); II - patients receiving IV TXA (TXA group); and III - patients receiving the exact TXA protocol plus intraoperative local infiltration analgesia (TXA + LIA group). Blood loss was measured according to the maximal decrease in Hb compared to the preoperative Hb level. RESULTS The mean hospitalization duration was 7.02 (SD 1.34) days in the control group, 6.08 (SD 1.06) days in the TXA group, and 5.56 (SD 0.79) in the TXA + LIA group. The most significant decrease in haemoglobin was found in the control group, which was an average of 30.08%. The average decrease in haemoglobin was 25.17% (p < 0.001) in the TXA group and 23.67% (p < 0.001) in the TXA + LIA group. A decrease in the rate of allogeneic blood transfusions was observed: 24.4% in the control group, 9.9% in the TXA group, and 8% in the TXA + LIA group (p < 0.01). CONCLUSIONS Compared to the separate administration of tranexamic acid, the combination of perioperative administration with local infiltration analgesia significantly reduced blood loss in patients after total knee replacement.
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Affiliation(s)
- Łukasz Wiktor
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children's Health Centre, Katowice, Poland.
- Department of Trauma and Orthopedic Surgery ZSM Hospital, Pokoju street 74, Chorzów, 41-500, Poland.
| | - Bartłomiej Osadnik
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children's Health Centre, Katowice, Poland
- Department of Trauma and Orthopedic Surgery ZSM Hospital, Pokoju street 74, Chorzów, 41-500, Poland
| | - Maria Damps
- Department of Anaesthesiology and Intensive Care, Upper Silesian Children's Health Centre, Katowice, Poland
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Gibbs VN, Champaneria R, Sandercock J, Welton NJ, Geneen LJ, Brunskill SJ, Dorée C, Kimber C, Palmer AJ, Estcourt LJ. Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2024; 1:CD013295. [PMID: 38226724 PMCID: PMC10790339 DOI: 10.1002/14651858.cd013295.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: 01/17/2024]
Abstract
BACKGROUND Hip and knee replacement surgery is a well-established means of improving quality of life, but is associated with a significant risk of bleeding. One-third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care. OBJECTIVES To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta-analysis (NMA) methodology. SEARCH METHODS We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP). SELECTION CRITERIA We included RCTs of people undergoing elective hip or knee surgery only. We excluded non-elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non-fibrin sealants. DATA COLLECTION AND ANALYSIS We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all-cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received. MAIN RESULTS We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra-articularly and orally at a total dose of greater than 3 g pre-incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate-certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre-incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low-certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low-certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low-certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low-certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low-certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all-cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low-certainty evidence). This was followed by TXA given intravenously and intra-articularly at a total dose of 2 g pre-incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low-certainty evidence) and TXA given intravenously and intra-articularly, total dose greater than 3 g pre-incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low-certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low-certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials). AUTHORS' CONCLUSIONS We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra-articular, oral and intravenous, or intravenous and intra-articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review.
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Affiliation(s)
- Victoria N Gibbs
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Rita Champaneria
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Josie Sandercock
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Nicky J Welton
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Louise J Geneen
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Catherine Kimber
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Antony Jr Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Cam N, Balkanli B, Altuntas Y, Kanar M, Ozdemir HM. The Effect of Local Tranexamic Acid Administration on Blood Loss and Transfusion in Total Knee Arthroplasty: A Retrospective Study. SISLI ETFAL HASTANESI TIP BULTENI 2023; 57:245-249. [PMID: 37899805 PMCID: PMC10600620 DOI: 10.14744/semb.2023.42800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/23/2023] [Accepted: 05/23/2023] [Indexed: 10/31/2023]
Abstract
Objectives The standard surgical method for primary gonarthrosis in advanced stages is total knee arthroplasty (TKA), despite the risk of bleeding that requires transfusion. Blood transfusions are potentially dangerous. The aim of this study was to determine whether there is a statistical difference in the amount of bleeding and the need for transfusion between patients who received and did not receive perioperative local tranexamic acid in TKA. Methods The hospital data system was used to access the data of patients who underwent TKA in our clinic between January 2015 and January 2022 with a diagnosis of gonarthrosis. Patients who underwent TKA and had gonarthrosis as the primary diagnosis were included in the study. They were separated into two groups: A control group (Group C) and a group that received perioperative local tranexamic acid (Group LTXA). The amount of bleeding was compared by taking into account patients' hemogram follow-ups, the amount of blood from their drains, and their transfusion needs during the postoperative period. Results The findings demonstrated that TKA patients who received local tranexamic acid administration experienced a significant decrease in perioperative blood loss and needed lesser transfusions. Conclusion The findings of our investigation are consistent with other studies and are in favor of the usage of TXA in TKA. To validate our findings and establish the ideal TXA dosage and administration method in TKA, additional research is required.
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Affiliation(s)
- Necmi Cam
- Department of Orthopedics and Traumatology, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Türkiye
| | - Bahadir Balkanli
- Department of Orthopedics and Traumatology, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Türkiye
| | - Yusuf Altuntas
- Department of Orthopedics and Traumatology, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Türkiye
| | - Muharrem Kanar
- Department of Orthopedics and Traumatology, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Türkiye
| | - Haci Mustafa Ozdemir
- Department of Orthopedics and Traumatology, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Türkiye
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Deng HM. Efficacy and safety of intravenous tranexamic acid in total shoulder arthroplasty: A meta-analysis. World J Clin Cases 2023; 11:2992-3001. [PMID: 37215404 PMCID: PMC10198082 DOI: 10.12998/wjcc.v11.i13.2992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/08/2023] [Accepted: 03/27/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Total shoulder arthroplasty (TSA) results in a large amount of perioperative blood loss due to severe trauma.
AIM To investigate the safety and efficacy of intravenous tranexamic acid (TXA) in TSA.
METHODS We searched the PubMed, Cochrane Library, Embase and Web of Science databases for randomized controlled trials (RCTs) on the use of TXA in TSA. And all the results were checked and assessed by Reference Citation Analysis (https://www.referencecitationanalysis.com/). A meta-analysis was performed with Review Manager 5.3 to calculate the odds ratio (OR) or weighted mean difference (WMD) of related outcome indicators.
RESULTS A total of 5 RCTs with level 1 evidence were included. There were 369 cases, with 186 in the TXA group and 183 in the placebo group. The meta-analysis showed that TXA can significantly reduce total blood loss during the perioperative period [WMD = -249.56, 95% confidence interval (CI): -347.6 to -151.52, P < 0.0001], and the incidence of adverse reactions was low (OR = 0.36, 95%CI: 0.16-0.83, P = 0.02). Compared with the placebo group, the TXA group had significantly less total haemoglobin loss (WMD = -34.39, 95%CI: -50.56 to -18.22), less haemoglobin fluctuation before and after the operation (WMD = -0.6, 95%CI: -0.93 to -0.27) and less 24-h drain output (WMD = -136.87, 95%CI: -165.87 to -106.49). There were no significant differences in the operation time (P = 0.11) or hospital length of stay (P = 0.30) between the two groups.
CONCLUSION The application of intravenous TXA in the perioperative period of TSA can significantly reduce the total volume of perioperative blood loss and reduce the incidence of adverse reactions, so TXA is worthy of widespread clinical use.
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Affiliation(s)
- Hua-Mei Deng
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou 510120, Guangdong Province, China
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Ling T, Zhang L, Huang L. The efficacy and safety of combined administration of intravenous and intra-articular tranexamic acid in total knee arthroplasty: An update meta-analysis. J Clin Pharm Ther 2022; 47:1312-1321. [PMID: 35790455 DOI: 10.1111/jcpt.13725] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/07/2022] [Accepted: 06/14/2022] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE This study was performed to compare the efficacy and safety of combined administration of intravenous (IV) and intra-articular (IA) tranexamic acid (TXA) with IV or IA TXA alone in total knee arthroplasty (TKA). METHODS PubMed, Embase, Cochrane Library and Web of Science were searched for randomized controlled trials (RCTs) in July 2021. Total blood loss, transfusion rate, postoperative haemoglobin drop, drain output, deep venous thrombosis (DVT) and pulmonary embolism (PE) were pooled. Data were analyzed using Stata 14.0 software. The study protocol was registered with PROSPERO, number CRD42020186654. RESULTS Ten RCTs involving 1306 patients were included. Combined TXA group provided lower total blood loss (SMD -0.47; 95% CI -0.64 to -0.30; p < 0.001), postoperative haemoglobin drop (SMD -0.47; 95% CI -0.60 to -0.33; p < 0.001) and drain output (SMD -0.50; 95% CI -0.71 to -0.29; p = 0.009) compared with IV or IA TXA alone group. No significant difference was found in terms of transfusion rate (OR 0.53; 95% CI 0.23 to 1.23; p = 0.137) and DVT (OR 0.55; 95% CI 0.18 to 1.68; p = 0.293). PE data was provided by all 10 studies, but PE only occurred in one patient in IV TXA alone group. WHAT IS NEW AND CONCLUSION Combined administration of IV and IA TXA was relatively more effective in reducing total blood loss, transfusion rate, postoperative haemoglobin drop, and drain output after TKA. TXA may not increase the risk of DVT/PE, but it also needs to be monitored in clinical application.
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Affiliation(s)
- Tao Ling
- Department of Pharmacy, Suqian First Hospital, Suqian, China
| | | | - Lingli Huang
- Department of Pharmacy, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
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Tan TK, Lee JY, Tay A, Kuster M. Intra-articular versus intravenous administration of tranexamic acid in lower limb total arthroplasty: a systematic review and meta-analysis of randomised clinical trials. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:709-738. [PMID: 35377071 DOI: 10.1007/s00590-022-03241-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/28/2022] [Indexed: 11/30/2022]
Abstract
AIM The ideal route of tranexamic acid (TXA) administration in total hip arthroplasty (THA) or total knee arthroplasty (TKA) remains controversial. This study aims to identify the optima route of TXA administration in THA or TKA. METHODS PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched until 4 August 2021 for randomised studies that compared intravenous (IV) or intra-articular (IA) administration of TXA in THA or TKA. RESULTS Sixty-seven studies enrolling 8335 patients (IA: 4162; IV: 4173) were eligible for quantitative and qualitative analysis. Comparable results were demonstrated in the incidence of venous thromboembolisation (OR:0.96, p = 0.84), total blood loss (MD: - 9.05, p = 0.36), drain output (MD: - 7.36, p = 0.54), hidden blood loss (MD: - 6.85, p = 0.47), postoperative haemoglobin level (MD: 0.01, p = 0.91), haemoglobin drop (MD: - 0.10, p = 0.22), blood transfusion rate (OR: 0.99, p = 0.87), total adverse events (OR: 1.12, p = 0.28), postoperative range of motion (MD: 1.08, p = 0.36), postoperative VAS pain score (MD: 0.13, p = 0.24) and postoperative D-dimer level (MD: 0.61, p = 0.64). IV route of TXA administration was associated with significantly longer length of hospital stay compared to IA route of administration (MD: - 0.22, p = 0.01). CONCLUSION In this meta-analysis, both IV and IA route of TXA administration were equally effective in managing blood loss and postoperative outcomes in lower limb joints arthroplasty. LEVEL OF EVIDENCE Level 1. PROSPERO Registration CRD42021271355.
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Affiliation(s)
- Tze Khiang Tan
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia.
| | | | - Aaron Tay
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Markus Kuster
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
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Haratian A, Shelby T, Hasan LK, Bolia IK, Weber AE, Petrigliano FA. Utilization of Tranexamic Acid in Surgical Orthopaedic Practice: Indications and Current Considerations. Orthop Res Rev 2021; 13:187-199. [PMID: 34703327 PMCID: PMC8541761 DOI: 10.2147/orr.s321881] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/05/2021] [Indexed: 01/16/2023] Open
Abstract
Tranexamic acid (TXA) is a lysine analog that exhibits an anti-fibrinolytic effect by directly preventing the activation of plasminogen as well as inhibiting activated plasmin from degrading fibrin clots, thereby promoting hemostasis and reducing the duration and quantity of blood loss. The aims of this study were to summarize the indications, routes of administration, safety, and clinical outcomes of TXA use throughout the different subspecialities in orthopedic surgery. Given that orthopedic procedures such as TKA, THA, fracture fixation, and various spine surgeries involve significant intraoperative blood loss, TXA is indicated in providing effective perioperative hemostasis. Additionally, use of TXA in orthopedic trauma has been indicated as a measure to reduce blood loss especially in a group with potential for hemodynamic compromise. TXA has been implicated in reducing the risk of blood transfusions in orthopedic trauma, joint surgery, and spine surgery, although this effect is not seen as prominently in sports medicine procedures. There remains disagreement in literature as to whether TXA via any route of administration can improve other clinically significant outcomes such as hospital length of stay and total operative time. Procedures that rely extensively on clarity on visualization of the surgical field such as knee and shoulder arthroscopies can greatly benefit from the use of TXA, thereby leading to less intraoperative bleeding, with better visual clarity of the surgical field. While most studies agree thrombosis due to TXA is unlikely, new research in cells and animal models are evaluating whether TXA can negatively impact other aspects of musculoskeletal physiology, however with conflicting results thus far. As of now, TXA remains a safe and effective means of promoting hemostasis and reducing intraoperative blood loss in orthopedic surgery.
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Affiliation(s)
- Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Tara Shelby
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith K Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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Li J, Liu R, Rai S, Ze R, Tang X, Hong P. Intra-articular vs. intravenous administration: a meta-analysis of tranexamic acid in primary total knee arthroplasty. J Orthop Surg Res 2020; 15:581. [PMID: 33267906 PMCID: PMC7709322 DOI: 10.1186/s13018-020-02119-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 11/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The optimal dosage and administration approach of tranexamic acid (TXA) in primary total knee arthroplasty (TKA) remains controversial. In light of recently published 14 randomized controlled trials (RCTs), the study aims to incorporate the newly found evidence and compare the efficacy and safety of intra-articular (IA) vs. intravenous (IV) application of TXA in primary TKA. METHODS PubMed, Embase, Web of Science, and Cochrane Library were searched for RCTs comparing IA with IV TXA for primary TKA. Primary outcomes included total blood loss (TBL) and drain output. Secondary outcomes included hidden blood loss (HBL), hemoglobin (Hb) fall, blood transfusion rate, perioperative complications, length of hospital stay, and tourniquet time. RESULT In all, 34 RCTs involving 3867 patients were included in our meta-analysis. Significant advantages of IA were shown on TBL (MD = 33.38, 95% CI = 19.24 to 47.51, P < 0.001), drain output (MD = 28.44, 95% CI = 2.61 to 54.27, P = 0.03), and postoperative day (POD) 3+ Hb fall (MD = 0.24, 95% CI = 0.09 to 0.39, P = 0.001) compared with IV. There existed no significant difference on HBL, POD1 and POD2 Hb fall, blood transfusion rate, perioperative complications, length of hospital stay, and tourniquet time between IA and IV. CONCLUSION Intra-articular administration of TXA is superior to intravenous in primary TKA patients regarding the performance on TBL, drain output, and POD3+ Hb fall, without increased risk of perioperative complications. Therefore, intra-articular administration is the recommended approach in clinical practice for primary TKA.
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Affiliation(s)
- Jin Li
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ruikang Liu
- First School of Clinical Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Department of Orthopaedics and Trauma Surgery, National Trauma Center, National Academy of Medical Sciences, Mahankal, Kathmandu, Nepal
| | - Renhao Ze
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xin Tang
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Pan Hong
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Porter SB, White LJ, Osagiede O, Robards CB, Spaulding AC. Tranexamic Acid Administration Is Not Associated With an Increase in Complications in High-Risk Patients Undergoing Primary Total Knee or Total Hip Arthroplasty: A Retrospective Case-Control Study of 38,220 Patients. J Arthroplasty 2020; 35:45-51.e3. [PMID: 31522854 DOI: 10.1016/j.arth.2019.08.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/20/2019] [Accepted: 08/05/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) administration to reduce postoperative blood loss and transfusion is a well-established practice for total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, clinical concerns remain about the safety of TXA in patients with a history of a prothrombotic condition. We sought to determine the risk of complications between high-risk and low-risk TKA and THA patients receiving TXA. METHODS We retrospectively reviewed 38,220 patients (8877 high-risk cases) who underwent primary TKA and THA between 2011 and 2017 at our institution. Intravenous TXA was administered in 20,501 (54%) of cases. The rates of thrombotic complications (deep vein thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], and cerebrovascular accident [CVA]) as well as mortality and readmission were assessed at 90 days postoperatively. Additionally, we evaluated 90-day postoperative occurrence of DVT and PE separate from occurrence of MI and CVA. Patients were categorized as high risk if they had a past medical history of a prothrombotic condition prior to surgery. RESULTS There was no significant difference in the odds of these adverse outcomes between high-risk patients who received TXA and high-risk patients who did not receive TXA (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.85-1.18). There were also no differences when evaluating the odds of 90-day postoperative DVT and PE (OR 0.84, 95% CI 0.59-1.19) nor MI and CVA (OR 0.91, 95% CI 0.56-1.49) for high-risk patients receiving TXA vs high-risk patients who did not receive TXA. CONCLUSION TXA administration to high-risk TKA and THA patients is not associated with a statistically significant difference in adverse outcomes. We present incremental evidence in support of TXA administration for high-risk patients undergoing primary arthroplasties.
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Affiliation(s)
- Steven B Porter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Launia J White
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Osayande Osagiede
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Christopher B Robards
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
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Jules-Elysee KM, Tseng A, Sculco TP, Baaklini LR, McLawhorn AS, Pickard AJ, Qin W, Cross JR, Su EP, Fields KG, Mayman DJ. Comparison of Topical and Intravenous Tranexamic Acid for Total Knee Replacement: A Randomized Double-Blinded Controlled Study of Effects on Tranexamic Acid Levels and Thrombogenic and Inflammatory Marker Levels. J Bone Joint Surg Am 2019; 101:2120-2128. [PMID: 31800425 PMCID: PMC7406146 DOI: 10.2106/jbjs.19.00258] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic drug. Topical administration of TXA during total knee arthroplasty (TKA) is favored for certain patients because of concerns about thrombotic complications, despite a lack of supporting literature. We compared local and systemic levels of thrombogenic markers, interleukin (IL)-6, and TXA between patients who received intravenous (IV) TXA and those who received topical TXA. METHODS Seventy-six patients scheduled for TKA were enrolled in this randomized double-blinded study. The IV group received 1.0 g of IV TXA before tourniquet inflation and again 3 hours later; a topical placebo was administered 5 minutes before final tourniquet release. The topical group received an IV placebo before tourniquet inflation and again 3 hours later; 3.0 g of TXA was administered topically 5 minutes before final tourniquet release. Peripheral and wound blood samples were collected to measure levels of plasmin-anti-plasmin (PAP, a measure of fibrinolysis), prothrombin fragment 1.2 (PF1.2, a marker of thrombin generation), IL-6, and TXA. RESULTS At 1 hour after tourniquet release, systemic PAP levels were comparable between the IV group (after a single dose of IV TXA) and the topical group. At 4 hours after tourniquet release, the IV group had lower systemic PAP levels than the topical group (mean and standard deviation, 1,117.8 ± 478.9 µg/L versus 1,280.7 ± 646.5 µg/L; p = 0.049), indicative of higher antifibrinolytic activity after the second dose. There was no difference in PF1.2 levels between groups, indicating that there was no increase in thrombin generation. The IV group had higher TXA levels at all time points (p < 0.001). Four hours after tourniquet release, wound blood IL-6 and TXA levels were higher than systemic levels in both groups (p < 0.001). Therapeutic systemic TXA levels (mean, 7.2 ± 7.4 mg/L) were noted in the topical group. Calculated blood loss and the length of the hospital stay were lower in the IV group (p = 0.026 and p = 0.025). CONCLUSIONS Given that therapeutic levels were reached with topical TXA and the lack of a major difference in the mechanism of action, coagulation, and fibrinolytic profile between topical TXA and a single dose of IV TXA, it may be a simpler protocol for institutions to adopt the use of a single dose of IV TXA when safety is a concern. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kethy M Jules-Elysee
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Audrey Tseng
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
| | - Thomas P Sculco
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
| | - Lila R Baaklini
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Alexander S McLawhorn
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
| | - Amanda J Pickard
- Donald B. and Catherine C. Marron Cancer Metabolism Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - WeiGe Qin
- Donald B. and Catherine C. Marron Cancer Metabolism Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Justin R Cross
- Donald B. and Catherine C. Marron Cancer Metabolism Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Edwin P Su
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
| | - Kara G Fields
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
| | - David J Mayman
- Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY
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13
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Wang Z, Zhang HJ. Comparative effectiveness and safety of tranexamic acid plus diluted epinephrine to control blood loss during total hip arthroplasty: a meta-analysis. J Orthop Surg Res 2018; 13:242. [PMID: 30241543 PMCID: PMC6151011 DOI: 10.1186/s13018-018-0948-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/11/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The standard protocol to achieve haemostasis during total hip arthroplasty (THA) is uncertain. Tranexamic acid plus diluted epinephrine (DEP) and tranexamic acid (TXA) alone are the two most common alternatives. The purpose of this study was to compare the efficacy and safety of TXA plus DEP to treat blood loss in THA patients. METHODS Published randomized controlled trials (RCTs) were identified from the following electronic databases: PubMed, Embase, Web of Science, Cochrane Library and Google from inception to July 10, 2018. Studies comparing TXA plus DEP with TXA alone to treat blood loss were included. Either a random-effects model or a fixed-effects model was used for meta-analysis depending on the heterogeneity. We used the need for transfusion as the primary outcome. Stata 12.0 was used for meta-analysis. RESULTS Six studies involving 703 patients were included in the present meta-analysis. The pooled results demonstrated that TXA plus DEP was associated with a lower transfusion rate than TXA alone (RR = 0.57, 95% CI 0.38-0.86, P = 0.006). Furthermore, TXA plus DEP was associated with less total blood loss and hidden blood loss by approximately 209.79 ml and 297.74 ml, respectively, than TXA alone. There was no significant difference in terms of intraoperative blood loss or the occurrence of deep venous thrombosis or haematoma between the TXA plus DEP and TXA alone groups (P > 0.05). CONCLUSIONS Our meta-analysis suggested that TXA plus DEP significantly decreased the need for transfusion, total blood loss and hidden blood loss among THA patients. Furthermore, TXA plus DEP did not increase the occurrence of DVT or haemostasis. Additional long-term follow-up RCTs are needed to identify the optimal doses of TXA and DEP.
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Affiliation(s)
- Zhao Wang
- Department of Orthopedics, Jingjiang People’s Hospital, Jingjiang, China
| | - Hao-jie Zhang
- Department of Orthopaedics, The 82rn Hospital of People’s Liberation Army of China, No. 100, Jiankangdong Road, Huai’an, Jiangsu China
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