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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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Bloom DA, Lin CC, Manzi JE, Mojica ES, Telgheder ZL, Chapman CB, Konda SR. The Efficacy of Tranexamic Acid for the Treatment of Traumatic Hip Fractures: A Network Meta-Analysis. J Orthop Trauma 2023; 37:341-345. [PMID: 36821447 DOI: 10.1097/bot.0000000000002583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES To compare the efficacy of different dosages of intravenous (IV) tranexamic acid (TXA) in the treatment of traumatic hip fractures against that of the control group of no TXA. DATA SOURCES This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to perform a network meta-analysis on the use of TXA for the treatment of hip fractures. The study team used Ovid MEDLINE, Cochrane Reviews, Scopus, Embase, and Web of Science databases to perform the search. Studies that were published in English between the years 2010 and 2020 were selected. STUDY SELECTION/DATA EXTRACTION For inclusion in this study, selected articles were required to be randomized controlled trials with at least 1 control group that had no antifibrinolytic intervention to serve as a control, and IV formulations of TXA were used as part of the treatment group. Furthermore, all study participants must have undergone surgical intervention for traumatic hip fractures. Studies that did not immediately meet criteria for inclusion were saved for a review by the full investigating team and were included based on consensus. DATA SYNTHESIS All statistical analyses conducted for this study were performed using R software (R Foundation for Statistical Computing, Vienna, Austria). Network meta-analyses were conducted with a frequentist approach with a random-effects model using the netmeta package version 0.9-6 in R. The frequentist equivalent to surface under the cumulative ranking probabilities, termed " P score," was used to rank different treatments. CONCLUSION The use of TXA in the surgical management of traumatic hip fractures reduces the number of transfusions and perioperative blood loss, with minimal to no increased incidence of thrombotic events when compared with those in controls. When comparing formulations, no route of administration is clearly superior in reducing perioperative blood loss. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | | | | | | | - Cary B Chapman
- Miami Orthopedics and Sports Medicine Institute, Coral Gables, FL; and
| | - Sanjit R Konda
- NYU Langone Medical Center's Hospital for Joint Diseases, New York, NY
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Ziranu A, Meschini C, De Marco D, Sircana G, Oliva MS, Rovere G, Corbingi A, Vitiello R, Maccauro G, Pola E. Prevention of postoperative anemia in hip hemiarthroplasty for femoral neck fractures: comparison between local haemostatic agents. Orthop Rev (Pavia) 2022; 14:38574. [PMID: 36267213 PMCID: PMC9568419 DOI: 10.52965/001c.38574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Tranexamic acid and fibrin sealant have been shown to be effective in reducing the need for transfusion after hip fracture surgery. Objective The aim of this study was to evaluate the efficacy of local haemostatic agents to reduce the need of postoperative transfusion in elederly patients after hip hemiarthroplasty. Methods All patients admitted to our institution with a diagnosis of proximal femur fracture from September 2018 to March 2021 were involved. Inclusion criteria were: diagnosis of femoral neck fracture, classified as AO 31B2-3, surgical treatment with hip hemiarthroplasty, hemoglobinemia on admission > 8 gr/dL. Patients were divided in four groups. Results EVICEL was used on 25 patients, TRANEX was used on 52 patients, standard hemostatic care was used on 73 patients, while post-surgical drain was used on 21 patients. 3 patients were transfused in the EVICEL group while 26 patients were transfused in the control group (p 0,0404), there was also statistical significant difference in the need of perioperative transfusion between EVICEL group and drain group with 10 patients transfused (p 0,0102). Statistical significant differences was found about haemoglobin variation in the first post-operative day between TRANEX group and control group (p 0,000155) and between TRANEX group and drain group (p 0,013) and also between TRANEX group and control group in the third post-operative day (p 0,0004). Conclusion This study demonstrates that the use of both fibrin sealant or TXA can reduce total blood loss and the need of transfusions in geriatric population with intracapsular femur fracture.
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Reale D, Andriolo L, Gursoy S, Bozkurt M, Filardo G, Zaffagnini S. Complications of Tranexamic Acid in Orthopedic Lower Limb Surgery: A Meta-Analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6961540. [PMID: 33532495 PMCID: PMC7834786 DOI: 10.1155/2021/6961540] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/23/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Tranexamic acid (TXA) is increasingly used in orthopedic surgery to reduce blood loss; however, there are concerns about the risk of venous thromboembolic (VTE) complications. The aim of this study was to evaluate TXA safety in patients undergoing lower limb orthopedic surgical procedures. DESIGN A meta-analysis was performed on the PubMed, Web of Science, and Cochrane Library databases in January 2020 using the following string (Tranexamic acid) AND ((knee) OR (hip) OR (ankle) OR (lower limb)) to identify RCTs about TXA use in patients undergoing every kind of lower limb surgical orthopedic procedures, with IV, IA, or oral administration, and compared with a control arm to quantify the VTE complication rates. RESULTS A total of 140 articles documenting 9,067 patients receiving TXA were identified. Specifically, 82 studies focused on TKA, 41 on THA, and 17 on other surgeries, including anterior cruciate ligament reconstruction, intertrochanteric fractures, and meniscectomies. The intravenous TXA administration protocol was studied in 111 articles, the intra-articular in 45, and the oral one in 7 articles. No differences in terms of thromboembolic complications were detected between the TXA and control groups neither in the overall population (2.4% and 2.8%, respectively) nor in any subgroup based on the surgical procedure and TXA administration route. CONCLUSIONS There is an increasing interest in TXA use, which has been recently broadened from the most common joint replacement procedures to the other types of surgeries. Overall, TXA did not increase the risk of VTE complications, regardless of the administration route, thus supporting the safety of using TXA for lower limb orthopedic surgical procedures.
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Affiliation(s)
- Davide Reale
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Andriolo
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Safa Gursoy
- Department of Orthopaedics and Traumatology, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Murat Bozkurt
- Department of Orthopaedics and Traumatology, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Sircana G, Cauteruccio M, Oliva MS, Piccirillo N, Pesare E, Minutillo F, Ziranu A. Fibrin sealant reduces need for transfusions after hip hemiarthroplasty for femoral neck fractures. Injury 2020; 51 Suppl 3:S23-S27. [PMID: 32564965 DOI: 10.1016/j.injury.2020.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 05/01/2020] [Accepted: 05/10/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Every year more than 300,000 proximal femur fractures are diagnosed. Their number will double within 30 years. In femoral neck fractures treated with hip hemiarthroplasty 90-days mortality is 29.5-51.6%. Haemorrhage is one amongst other complications that is associated with increasing postoperative mortality. Transfusion rate in these patients ranges from 25.7% to 39%. Blood transfusions expose to complications. Fibrin sealants are useful in reducing perioperative need for transfusions, total blood loss, blood loss from drainage. The aim of this study is to assess whether the use of a fibrin sealant during hip hemiarthroplasty implant reduces the need for transfusion. PATIENT AND METHODS All patients admitted with a proximal femur fracture from September 2018 to May 2019 were reviewed. Inclusion criteria were: femoral neck fracture AO 31B2-3, hip hemiarthroplasty. Exclusion criteria were: previous surgery on the affected hip, coagulation disorders, hematopoietic disorders. Patients were divided in fibrin sealant group and control group. All patients underwent partial hip replacement through a posterolateral approach. 4 ml of fibrin sealant (EVICEL, Omrix Biopharmaceuticals, Diegem, Belgium) were sprayed on the soft tissues of patients included in the fibrin sealant group. Primary outcome of our study was need for perioperative transfusion. Secondary outcomes were: mean red blood cell transfused volume, variations in haematocrit and haemoglobin and total blood volume loss. RESULTS Eighty-one consecutive patients were enrolled. EVICEL was used on 19 patients, standard haemostatic care on 62 patients. Two patients were transfused in the fibrin sealant group, 22 in the control group (p 0,0371). Mean transfused volume was 21,05 ml in the fibrin sealant group and 116,16 ml in the control group (p 0,0017). No significant difference could be found in haematocrit and haemoglobin variation and total blood loss. DISCUSSION A reduction in transfusional need with the use of fibrin sealants was reported in studies on total hip arthroplasty and was confirmed by our study. CONCLUSION EVICEL reduces need for transfusion in patients undergoing hip hemiarthroplasty for a femoral neck fracture. It must be held among the options when a stricter control on transfusional requirement is needed.
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Affiliation(s)
- Giuseppe Sircana
- UOC Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma
| | - Michele Cauteruccio
- UOC Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma
| | - Maria Serena Oliva
- UOC Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma.
| | - Nicola Piccirillo
- UOC Emotrasfusione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma
| | - Elisa Pesare
- UOC Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma
| | - Felice Minutillo
- UOC Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma
| | - Antonio Ziranu
- UOC Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma
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Effect of Intravenous Aminocaproid Acid on Blood Loss and Transfusion Requirements After Bilateral Varus Rotational Osteotomy: A Double-blind, Placebo-controlled Randomized Trial. J Pediatr Orthop 2020; 40:e454-e459. [PMID: 32501914 PMCID: PMC7274150 DOI: 10.1097/bpo.0000000000001480] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND ε-Aminocaproic acid (EACA) is an antifibrinolytic agent that has been shown to decrease blood loss and transfusion requirements in several populations undergoing various surgical procedures. However, the efficacy of EACA has not been assessed in pediatric patients with cerebral palsy undergoing bilateral varus rotational femoral osteotomies. The purpose of this study was to assess the efficacy of intravenous EACA in reducing calculated intraoperative blood loss and transfusions in this population. METHODS Patients aged 18 years or younger were eligible. Patients were randomized to receive EACA or placebo (saline), and randomization was stratified based on sex and whether or not additional soft tissue or osseous procedures were performed. On the basis of retrospective data, the calculated sample size was 12 patients per arm to detect a difference of 250-mL blood loss. The primary outcome was calculated intraoperative blood loss. Secondary outcomes included transfusion requirements, 24-hour drain output, length of stay, and incidence of complications. RESULTS The mean age of patients in this study was 8 years (SD: 2.4 y). There were no differences in age, sex, height, weight, type of anesthesia, operative time, and associated procedures between the EACA and placebo groups (P>0.05). Preoperative hematocrit was lower in the EACA group (37.1 vs. 40.0, P=0.04). Calculated intraoperative blood loss was 536 mL in the EACA group and 628 mL in the placebo group (P=0.45). Transfusions were required in 62% of patients in the EACA group and 67% of patients in the placebo group (P=0.68). Total 24-hour drain output was 72.5 mL in the EACA group and 103.3 mL in the placebo group (P=0.37). Length of stay was similar between both groups, and there were no drug or placebo-related complications in either group. CONCLUSIONS There was no difference in blood loss or transfusion requirements associated with EACA compared with placebo; however, this study is underpowered to detect smaller differences in blood loss. Additional studies with larger sample sizes are needed to confirm these findings and further elucidate the indications for antifibrinolytic agents in pediatric patients. LEVEL OF EVIDENCE Level I.
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The effect of tranexamic acid on wound complications in primary total Hip Arthroplasty: A meta-analysis. Surgeon 2020; 18:53-61. [DOI: 10.1016/j.surge.2019.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 04/14/2019] [Accepted: 05/16/2019] [Indexed: 11/19/2022]
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Xin WQ, Gao YL, Shen J, Yang XY. Intravenous tranexamic acid reduces blood transfusions in revision total hip arthroplasty: a meta-analysis. J Comp Eff Res 2019; 8:917-928. [PMID: 31436114 DOI: 10.2217/cer-2019-0030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Aim: We performed a meta-analysis to systematically assess the efficacy and safety of intravenous tranexamic acid in revision total hip arthroplasty. Method: Potential academic articles were identified from Cochrane Library, Medline, PubMed, EMBASE, ScienceDirect and other databases. The time range we retrieved from was that from the inception of electronic databases to February 2019. Gray studies were identified from the references of included literature reports. STATA version 11.0 was used to analyze the pooled data. Results: A total of eight articles were involved in our study. The overall participants of tranexamic acid (TXA) group were 3533, whereas it was 11,007 in the control group. Our meta-analysis showed that TXA is preferable for revision total hip arthroplasty because of its lower value of hemoglobin reduction (weighted mean difference = -1.277-1.405; 95% CI: -1.996 to -0.559; p < 0.001), the rate of blood transfusion (odds ratio: 0.233; 95% CI: 0.129-0.422; p < 0.001) and the number of red blood cell units transfused (weighted mean difference = -0.978; 95% CI = -1.631 to -0.324; p = 0.003). However, there was no difference in calculated blood loss (p = 0.075), operation duration (p = 0.569) and venous thromboembolism complications (p = 0.338). Conclusion: Based on available evidence, use of intravenous TXA for patients undergoing revision arthroplasty may reduce hemoglobin reduction, number of red blood cell units transfused and blood transfusion rate without increasing the risk of venous thromboembolism and length of operation duration. Given the relevant possible biases in our study, adequately powered and better-designed studies with long-term follow-up are required to reach a firmer conclusion.
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Affiliation(s)
- Wen-Qiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, 30052, PR China
| | - Ya-Long Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, 30052, PR China
| | - Jun Shen
- Department of Neurosurgery, Yijishan Hospital of Wannan Medical College, Wuhu, PR China
| | - Xin-Yu Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, 30052, PR China
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Prevention of postoperative bleeding in hip fractures treated with prosthetic replacement: efficacy and safety of fibrin sealant and tranexamic acid. A randomised controlled clinical trial (TRANEXFER study). Arch Orthop Trauma Surg 2019; 139:597-604. [PMID: 30539285 DOI: 10.1007/s00402-018-3089-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION We assessed the efficacy of fibrin sealant (FS) and tranexamic acid (TXA) administered topically in patients with a hip fracture treated with prosthetic replacement. MATERIALS AND METHODS Parallel, multicentre, open label, randomised, clinical trial. We compared three interventions to reduce blood loss: (1) 10 ml of FS, (2) 1 g of topical TXA, both administered at the end of the surgery, and (3) usual haemostasis (control group). The main outcome was blood loss collected in drains. Other secondary variables were total blood loss, hidden blood loss, transfusion rate, average hospital stay, complications, adverse events, and mortality. RESULTS A total of 158 patients were included, 56 in the FS group, 52 in the TXA group, and 50 in the control group. The total amount of blood collected in drains was lower in the TXA group (148.6 ml, SD 122.7 in TXA; 168.2 ml, SD 137.4 in FS; and 201.5 ml, SD 166.5 in control group) without achieving statistical significance (p = 0.178). The transfusion rate was lower in the TXA group (32.7%), compared with FS group (42.9%) and control group (44.0%), without statistical significance (p = 0.341). There were no complications or adverse effects related to the evaluated interventions. CONCLUSIONS The use of TXA and FS administered topically prior to surgical closure in patients with a sub-capital femoral fracture undergoing arthroplasty did not significantly reduce either postoperative blood loss or transfusion rate, compared with a group that only received usual haemostasis.
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Zhao Z, Ma J, Ma X. Comparative efficacy and safety of different hemostatic methods in total hip arthroplasty: a network meta-analysis. J Orthop Surg Res 2019; 14:3. [PMID: 30609925 PMCID: PMC6319007 DOI: 10.1186/s13018-018-1028-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 12/03/2018] [Indexed: 11/29/2022] Open
Abstract
Background It is unclear which kind of interventional therapy is the best when reducing blood loss in patients prepared for total hip arthroplasty (THA). We performed this network meta-analysis to rank the best intervention arm for blood loss control in THA patients. Methods We searched electronic databases about randomized controlled trials (RCTs) to compare three treatments (topical tranexamic acid (TXA), intravenous TXA, and topical fibrin sealant (FS)) versus placebo for the people prepared for THA. Traditional and network meta-analyses were performed. The quality assessment was conducted using Cochrane Collaboration’s tool. The network meta-analysis was conducted using Stata 13.0 software. Results Finally, a total of 32 RCTs were included in this network meta-analysis. Topical TXA, intravenous TXA, and topical FS significantly decreased the need for transfusion and total blood loss when compared with placebo. And intravenous TXA ranks the first hemostasis agent for reducing the need for transfusion and total blood loss. There was no significant difference between these three treatments (intravenous TXA, topical TXA, and topical FS) in the occurrence of deep venous thrombosis (DVT). Conclusion Intravenous TXA may be the best way to reduce the need for transfusion and total blood loss. More direct studies that focused on topical TXA versus FS are needed in the future.
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Affiliation(s)
- Zhihu Zhao
- Department of orthopedics, Tianjin Hospital, Tianjin, China
| | - Jianxiong Ma
- Tianjin Institute of Orthopedics in Traditional Chinese and Western Medicine, Tianjin Hospital, NO.155 Munan Road, Tianjin, 300050, China
| | - Xinlong Ma
- Tianjin Institute of Orthopedics in Traditional Chinese and Western Medicine, Tianjin Hospital, NO.155 Munan Road, Tianjin, 300050, China.
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Yates J, Perelman I, Khair S, Taylor J, Lampron J, Tinmouth A, Saidenberg E. Exclusion criteria and adverse events in perioperative trials of tranexamic acid: a systematic review and meta-analysis. Transfusion 2018; 59:806-824. [PMID: 30516835 DOI: 10.1111/trf.15030] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an inexpensive therapy effective at minimizing perioperative blood loss and transfusion. However, it remains underutilized due to safety concerns. To date, no evidence-based guidelines exist identifying which patients should not receive TXA therapy. This study determined patient groups for whom safety information regarding TXA is lacking due to common exclusion from perioperative TXA trials. STUDY DESIGN AND METHODS A systematic review searching the databases Medline, EMBASE, CENTRAL, and Clinicaltrials.gov was performed. Randomized controlled trials (RCTs) administering systemic TXA perioperatively to elective or emergent surgery patients were eligible. Our primary outcome was to describe exclusion criteria of RCTs, and the secondary outcome was TXA safety. A descriptive synthesis of exclusion criteria was performed, and TXA safety was assessed by meta-analysis. RESULTS A total of 268 eligible RCTs were included. Meta-analysis showed that systemic TXA did not increase risk of adverse events compared to placebo or no intervention (relative risk, 1.05; 95% confidence interval, 0.99-1.12). Patient groups commonly excluded from perioperative TXA trials, and thus potentially lacking TXA safety data, were those with major comorbidities, a history of thromboembolism, medication use affecting coagulation, TXA allergy, and coagulopathy. Exclusion of patients with major comorbidities may not be necessary; we showed that the risk of adverse events was similar in studies that excluded patients with major comorbidities and those that did not. CONCLUSION Sufficient evidence exists to develop perioperative guidelines for TXA use in many populations. Further studies evaluating perioperative TXA use in patients with a history of thromboembolism are warranted.
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Affiliation(s)
- Jeffrey Yates
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Iris Perelman
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Simonne Khair
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Taylor
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jacinthe Lampron
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
| | - Elianna Saidenberg
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
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Senturk O. Can Low-dose Tranexamic Acid Decrease Blood Loss and Transfusion Requirements in Total Knee Arthroplasty? Cureus 2018; 10:e2640. [PMID: 30034962 PMCID: PMC6050166 DOI: 10.7759/cureus.2640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Introduction Tranexamic acid (TA) has been used successfully in primary total knee arthroplasty (TKA) to minimize blood loss and transfusions. The aim of this study was to evaluate the effect of perioperative single low-dose TA administration on postoperative blood loss and necessity for blood transfusion in patients undergoing total knee arthroplasty under spinal anesthesia. Material and Methods Data of patients undergoing TKA between January 2013 through December 2015 were retrospectively reviewed. Patients that underwent unilateral knee arthroplasty under spinal anesthesia were separated into two groups: those where TA was used (10 mg/kg) and a control group where TA was not used. The following data were collected from medical records and compared between groups according to demographics, hemoglobin levels, and drainage amount. Results A total of 48 patients' data were evaluated (TA: 20; control: 28). The use of tranexamic acid in total knee arthroplasties seemed to reduce the postoperative drainage rate and blood transfusion requirement. Average 24-hour drainage levels were significantly lower in the TA group when compared to the control group. Required 24-hour total blood transfusion amounts were significantly higher in the control group. There was no difference in preoperative and postoperative sixth or 24th-hour hemoglobin levels between the groups. Conclusion A low or single dose of TA is a safe and effective agent that significantly lowers blood loss and allogeneic blood transfusion requirements.
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Affiliation(s)
- Ozgur Senturk
- Anesthesiology and Reanimation, Maltepe University Faculity of Medicine, istanbul, TUR
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13
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Edwards SJ, Crawford F, van Velthoven MH, Berardi A, Osei-Assibey G, Bacelar M, Salih F, Wakefield V. The use of fibrin sealant during non-emergency surgery: a systematic review of evidence of benefits and harms. Health Technol Assess 2018; 20:1-224. [PMID: 28051764 DOI: 10.3310/hta20940] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Fibrin sealants are used in different types of surgery to prevent the accumulation of post-operative fluid (seroma) or blood (haematoma) or to arrest haemorrhage (bleeding). However, there is uncertainty around the benefits and harms of fibrin sealant use. OBJECTIVES To systematically review the evidence on the benefits and harms of fibrin sealants in non-emergency surgery in adults. DATA SOURCES Electronic databases [MEDLINE, EMBASE and The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and the Cochrane Central Register of Controlled Trials)] were searched from inception to May 2015. The websites of regulatory bodies (the Medicines and Healthcare products Regulatory Agency, the European Medicines Agency and the Food and Drug Administration) were also searched to identify evidence of harms. REVIEW METHODS This review included randomised controlled trials (RCTs) and observational studies using any type of fibrin sealant compared with standard care in non-emergency surgery in adults. The primary outcome was risk of developing seroma and haematoma. Only RCTs were used to inform clinical effectiveness and both RCTs and observational studies were used for the assessment of harms related to the use of fibrin sealant. Two reviewers independently screened all titles and abstracts to identify potentially relevant studies. Data extraction was undertaken by one reviewer and validated by a second. The quality of included studies was assessed independently by two reviewers using the Cochrane Collaboration risk-of-bias tool for RCTs and the Centre for Reviews and Dissemination guidance for adverse events for observational studies. A fixed-effects model was used for meta-analysis. RESULTS We included 186 RCTs and eight observational studies across 14 surgical specialties and five reports from the regulatory bodies. Most RCTs were judged to be at an unclear risk of bias. Adverse events were inappropriately reported in observational studies. Meta-analysis across non-emergency surgical specialties did not show a statistically significant difference in the risk of seroma for fibrin sealants versus standard care in 32 RCTs analysed [n = 3472, odds ratio (OR) 0.84, 95% confidence interval (CI) 0.68 to 1.04; p = 0.13; I2 = 12.7%], but a statistically significant benefit was found on haematoma development in 24 RCTs (n = 2403, OR 0.62, 95% CI 0.44 to 0.86; p = 0.01; I2 = 0%). Adverse events related to fibrin sealant use were reported in 10 RCTs and eight observational studies across surgical specialties, and 22 RCTs explicitly stated that there were no adverse events. One RCT reported a single death but no other study reported mortality or any serious adverse events. Five regulatory body reports noted death from air emboli associated with fibrin sprays. LIMITATIONS It was not possible to provide a detailed evaluation of individual RCTs in their specific contexts because of the limited resources that were available for this research. In addition, the number of RCTs that were identified made it impractical to conduct independent data extraction by two reviewers in the time available. CONCLUSIONS The effectiveness of fibrin sealants does not appear to vary according to surgical procedures with regard to reducing the risk of seroma or haematoma. Surgeons should note the potential risk of gas embolism if spray application of fibrin sealants is used and not to exceed the recommended pressure and spraying distance. Future research should be carried out in surgery specialties for which only limited data were found, including neurological, gynaecological, oral and maxillofacial, urology, colorectal and orthopaedics surgery (for any outcome); breast surgery and upper gastrointestinal (development of haematoma); and cardiothoracic heart or lung surgery (reoperation rates). In addition, studies need to use adequate sample sizes, to blind participants and outcome assessors, and to follow reporting guidelines. STUDY REGISTRATION This study is registered as PROSPERO CRD42015020710. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Sridharan K, Sivaramakrishnan G. Tranexamic acid in total hip arthroplasty: Mixed treatment comparisons of randomized controlled trials and cohort studies. J Orthop 2018; 15:81-88. [PMID: 29657445 DOI: 10.1016/j.jor.2018.01.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 01/14/2018] [Indexed: 01/08/2023] Open
Abstract
Background The present study is a network meta-analysis of various routes of tranexamic acid (TXA) in patients with total hip arthroplasty (THA). Methods Randomized controlled trials and cohort studies evaluating TXA in patients with THA were included. Number of patients requiring blood transfusion was the primary outcome. Results Pooled estimate for TXA use against placebo for blood transfusion rate was 0.30 [0.23, 0.39] favoring TXA. Maximum reduction in the risk of blood transfusion was observed with topical plus intra-operative intravenous TXA. Conclusion Combined topical and intravenous TXA during surgery may perform better than other modes in patients undergoing THA.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Gowri Sivaramakrishnan
- School of Oral Health, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
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15
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A Systematic Review and Meta-analysis of the Topical Administration of Fibrin Sealant in Total Hip Arthroplasty. Sci Rep 2018; 8:78. [PMID: 29311570 PMCID: PMC5758515 DOI: 10.1038/s41598-017-16779-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 11/15/2017] [Indexed: 11/14/2022] Open
Abstract
Patients who undergo total hip arthroplasty (THA) may experience a large amount of blood loss. The objective of our study is to include randomized controlled trials (RCTs) and compare the clinical outcomes of fibrin sealant (FS) versus placebo after a THA. In October 2015, we searched the following databases: Medline, Embase, PubMed, the Cochrane Controlled Trials Register, Web of Science, the China National Knowledge Infrastructure, the China Wanfang database and Google Scholar. Finally, seven studies that included 679 patients met the inclusion criteria. The meta-analysis indicated that the topical administration of FS was associated with a reduction of the need for transfusion compared to the control group (P = 0.05). And topical FS will reduce total blood loss after THA (P = 0.0003) and blood loss in drainage (P = 0.002). However, there was no significant difference in terms of the intraoperative blood loss (P = 0.62) and the rate of deep venous thrombosis (DVT), fever, pain, anemia, hematoma and oozing. In conclusion, the use of FS in patients who are undergoing THA may reduce perioperative blood loss and attenuate the decrease in Hb. Furthermore, FS do not decrease the intraoperative blood loss without an increase in the risk of postoperative DVT, fever, pain, anemia, hematoma and oozing.
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Zhu J, Zhu Y, Lei P, Zeng M, Su W, Hu Y. Efficacy and safety of tranexamic acid in total hip replacement: A PRISMA-compliant meta-analysis of 25 randomized controlled trials. Medicine (Baltimore) 2017; 96:e9552. [PMID: 29384974 PMCID: PMC6393088 DOI: 10.1097/md.0000000000009552] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hip osteoarthritis is one of the most prevalent musculoskeletal degenerative diseases in elderly. Total hip arthroplasty (THA) is the most effective surgical treatment for end stage hip osteoarthritis. Tranexamic acid (TA) is a potent drug to reduce surgical blood loss in surgery, therefore, as a potential drug for application in THA. OBJECTIVES To identify the combined efficacy of TA administration in THA. A meta-analysis including 25 randomized controlled trials was conducted for generating synthesized effects. METHODS This meta-analysis followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines for reporting systematic reviews and meta-analysis. A total of 25 Randomized controlled trials (RCTs) were included for meta-analysis. RESULTS The pooled results illustrated that total blood loss, intraoperative blood loss, postoperative blood loss, hemoglobin drop, transfusion rate, and average hospital stay were significantly lower than controls (standardized mean difference or odds ratio (OR) (95%CI): -0.87, (-1.13,-0.61), -0.68, (-0.96,-0.39), -1.41, (-2.24,-0.59), -1.11, (-1.63,-0.58), 0.28, (0.20,-0.38), -0.17, (-0.49,0.14), P < .05, respectively). Moreover, TA acts efficiently without increasing risk of thromboembolic events with OR = 1.14, 95%CI = 0.50-2.62, P = .75. Subgroup analysis indicated no statistically significant differences between a higher dose of topical TA (≥2 g or 15 mg/kg) or a lower dose (<2 g or 15 mg/kg). CONCLUSION The findings indicated that TA is clinically effective and safe in patients receiving total hip arthroplasty.
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17
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Sridharan K, Sivaramakrishnan G. Tranexamic acid in total hip arthroplasty: A recursive cumulative meta-analysis of randomized controlled trials and assessment of publication bias. J Orthop 2017; 14:323-328. [PMID: 28559649 PMCID: PMC5440691 DOI: 10.1016/j.jor.2017.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 05/14/2017] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION TXA has been evaluated in THA in several randomized controlled trials for the past 16 years. We attempted to evaluate the trends in the evidence using recursive cumulative meta-analysis and publication bias using Rosenthal and 'Trim and Fill' methods. METHODS Electronic databases were searched for randomized controlled clinical trials comparing TXA with either placebo (or no TXA administration) or TXA, administered through different routes in patients with osteoarthritis or osteonecrosis of the hip who underwent THA. We considered the total number of patients requiring blood transfusion as the clinical outcome for both the analyses and used quality effects model for assessing the changes in the pooled estimates with addition of new clinical trial data. We also assessed the publication bias by plotting individual study estimates with the standard errors using Rosenthal and 'Trim and Fill'methods. RESULTS A total of 20 studies were included. The pooled cumulative meta-analysis indicates that from 2014 the addition of estimate from new studies in the following years is only narrowing the confidence interval without any significant change in the point estimate. Rosenthal fail-safe-N for the comparisons of intravenous bolus TXA, intra-operative and post-operative intravenous TXA and topical with control groups were 54, 6 and 16 respectively. Fail-safe-N for the combined intravenous and topical TXA with intravenous TXA alone was 13. CONCLUSION Adequate evidence exists supporting the use of intravenous TXA in reducing the need for blood transfusion in THA. There is possible existence of small studies with null effects evaluating the use of TXA in THA.
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Affiliation(s)
- Kannan Sridharan
- Associate Professor in Pharmacology, School of Health Sciences, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | - Gowri Sivaramakrishnan
- Assistant Professor in Prosthodontics, School of Oral Health, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
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Melo GLR, Lages DS, Madureira Junior JL, Pellucci GDP, Pellucci JWJ. The use of tranexamic acid in patients submitted to primary total hip arthroplasty: an evaluation of its impact in different administration protocols. Rev Bras Ortop 2017; 52:34-39. [PMID: 28971084 PMCID: PMC5619999 DOI: 10.1016/j.rboe.2017.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/26/2017] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES There is still no consensus as to the best form and dosages of use of tranexamic acid. The aim of this study was to evaluate the use of tranexamic acid in total hip arthroplasty, in order to reduce blood loss and decrease hemoglobin, taking into account different administration protocols. METHODS 42 patients submitted to total hip arthroplasty were divided into three groups. The study was prospective and randomized. Group 1 received a venous dose of tranexamic acid of 15 mg/kg, 20 min prior to bolus incision. Group 2 received an intravenous dose of 15 mg/kg bolus, 20 min before the incision, and an extra dose of 10 mg/kg by infusion pump during the duration of the surgical procedure. Patients in group 3 did not receive tranexamic acid, being the control group. Pre- and post-operative hemoglobin levels were measured and blood loss was measured 24 h after surgery using a Portovac drain. RESULTS There was a significant reduction in the amount of bleeding through the Portovac drain and reduction in postoperative hemoglobin drop in patients who used tranexamic acid. There was neither significant difference in hemoglobin drop between groups 1 and 2, nor was there a need for hemotransfusion. Two patients in group 3 required blood transfusion. CONCLUSIONS The findings demonstrated that the use of intravenous tranexamic acid in total hip arthroplasty reduced postoperative bleeding rates and significantly reduced serum hemoglobin without increasing thromboembolic effects. The bolus and bolus + infusion pump methods were shown to have a similar influence on hemoglobin and need for blood transfusion.
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Qiu M, Zhang X, Cai H, Xu Z, Lin H. The impact of hemocoagulase for improvement of coagulation and reduction of bleeding in fracture-related hip hemiarthroplasty geriatric patients: A prospective, single-blinded, randomized, controlled study. Injury 2017; 48:914-919. [PMID: 28238301 DOI: 10.1016/j.injury.2016.11.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 05/27/2016] [Accepted: 11/26/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Uncontrolled bleeding is associated with poor outcomes and mortality in geriatric patients undergoing hemiarthroplasty. Hemocoagulase agkistrodon is a hemocoagulative, anti-hemorrhagic enzyme complex from Deinagkistrodon acutus snake venom. This study aimed to investigate the efficacy of hemocoagulase agkistrodon on coagulation and bleeding outcomes in fracture-related hemiarthroplasty. PATIENTS AND METHODS This was a prospective, single-blinded, randomized controlled trial carried out between October 2013 and September 2014 in 96 geriatric patients undergoing hemiarthroplasty for unilateral femoral neck fracture. Patients were administrated hemocoagulase agkistrodon (n=48) or normal saline (n=48). Intraoperative blood loss, transfusion volume and rate, and drainage were assessed. Hemoglobin (Hb) and coagulation parameters (prothrombin time [PT], thrombin time [TT], plasma fibrinogen [FIB], and activated partial thromboplastin time [aPTT]) were recorded preoperatively and 30min and 1, 3, and 5days after surgery. Complications were followed up for 4 weeks. RESULTS Compared to controls, hemocoagulase patients exhibited lower intraoperative blood loss (P<0.01) and postoperative blood loss, total drainage, mean transfusion volume, and transfusion rates (all P<0.05), with lower aPTT at 30min (P<0.05). No significant differences in postoperative FIB were observed. Controls exhibited significantly higher PP and TT on day 1, and Hb on days 1, 3, and 5 (P<0.05). No serious complications were reported. CONCLUSIONS Hemocoagulase reduced blood loss and transfusion in fracture-related hip hemiarthroplasty without increasing short-term adverse event rates. In geriatric populations, hemocoagulase could be used for limiting bleeding and related complications. TRIAL REGISTRATION This trial is registered in the Chinese Clinical Trial Register (no. ChiCTR-TRC-14004379).
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Affiliation(s)
- Meiguang Qiu
- Department of Surgery, Fujian Provincial Hospital Emergency Center; Provincial Clinical College of Fujian Medical University; Fujian Provincial Emergency Medicine Institute, Fuzhou, China
| | - Xuming Zhang
- Department of Surgery, Fujian Provincial Hospital Emergency Center; Provincial Clinical College of Fujian Medical University; Fujian Provincial Emergency Medicine Institute, Fuzhou, China.
| | - Hongru Cai
- Department of Surgery, Fujian Provincial Hospital Emergency Center; Provincial Clinical College of Fujian Medical University; Fujian Provincial Emergency Medicine Institute, Fuzhou, China
| | - Zhixian Xu
- Department of Surgery, Fujian Provincial Hospital Emergency Center; Provincial Clinical College of Fujian Medical University; Fujian Provincial Emergency Medicine Institute, Fuzhou, China
| | - Hao Lin
- Department of Surgery, Fujian Provincial Hospital Emergency Center; Provincial Clinical College of Fujian Medical University; Fujian Provincial Emergency Medicine Institute, Fuzhou, China
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Zhang P, Liang Y, Chen P, Fang Y, He J, Wang J. Combined application versus topical and intravenous application of tranexamic acid following primary total hip arthroplasty: a meta-analysis. BMC Musculoskelet Disord 2017; 18:90. [PMID: 28222709 PMCID: PMC5320770 DOI: 10.1186/s12891-017-1429-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 01/23/2017] [Indexed: 12/21/2022] Open
Abstract
Background The use of intravenous (IV) or topical tranexamic acid (TXA) in total hip arthroplasty has been proven to be effective and safe in total hip arthroplasty. However, which of these two administration routes is better has not been determined. The combined administration of TXA has been used in total knee arthroplasty with satisfactory results. We hypothesized that combined application of TXA may be the most effective way without increased rate of thrombotic events such as deep vein thrombosis (DVT) and pulmonary embolisms (PE) in patients subjected to primary total hip replacement (THA). A meta-analysis was conducted to compare the efficacy and safety of the combined use of tranexamic acid (TXA) relative to topical or intravenous (IV) use alone for treatment of primary THA. The outcomes included total blood loss, postoperative hemoglobin decline, transfusion rates, and the incidence rates of deep vein thrombosis (DVT) and pulmonary embolisms (PE). Methods We searched electronic databases including PubMed, EMBASE, the Cochrane Library, Web of Science, the Chinese Biomedical Literature database, the CNKI database, and Wanfang Data until September 2016. The references of the included articles were also checked for additional potentially relevant studies. There were no language restrictions for the search. The data of the included studies were analyzed using RevMan 5.3 software. Results Seven studies met the inclusion criteria, encompassing a total of 1762 patients. Our meta-analysis demonstrated that total blood loss, postoperative hemoglobin decline, and transfusion rates were significantly lower for patients that received the combined treatment compared to patients that received either topical or intravenous administration of TXA. No statistical differences were found in the incidence of deep venous thrombosis (DVT) or pulmonary embolism (PE). Conclusion The group that received the combined treatment had lower total blood loss, postoperative hemoglobin decline, and transfusion rates without an increased rate of thrombotic events (DVT or PE). The topical or intravenous use of TXA in primary THA is generally considered to be safe and effective. This meta-analysis demonstrated that combined TXA application may be superior to topical or intravenous application of TXA alone. However, larger, high-quality randomized control trials are required for greater confidence in this finding.
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Affiliation(s)
- Pei Zhang
- Dalian Medical University, Dalian, Liaoning, 116044, China
| | - Yuan Liang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Nantong West Road 98, Yangzhou, 225001, China
| | - Pengtao Chen
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Nantong West Road 98, Yangzhou, 225001, China
| | - Yongchao Fang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Nantong West Road 98, Yangzhou, 225001, China
| | - Jinshan He
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Nantong West Road 98, Yangzhou, 225001, China. .,Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou, China.
| | - Jingcheng Wang
- Dalian Medical University, Dalian, Liaoning, 116044, China. .,Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Nantong West Road 98, Yangzhou, 225001, China. .,Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou, China.
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Tranexamic acid versus fibrin sealant in primary total hip replacement: a comparative study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:923-928. [PMID: 28124132 DOI: 10.1007/s00590-017-1910-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 01/16/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND The effectiveness of intravenous tranexamic acid (TA) in reducing blood loss and transfusion requirements during total hip replacement (THR) is well recognised. The aim of this study was to assess the effectiveness of a fibrin sealant in comparison to intravenous TA and a control group. PATIENTS AND METHODS We prospectively studied 273 patients with primary hip osteoarthritis who underwent a THR between February 2012 and September 2013. The first 73 patients acted as the control group. The next 100 consecutive patients received fibrin sealant spray, and the last 100 patients received 1 g TA on induction. RESULTS The demographic characteristics, surgical time, surgeon grade, anaesthetic type and pre-operative haemoglobin of the three groups were comparable. Both fibrin sealant and intravenous TA were effective in reducing blood loss during THR (15%, p = 0.04 and 22.5%, p = 0.01, respectively), when compared to the control group. However, neither treatment was found to be superior to the other in preventing blood loss p = 0.39. Tranexamic acid was superior to fibrin sealant in decreasing allogeneic transfusion requirements (0 vs. 10%, p = 0.05). There was no significant difference between the groups with regard to proportion of patients with wound leaking problems. CONCLUSION Both fibrin sealant and intravenous tranexamic acid were effective in reducing blood loss. However, tranexamic acid use reduced post-operative transfusion requirements.
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Combined use of intravenous and topical tranexamic acid following cementless total hip arthroplasty: a randomised clinical trial. Hip Int 2017; 26:36-42. [PMID: 26391263 DOI: 10.5301/hipint.5000291] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2015] [Indexed: 02/05/2023]
Abstract
PURPOSE This study was designed to compare the efficacy and safety of the combined use of tranexamic acid (TXA) with the intravenous (IV) or local use alone in total hip arthroplasty (THA). METHODS 210 patients were randomised to a IV group, a local group or a combined group. Participants received 1.5 g IV-TXA in the IV group, 3 g local TXA in the local group, or 1 g IV-TXA combined with 2 g local TXA in the combined group. The primary outcomes were total blood loss (TBL), maximum haemoglobin drop, and the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE). RESULTS TBL was (776.75 ± 188.95) ml in the combined group, which was significantly lower than in the IV group or the local group (p = 0.015, p = 0.001 respectively). Likewise, the mean values of maximum hemoglobin drop in the combined, IV, and local groups were 2.98 ± 0.78, 3.36 ± 0.78, and 3.89 ± 0.72 g/dL, respectively, with a significant intergroup difference (p<0.001 for all). Asymptomatic DVT was detected in 1 patient of the IV group, and 2 patients of the combined group with the use of ultrasound. There were no episodes of PE, and no significant differences were seen between groups in terms of complications. CONCLUSIONS Combined use of intravenous TXA and local TXA in primary unilateral THA can effectively decrease total blood loss and increase postoperative haemoglobin levels without influencing complication rates. It is suggested that this combined TXA regimen is more effective in decreasing blood loss in cementeless THA than intravenous or local administration alone.
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Melo GLR, Lages DS, Madureira Junior JL, Pellucci GDP, Pellucci JWJ. O uso do ácido tranexâmico em pacientes submetidos a artroplastia total primária do quadril: uma avaliação do seu impacto em diferentes protocolos de administração. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2017.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Wang Z, Xiao L, Guo H, Zhao G, Ma J. The efficiency and safety of fibrin sealant for reducing blood loss in primary total hip arthroplasty: A systematic review and meta-analysis. Int J Surg 2016; 37:50-57. [PMID: 27939268 DOI: 10.1016/j.ijsu.2016.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 12/01/2016] [Accepted: 12/04/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Total hip arthroplasty (THA) is associated with substantial blood loss. The objective of present systematic review and meta-analysis is to provide evidence from randomized controlled trials (RCTs) on the efficiency and safety of administration of fibrin sealant (FS) for reducing blood loss in patients undergoing primary THA. METHODS Potential relevant studies were identified from electronic databases including Medline, PubMed, Embase, ScienceDirect, web of science and Cochrane Library. Gray academic studies were also identified from the reference list of included studies. There was no language restriction. Pooling of data was carried out by using RevMan 5.1. RESULTS Six randomized controlled trials (RCTs) met the inclusion criteria. Current meta-analysis indicated that there were significant differences in terms of total blood loss (MD = -153.77, 95% CI: -287.21 to -20.34, P = 0.02), postoperative hemoglobin level (MD = -0.25, 95% CI: -0.46 to -0.05, P = 0.02) and transfusion rate (RD = -0.12, 95% CI: -0.22 to -0.03, P = 0.01) between groups. No significant differences were found regarding the incidence of deep venous thrombosis (DVT) (RD = 0.00, 95% CI: -0.01to 0.01, P = 0.51) or other side effects. CONCLUSION Administration of fibrin sealant in total hip arthroplasty may reduce total blood loss, postoperative hemoglobin decline and transfusion requirements. Moreover, no adverse effect was related to FS. Due to the limited quality of the evidence currently available, higher quality RCTs are required.
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Affiliation(s)
- Zhiyuan Wang
- Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, 710054, PR China
| | - Lin Xiao
- Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, 710054, PR China
| | - Hao Guo
- Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, 710054, PR China
| | - Guanghui Zhao
- Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, 710054, PR China
| | - Jianbing Ma
- Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, 710054, PR China.
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Zhang P, Liang Y, Chen P, Fang Y, He J, Wang J. Intravenous versus topical tranexamic acid in primary total hip replacement: A meta-analysis. Medicine (Baltimore) 2016; 95:e5573. [PMID: 27977590 PMCID: PMC5268036 DOI: 10.1097/md.0000000000005573] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND As the prevalence of total hip arthroplasty (THA) is increasing, it is usually associated with considerable blood loss. Tranexamic acid (TXA) has been reported to reduce perioperative blood loss in hip joint arthroplasty. But the best route of TXA administration continues to be controversial. So, we conducted a meta-analysis that integrated all data from the 7 included trials to compare the effectiveness and safety of topical and intravenous TXA administration in primary THA. The endpoints assessed in this meta-analysis include the comparisons of total blood loss, postoperative hemoglobin decline, transfusion rates, the incidence rate of deep vein thrombosis (DVT), pulmonary embolisms (PE), and wound infection. METHODS Literature searches of PubMed, EMBASE, the Cochrane Library, the Chinese Biomedical Literature database, the CNKI database, and Wan Fang Data were performed up to August 30, 2016. Randomized controlled trials (RCTs) were included in our meta-analysis if they compared the efficiency and safety of intravenous versus topical administration of TXA in patients who underwent primary THA. The endpoints included the comparisons of total blood loss, postoperative hemoglobin decline, transfusion rates, the incidence rate of DVT, PE, and wound infection. A meta-analysis was performed following the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. The pooling of data was carried out by using RevMan 5.3, Denmark. RESULTS Seven RCTs involving 964 patients met the inclusion criteria. Our meta-analysis indicated that there were no significant differences in the 2 groups in terms of total blood loss ([mean difference (MD) = -14.74, 95% confidence interval (CI): -89.21 to 59.74, P = 0.7], transfusion rates [RD = -0.02, 95% CI: -0.05 to 0.02, P = 0.39]; no significant differences were found regarding the incidence of adverse effects such as deep venous thrombosis [DVT] [RD = 0.00, 95% CI: -0.01 to 0.01, P = 1.00], PE [RD = 0.00, 95% CI: -0.01 to 0.01, P = 0.71], or wound infection [RD = -0.01, 95% CI: -0.06 to 0.04, P = 0.66]). The pooled results showed that the intravenous groups had a lower postoperative hemoglobin decline (MD = -0.47, 95% CI: -0.74 to -0.20, P = 0.0006). It was probably due to insufficient data and the varied reporting of outcomes. There was some inherent heterogeneity due to the small sample size of each primary study. CONCLUSION The topical and intravenous administrations of TXA have a similar effect on the decrease of blood loss without an increased risk of complications (DVT, PE, and wound infection). Intravenous TXA administration may have a maximum efficacy. Topical TXA administration may be preferred in patients who with high risk of thromboembolic events. However, larger, high-quality RCTs are required to explore the optimal regimen, dosage, timing still in the future in order to recommend TXA widespread use in total joint arthroplasty.
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Affiliation(s)
- Pei Zhang
- Dalian Medical University, Dalian, Liaoning
| | - Yuan Liang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou, Jiangsu, China
| | - Pengtao Chen
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou, Jiangsu, China
| | - Yongchao Fang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou, Jiangsu, China
| | - Jinshan He
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou, Jiangsu, China
| | - Jingcheng Wang
- Dalian Medical University, Dalian, Liaoning
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou, Jiangsu, China
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Li J, Li HB, Zhai XC, Qin-lei, Jiang XQ, Zhang ZH. Topical use of topical fibrin sealant can reduce the need for transfusion, total blood loss and the volume of drainage in total knee and hip arthroplasty: A systematic review and meta-analysis of 1489 patients. Int J Surg 2016; 36:127-137. [DOI: 10.1016/j.ijsu.2016.10.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 10/15/2016] [Indexed: 10/20/2022]
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A systematic review and meta-analysis of the use of antifibrinolytic agents in total hip arthroplasty. Hip Int 2016; 25:502-9. [PMID: 26620803 DOI: 10.5301/hipint.5000285] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Antifibrinolytic agents such as tranexamic acid (TXA), epsilon aminocaproic acid (EACA), and aprotinin are widely used to reduce bleeding and the need for transfusion in cardiac, orthopaedic, and hepatic surgery. We aimed to assess the efficacy and safety of antifibrinolytic agents in total hip arthroplasty (THA). METHODS A systematic literature search was performed using MEDLINE, PubMed, EMBASE, and Cochrane databases, as well as the reference lists of relevant articles. Only randomised controlled trials were eligible for this study. The weighted mean difference in blood loss, number of transfusions per patient, and the summary risk ratio of transfusion requirements and deep-vein thrombosis (DVT) were calculated in the antifibrinolytic agents-treated and control groups. RESULTS A total of 28 randomised controlled trials involving 2,131 patients were included. Patients receiving antifibrinolytic agents had a reduced total blood loss by a mean of 389.14 ml (95% CI, -483.05 to -295.23), and the number of blood transfusions per patient by 0.65 units (95% CI, -1.19 to -0.12). Antifibrinolytic agents led to a significant reduction in transfusion requirements (RR 0.55; 95% CI, 0.43 to 0.70) and no increase in the risk of DVT (RR 0.85; 95% CI, 0.51 to 1.42). CONCLUSIONS Our meta-analysis demonstrated that antifibrinolytic agents significantly reduce blood loss and blood transfusion requirements while not increasing the risk of DVT in patients undergoing total hip arthroplasty.
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Moskal JT, Capps SG. Meta-analysis of Intravenous Tranexamic Acid in Primary Total Hip Arthroplasty. Orthopedics 2016; 39:e883-92. [PMID: 27248332 DOI: 10.3928/01477447-20160526-02] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/11/2016] [Indexed: 02/03/2023]
Abstract
Previous meta-analyses established that tranexamic acid confers benefits when used during total hip arthroplasty (THA). However, 2 of these meta-analyses included a variety of routes of administration of tranexamic acid in THA (topical, intravenous, oral, and intra-articular), another meta-analysis included a variety of antifibrinolytic drugs (not restricted to a single drug), and the final meta-analysis included nonrandomized controlled trials. This meta-analysis focused on a single medication, tranexamic acid, administered in a specific way, intravenously in patients undergoing primary THA, using data reported only in randomized controlled studies. Outcomes were restricted to blood loss, allogeneic transfusion rates, and complications. Other outcomes, such as return to function or clinical scores, could not be evaluated because of lack of consistent reporting. To better understand the effects of intravenous tranexamic acid in THA on clinical outcomes, such as recovery, return to function, and patient-reported outcome measures, it would be helpful to have more controlled trials examining these measures in a standardized manner. Intravenous tranexamic acid was beneficial for blood loss intraoperatively, blood loss through drains, and total blood loss during hospitalization, in addition to reducing allogeneic transfusion rates. No difference between intravenous tranexamic acid and placebo was found for most complications, except deep venous thrombosis, which showed favorable results with placebo. [Orthopedics.2016; 39(5):e883-e892.].
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Gao F, Ma J, Sun W, Guo W, Li Z, Wang W. Topical fibrin sealant versus intravenous tranexamic acid for reducing blood loss following total knee arthroplasty: A systematic review and meta-analysis. Int J Surg 2016; 32:31-7. [DOI: 10.1016/j.ijsu.2016.06.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/13/2016] [Accepted: 06/11/2016] [Indexed: 10/21/2022]
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Abstract
OBJECTIVE To evaluate the net clinical benefit of tranexamic acid use in patients undergoing total knee or total hip replacement. METHODS This is a retrospective study of patients undergoing total knee or total hip replacement. The primary outcome was the net clinical benefit of tranexamic acid use. Secondary outcomes included length of stay, incidence of venous thromboembolism, change in hemoglobin, and number of units of blood transfused. RESULTS Four hundred and six patients were screened for inclusion and 327 patients met inclusion criteria; 174 patients received tranexamic acid versus 153 patients who received usual care. Tranexamic acid demonstrated a positive net clinical benefit versus usual care (40.8% vs 13.7%, P < .01) but did not affect length of stay (3.39 vs 3.37 days, respectively, P = .76). Venous thromboembolism was comparable between groups (2.3% vs 0.7%, P = .38). Average change in hemoglobin and need for transfusion were lower in the treatment group versus the usual care group, respectively (3.46 vs 4.26 mg/dL, P < .01). CONCLUSION Tranexamic acid demonstrated a significant benefit in decreasing change in hemoglobin as well as the need for blood transfusion with no increase in the risk of venous thromboembolism in patients undergoing total knee or total hip replacement.
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Affiliation(s)
| | - Mate M Soric
- 1 Northeast Ohio Medical University, Rootstown, OH, USA.,2 Internal Medicine, University Hospitals Geauga Medical Center, Chardon, OH, USA
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Min JK, Zhang QH, Li HD, Li H, Guo P. The Efficacy of Bipolar Sealer on Blood Loss in Primary Total Hip Arthroplasty: A Meta-Analysis. Medicine (Baltimore) 2016; 95:e3435. [PMID: 27175643 PMCID: PMC4902485 DOI: 10.1097/md.0000000000003435] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The blood loss during total hip arthroplasty is difficult to manage and there is no consensus about the effect of bipolar sealer used during operation. Thus, a systematic review of randomized controlled trials (RCTs) was performed to evaluate the efficacy and safety of blood loss using bipolar sealer after total hip arthroplasty (THA).Relevant literature of comparisons of bipolar sealer after THA for blood loss were searched for in Embase, PubMed, Web of Science, the Cochrane Central Register of Controlled Trials, and Google scholar from their inception to October, 2015. High-quality RCTs were selected to evaluate the need for transfusion, blood loss, and other complications. The software RevMan 5.30 was used for the meta-analysis.Six studies reporting on 6 RCTs comprising 751 patients were included. Compared with standard electrocautery, bipolar sealer was associated with lower rates of need for transfusion (relative risk [RR] = 0.60; 95% confidence interval [CI] 0.39-0.94), estimated blood loss (mean differences [MD] = -127.39; 95% CI -233.32 to -21.46; P = 0.02), and lower total blood loss (MD = -226.57; 95% CI -350.80-102.34; P = 0.0004). There is no significant difference between the hemoglobin drop, blood loss in drainage, intraoperative blood loss, Harris score, and rates of infection.The present meta-analysis indicated that bipolar sealer can decrease the need for transfusion and total blood loss; however, there is no benefit of bipolar sealer from the recovery. It is still need for samples to determine the balance between the economic cost and transfusion.
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Affiliation(s)
- Ji-Kang Min
- From the Department of Orthopaedics, The First People's Hospital of Huzhou, Huzhou, Zhe Jiang Province, China
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Estcourt LJ, Desborough M, Brunskill SJ, Doree C, Hopewell S, Murphy MF, Stanworth SJ. Antifibrinolytics (lysine analogues) for the prevention of bleeding in people with haematological disorders. Cochrane Database Syst Rev 2016; 3:CD009733. [PMID: 26978005 PMCID: PMC4838155 DOI: 10.1002/14651858.cd009733.pub3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND People with haematological disorders are frequently at risk of severe or life-threatening bleeding as a result of thrombocytopenia (reduced platelet count). This is despite the routine use of prophylactic platelet transfusions to prevent bleeding once the platelet count falls below a certain threshold. Platelet transfusions are not without risk and adverse events may be life-threatening. A possible adjunct to prophylactic platelet transfusions is the use of antifibrinolytics, specifically the lysine analogues tranexamic acid (TXA) and epsilon aminocaproic acid (EACA). This is an update of a Cochrane review first published in 2013. OBJECTIVES To determine the efficacy and safety of antifibrinolytics (lysine analogues) in preventing bleeding in people with haematological disorders. SEARCH METHODS We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (The Cochrane Library 2016, Issue 3), MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1937), the Transfusion Evidence Library (from 1950) and ongoing trial databases to 07 March 2016. SELECTION CRITERIA We included RCTs involving participants with haematological disorders, who would routinely require prophylactic platelet transfusions to prevent bleeding. We only included trials involving the use of the lysine analogues TXA and EACA. DATA COLLECTION AND ANALYSIS Two review authors independently screened all electronically-derived citations and abstracts of papers, identified by the review search strategy, for relevancy. Two review authors independently assessed the full text of all potentially relevant trials for eligibility, completed the data extraction and assessed the studies for risk of bias using The Cochrane Collaboration's 'Risk of bias' tool. We requested missing data from one author but the data were no longer available. The outcomes are reported narratively: we performed no meta-analyses because of the heterogeneity of the available data. MAIN RESULTS We identified three new studies in this update of the review. In total seven studies were eligible for inclusion, three were ongoing RCTs and four were completed studies. The four completed studies were included in the original review and the three ongoing studies were included in this update. We did not identify any RCTs that compared TXA with EACA.Of the four completed studies, one cross-over TXA study (eight participants) was excluded from the outcome analysis because it had very flawed study methodology. Data from the other three studies were all at unclear risk of bias due to lack of reporting of study methodology.Three studies (two TXA (12 to 56 participants), one EACA (18 participants) reported in four articles (published 1983 to 1995) were included in the narrative review. All three studies compared the drug with placebo. All three studies included adults with acute leukaemia receiving chemotherapy. One study (12 participants) only included participants with acute promyelocytic leukaemia. None of the studies included children. One of the three studies reported funding sources and this study was funded by a charity.We are uncertain whether antifibrinolytics reduce the risk of bleeding (three studies; 86 participants; very low-quality evidence). Only one study reported the number of bleeding events per participant and there was no difference in the number of bleeding events seen during induction or consolidation chemotherapy between TXA and placebo (induction; 38 participants; mean difference (MD) 1.70 bleeding events, 95% confidence interval (CI) -0.37 to 3.77: consolidation; 18 participants; MD -1.50 bleeding events, 95% CI -3.25 to 0.25; very low-quality evidence). The two other studies suggested bleeding was reduced in the antifibrinolytic study arm, but this was statistically significant in only one of these two studies.Two studies reported thromboembolism and no events occurred (68 participants, very low-quality evidence).All three studies reported a reduction in platelet transfusion usage (three studies, 86 participants; very low-quality evidence), but this was reported in different ways and no meta-analysis could be performed. No trials reported the number of platelet transfusions per participant. Only one study reported the number of platelet components per participant and there was a reduction in the number of platelet components per participant during consolidation chemotherapy but not during induction chemotherapy (consolidation; 18 participants; MD -5.60 platelet units, 95% CI -9.02 to -2.18: induction; 38 participants, MD -1.00 platelet units, 95% CI -9.11 to 7.11; very low-quality evidence).Only one study reported adverse events of TXA as an outcome measure and none occurred. One study stated side effects of EACA were minimal but no further information was provided (two studies, 74 participants, very low-quality evidence).None of the studies reported on the following pre-specified outcomes: overall mortality, adverse events of transfusion, disseminated intravascular coagulation (DIC) or quality of life (QoL). AUTHORS' CONCLUSIONS Our results indicate that the evidence available for the use of antifibrinolytics in haematology patients is very limited. The trials were too small to assess whether or not antifibrinolytics decrease bleeding. No trials reported the number of platelet transfusions per participant. The trials were too small to assess whether or not antifibrinolytics increased the risk of thromboembolic events or other adverse events. There are three ongoing RCTs (1276 participants) due to be completed in 2017 and 2020.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Michael Desborough
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Susan J Brunskill
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Sally Hopewell
- University of OxfordOxford Clinical Trials Research UnitNDORMSWindmill RoadOxfordOxfordshireUKOX3 7LD
| | - Michael F Murphy
- Oxford University Hospitals and the University of OxfordNHS Blood and Transplant; National Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe HospitalHeadingtonOxfordUK
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and the University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
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Wang C, Kang P, Ma J, Yue C, Xie J, Pei F. Single-dose tranexamic acid for reducing bleeding and transfusions in total hip arthroplasty: A double-blind, randomized controlled trial of different doses. Thromb Res 2016; 141:119-23. [PMID: 27016618 DOI: 10.1016/j.thromres.2016.02.027] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/14/2016] [Accepted: 02/24/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Tranexamic acid can be effective at decreasing blood loss and transfusion requirements associated with total hip arthroplasty (THA), but few studies have compared the efficacy of different intravenous dosing regimes. This double-blind, randomized controlled trial compared the ability of two doses of intravenous TXA (IV-TXA, 10 or 15mg/kg) to reduce bleeding and transfusions associated with THA. MATERIALS AND METHODS A total of 124 patients scheduled for THA were consecutively randomized 1:1:1 into three parallel arms: control (placebo), 10mg/kg IV-TXA and 15mg/kg IV-TXA. RESULTS The proportion of patients who experienced bleeding and required transfusions was significantly lower in the 15mg/kg IV-TXA group (1 of 42, 2.4%) than in the 10mg/kg IV-TXA group (8 of 39, 20.5%; P=0.012) and in the control group (10 of 38, 26.3%; P=0.002). In fact, this proportion was similar between the 10mg/kg IV-TXA and control groups (P=0.547). Ultrasound examination on postoperative day 3 revealed only one case of asymptomatic deep vein thrombosis (in the femoral vein) in the 10mg/kg IV-TXA group, which was managed by administering low-molecular-weight heparin. No cases of deep-vein thrombosis were observed in the other two groups. No cases of symptomatic pulmonary embolism were observed. CONCLUSION IV-TXA at 10mg/kg significantly reduced blood loss and mitigated the decrease in hemoglobin and hematocrit after THA, but it did not significantly reduce the need for transfusions. In contrast, a dose of 15mg/kg reduced both bleeding and transfusion requirements. Our results argue for a dose of 15mg/kg when using single-dose IV-TXA. LEVEL OF EVIDENCE Therapeutic Level I.
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Affiliation(s)
- Changde Wang
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province 610041, China; Department of Orthopedic Surgery, Affiliated Hospital, Northwest University for Nationalities, Lanzhou, Gansu Province 730030, China.
| | - Pengde Kang
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province 610041, China.
| | - Jun Ma
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province 610041, China.
| | - Chen Yue
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province 610041, China.
| | - Jinwei Xie
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province 610041, China.
| | - Fuxing Pei
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province 610041, China.
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McLawhorn AS, Levack AE, Fields KG, Sheha ED, DelPizzo KR, Sink EL. Association of Epsilon-Aminocaproic Acid With Blood Loss and Risk of Transfusion After Periacetabular Osteotomy: A Retrospective Cohort Study. J Arthroplasty 2016; 31:626-32. [PMID: 26626774 DOI: 10.1016/j.arth.2015.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 10/02/2015] [Accepted: 10/09/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Periacetabular osteotomy (PAO) reorients the acetabular cartilage through a complex series of pelvic osteotomies, which risks significant blood loss often necessitating blood transfusion. Therefore, it is important to identify effective strategies to manage blood loss and decrease morbidity after PAO. The purpose of this study was to determine the association of epsilon-aminocaproic acid (EACA), an antifibrinolytic agent, with blood loss from PAO. METHODS Ninety-three patients out of 110 consecutive patients that underwent unilateral PAO for acetabular dysplasia met inclusion criteria. Fifty patients received EACA intraoperatively. Demographics, autologous blood predonation, anesthetic type, intraoperative estimated blood loss (EBL), cell-saver utilization, and transfusions were recorded. Total blood loss was calculated. Two-sample t-test and chi-square or Fisher's exact test were used as appropriate. The associations between EACA administration and calculated EBL, cell-saver utilization, intraoperative EBL, and maximum difference in postoperative hemoglobin were assessed via multiple regression, adjusting for confounders. Post hoc power analysis demonstrated sufficient power to detect a 250-mL difference in calculated EBL between groups. Alpha level was 0.05 for all tests. RESULTS No demographic differences existed between groups. Mean blood loss and allogeneic transfusion rates were not statistically significant between groups (P = .093 and .170, respectively). There were no differences in cell-saver utilization, intraoperative EBL, and/or postoperative hemoglobin. There was a higher rate of autologous blood utilization in the group not receiving EACA because of a clinical practice change. CONCLUSIONS EACA administration was not associated with a statistically significant reduction in blood loss or allogeneic transfusion in patients undergoing PAO.
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Affiliation(s)
| | - Ashley E Levack
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Kara G Fields
- Healthcare Research Institute, Hospital for Special Surgery, New York, New York
| | - Evan D Sheha
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Kathryn R DelPizzo
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York
| | - Ernest L Sink
- Department of Orthopaedic Surgery, Center for Hip Preservation, Hospital for Special Surgery, New York, New York
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Low Dose Perioperative Intravenous Tranexamic Acid in Patients Undergoing Total Knee Arthroplasty: A Double-Blind Randomized Placebo Controlled Clinical Trial. JOURNAL OF BLOOD TRANSFUSION 2015; 2015:948304. [PMID: 26770871 PMCID: PMC4684898 DOI: 10.1155/2015/948304] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 10/22/2015] [Accepted: 10/26/2015] [Indexed: 01/07/2023]
Abstract
Background and Objectives. The null hypothesis of this study was that TA has no effect on postsurgical bleeding in patients undergoing TKA. Methods. This study was a double-blind randomized trial. In the first group (T) patients received 500 mg of intravenous Tranexamic acid (TA) twice (once preoperatively and once 3 hours postoperatively) and in the second group (P) they received slow infusion of normal saline as placebo. The primary outcome of the study was the level of Hb 48 hours after surgery. Results. Hb levels 48 hours after surgery as the primary outcome were 10.92 ± 0.97 and 10.23 ± 0.98 (g/dL) in groups T and P, respectively, and the difference was statistically significant (P = 0.001). Statistically significant differences were also observed in Hb levels 6 and 24 hours after surgery, the drain output 48 hours after surgery, and the number of units of packed cells transfused between study groups (P < 0.05). There was no significant difference in duration of hospitalization between the study groups (P = n.s.). Conclusions. The low dose perioperative intravenous TA significantly reduces blood loss, requirement for blood transfusion, and drain output in patients undergoing TKA. However, duration of hospitalization did not change significantly.
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Abstract
Perioperative blood loss is a significant concern for patients undergoing total joint arthroplasty. A growing body of evidence has shown tranexamic acid (TXA) to be effective in decreasing perioperative blood loss and transfusion requirements in both primary and revision hip and knee arthroplasty. TXA is a synthetic drug that limits blood loss through inhibition of fibrinolysis and clot degradation. Both topical and intravenous administration of TXA, in a variety of dosing regimens, has proven effective. Further investigation is required to determine the optimal dose and dosing regimens; however, evidence exists to recommend an initial intravenous dose be given before beginning the procedure, with at least one additional intravenous dose administered postoperatively. Additionally, topical TXA doses >2 g appear to be more efficacious than lower doses. Finally, relatively few adverse reactions have been reported in arthroplasty patients, and no study to date has demonstrated an increased risk of symptomatic venous thromboembolic events in this patient population.
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Baker JE, Pavenski K, Pirani RA, White A, Kataoka M, Waddell JP, Ho A, Schemitsch EH, Lo N, Bogoch ER, Pronovost A, Luke K, Howell A, Nassis A, Tsui AKY, Tanzini RM, Pulendrarajah R, Mazer CD, Freedman J, Hare GMT. Universal tranexamic acid therapy to minimize transfusion for major joint arthroplasty: a retrospective analysis of protocol implementation. Can J Anaesth 2015; 62:1179-87. [PMID: 26335903 DOI: 10.1007/s12630-015-0460-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 08/13/2015] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Tranexamic acid (TXA) therapy can reduce red blood cell (RBC) transfusion; however, this therapy remains underutilized in many surgical patient populations. We assessed whether implementation of a protocol to facilitate universal administration of TXA in patients undergoing total hip or knee arthroplasty would reduce the incidence of RBC transfusion without increasing adverse clinical outcomes. METHODS We implemented a quality of care policy to provide universal administration of intravenous TXA at a dose of 20 mg·kg(-1) iv to all eligible patients undergoing total hip or knee arthroplasty from October 21, 2013 to April 30, 2014. We compared data from an equal number of patients before and after protocol implementation (n = 422 per group). The primary outcome was RBC transfusion with secondary outcomes including postoperative hemoglobin concentration (Hb) and length of hospital stay. Adverse events were identified from the electronic medical records. Data were analyzed by a Chi square test and adjusted logistic and linear regression analysis. RESULTS Implementation of the protocol resulted in an increase in TXA utilization from 45.8% to 95.3% [change 49.5%; 95% confidence interval (CI), 44.1 to 54.5; P < 0.001]. This change was associated with a reduction in the rate of RBC transfusion from 8.8% to 5.2%, (change -3.6%; 95% CI, -0.1 to -7.0; P = 0.043). Pre- and post-protocol mean [standard deviation (SD)] Hb values were similar, including the nadir Hb prior to RBC transfusion [72 (8) g·L(-1) vs 70 (8) g·L(-1), respectively; mean difference -1 g·L(-1); 95% CI, -3 to 5; P = 0.569]. Length of stay was not altered, and no increase in adverse events was observed. CONCLUSIONS Implementation of a perioperative TXA protocol was associated with both an increase in TXA use and a reduction in RBC transfusion following hip or knee arthroplasty. Adverse events and length of hospital stay were not influenced by the protocol.
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Affiliation(s)
- James E Baker
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada
| | - Katerina Pavenski
- St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.,Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Razak A Pirani
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada
| | - Alexander White
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada
| | - Mark Kataoka
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada
| | - James P Waddell
- Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alexander Ho
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada
| | - Emil H Schemitsch
- Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Nick Lo
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada
| | - Earl R Bogoch
- Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Antoine Pronovost
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada
| | - Katherine Luke
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Ontario Transfusion Coordinators (ONTraC), Toronto, ON, Canada
| | - Alanna Howell
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Ontario Transfusion Coordinators (ONTraC), Toronto, ON, Canada
| | - Anna Nassis
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Ontario Transfusion Coordinators (ONTraC), Toronto, ON, Canada
| | - Albert K Y Tsui
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Rosa Maria Tanzini
- Department of Pharmacy, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Robisa Pulendrarajah
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - John Freedman
- St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.,Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Gregory M T Hare
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada. .,Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
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Prospective randomised evaluation of a collagen/thrombin and autologous platelet haemostatic agent during cementless total hip arthroplasty. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:455-63. [PMID: 26057484 DOI: 10.2450/2015.0291-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 02/02/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Total hip arthroplasty (THA) can be associated with substantial peri-operative blood loss which can negatively influence a patient's clinical outcome. Few haemostatic agents have been tested in THA. The aim of this study was to determine whether the use of a collagen/thrombin/ autologous platelet haemostatic agent would result in a significant decrease of blood transfusions for patients undergoing primary THA. MATERIALS AND METHODS THA patients meeting inclusion/exclusion criteria (n=109) were enrolled in this prospective, double-blind trial and randomised to a treatment arm (standard haemostatic methods plus haemostatic agent) or control arm (standard haemostatic methods only). The primary outcome was transfusion. Secondary outcome measures included peri-operative narcotic usage and post-operative haemoglobin levels, pain scores, function, and general health quality of life. RESULTS Transfusions were required by 5/60 (8.3%) patients in the treatment group and 7/49 (14.3%) in the control group (p=0.33). The mean number of units transfused was not significantly different between the treatment group (2.2±1.3) and the control group (1.6±0.5) (p=0.36). Haemoglobin values on post-operative days 1, 2, and 3 were significantly higher in the treatment group (p=0.002, 0.04, and 0.02, respectively). Hip Disability and Osteoarthritis Outcome Score and Short Form-12 scores were not different between the two groups. DISCUSSION In relatively healthy patients undergoing primary cementless THA there was no significant difference in number of transfusions or number of units transfused. It is unlikely that we will routinely use the investigated haemostatic agent to reduce blood loss in a healthy patient undergoing THA. The product may have some benefit in patients who refuse blood transfusions, have minimal ability to increase blood volume, are undergoing total joint revision, or have markedly low pre-operative haemoglobin levels, but this needs to be demonstrated.
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Nadeau RP, Howard JL, Naudie DDR. Antifibrinolytic Therapy for Perioperative Blood Conservation in Lower-Extremity Primary Total Joint Arthroplasty. JBJS Rev 2015; 3:01874474-201506000-00001. [PMID: 27490016 DOI: 10.2106/jbjs.rvw.n.00068] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Richard P Nadeau
- Department of Surgery, Division of Orthopaedics, Schulich School of Medicine, Western University, London Health Sciences Center, University Hospital, 339 Windermere Road, London, Ontario, Canada, N6A 5A5
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Abstract
Periprosthetic joint infection (PJI) has moved into the first place as the cause of failure following total knee arthroplasty (TKA). Recent studies have shown that PJI results in higher mortality in patients than many cancers. The economic burden of treating PJI is likely to exceed $1 billion this year in the US. Thus, it is paramount that all efforts are invested to prevent this dreaded complication after total joint arthroplasty (TJA). This article summarizes some of the most effective and proven strategies for prevention of PJI. It is hoped that the article will be of benefit to the readers of the journal.
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Pinzón-Florez CE, Vélez Cañas KM, Díaz Quijano DM. Efficiency of tranexamic acid in perioperative blood loss in hip arthroplasty: a systematic literature review and meta-analysis. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:253-264. [PMID: 25542068 DOI: 10.1016/j.redar.2014.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 09/30/2014] [Accepted: 10/01/2014] [Indexed: 06/04/2023]
Abstract
INTRODUCTION AND OBJECTIVE Tranexamic acid (TXA) is an antifibrinolytic drug used to reduce bleeding in mortality risk situations such as trauma. Our objective was to conduct a systematic literature review to evaluate the effectiveness and safety of TXA in reducing bleeding in hip arthroplasty. MATERIAL AND METHODS A systematic literature review and meta-analysis of primary studies similar to controlled trials was performed. Literature was searched in MEDLINE, Embase, Cochrane, LILACS, SciELO and Google Scholar. The review was proposed and undertaken by 2 reviewers and the inclusion criteria were: a) patients undergoing arthroplasty for primary unilateral hip replacement; b) comparison of a treatment group with TXA to a control group that received a placebo or no treatment at all, and c) outcome measures, total blood loss, number of patients receiving allogeneic transfusion and/or incidence of thromboembolic complications. The search was restricted to studies published from 1966 to June 2013. RESULTS A total of 16 studies with 246 patients were retrieved for this review. The total blood loss outcome evidenced a weighted mean difference in favor of TXA vs. controls undergoing hip arthroplasty (-0.45 [P<0.001, 95% CI -0.65 to -0.24]). Weighted relative risk was estimated for the allogeneic transfusion requirement outcome, showing a trend in favor the TXA arm, with fewer patients requiring allogeneic transfusion in hip surgery (0.8 [P<0.02, 95% CI 0.57 to 1.11]); however, this trend was not statistically significant. LIMITATIONS There is a noticeable difference in methods for quantifying total blood loss across the studies reviewed. The need for transfusion outcomes are probably not significant taking into account the number of events in the TXA group. CONCLUSIONS TXA can be routinely used to reduce intra- and post-operative blood loss in primary hip arthroplasty.
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Affiliation(s)
- C E Pinzón-Florez
- Grupo de Investigación Clínica, Facultad de Medicina, Universidad de La Sabana, Chía, Cundinamarca, Colombia.
| | - K M Vélez Cañas
- Programa de Anestesiología, Facultad de Medicina, Universidad del Rosario, Bogotá D. C., Colombia
| | - D M Díaz Quijano
- Grupo de Investigación Clínica, Facultad de Medicina, Universidad de La Sabana, Chía, Cundinamarca, Colombia
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Hourlier H, Reina N, Fennema P. Single dose intravenous tranexamic acid as effective as continuous infusion in primary total knee arthroplasty: a randomised clinical trial. Arch Orthop Trauma Surg 2015; 135:465-71. [PMID: 25666288 DOI: 10.1007/s00402-015-2168-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION A randomised, double-blind clinical trial was conducted comparing the efficacy of tranexamic acid (TXA) as a single intravenous bolus or a continuous infusion to patients undergoing total knee arthroplasty (TKA). Study hypothesis was that a second dose of TXA would not offer any clinical benefits over the single infusion. MATERIALS AND METHODS One hundred and six patients were randomised to a single intraoperative dose of 30 mg/kg tranexamic acid (OS group, n = 54), or to a loading dose of 10 mg/kg tranexamic acid followed 2 h later by a continuous 2 mg/kg/h infusion for 20 h (OD group, n = 52). The primary outcome was blood loss calculated from haematological values and perioperative transfusions. Secondary outcomes included the occurrence of major complications within the first postoperative year. RESULTS All patients completed tranexamic acid therapy without adverse events. The mean blood loss was 1,148 ± 585 ml in group OS and 1,196 ± 614 ml in group OD (p = 0.68). No patients received a transfusion. There were no occurrences of major complications up to 6-weeks follow-up. CONCLUSIONS The study demonstrated that a single bolus of tranexamic acid 30 mg/kg is as effective as a continuous infusion in patients undergoing tranexamic acid. The single application of tranexamic acid as part of routine care is recommended.
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Affiliation(s)
- Hervé Hourlier
- Department of Orthopedic Surgery, Polyclinique de la Thiérache, Rue du Dr Koral, 59212, Wignehies, France,
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Shander A, Kaplan LJ, Harris MT, Gross I, Nagarsheth NP, Nemeth J, Ozawa S, Riley JB, Ashton M, Ferraris VA. Topical hemostatic therapy in surgery: bridging the knowledge and practice gap. J Am Coll Surg 2014; 219:570-9.e4. [PMID: 25151345 DOI: 10.1016/j.jamcollsurg.2014.03.061] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/02/2014] [Accepted: 03/03/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology, Critical Care Medicine, and Hyperbaric Medicine, Englewood Hospital & Medical Center, Englewood, NJ; Department of Surgery, Englewood Hospital & Medical Center, Englewood, NJ; Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Lewis J Kaplan
- Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale School of Medicine, New Haven, CT; Tactical Medicine, Tactical Police Surgeon, Police Departments, South Central SWAT North Haven, North Branford, East Haven, CT
| | - Michael T Harris
- Department of Surgery, Englewood Hospital & Medical Center, Englewood, NJ; Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Irwin Gross
- Department of Transfusion Services, Eastern Maine Medical Center, Bangor, ME
| | - Nimesh P Nagarsheth
- Department of Obstetrics and Gynecology, Englewood Hospital & Medical Center, Englewood, NJ; Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeffrey Nemeth
- Department of Pharmacy, Englewood Hospital & Medical Center, Englewood, NJ
| | - Sherri Ozawa
- Institute for Bloodless Medicine and Patient Blood Management, Englewood Hospital & Medical Center, Englewood, NJ
| | - Jeffrey B Riley
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester MN
| | | | - Victor A Ferraris
- Division of Cardiothoracic Surgery, University of Kentucky, Lexington, KY
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Chang CH, Chang Y, Chen DW, Ueng SWN, Lee MS. Topical tranexamic acid reduces blood loss and transfusion rates associated with primary total hip arthroplasty. Clin Orthop Relat Res 2014; 472:1552-7. [PMID: 24385043 PMCID: PMC3971210 DOI: 10.1007/s11999-013-3446-0] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 12/20/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Systemic tranexamic acid can decrease blood loss and rates of transfusion in patients undergoing total hip arthroplasty (THA). However, the efficacy of topical tranexamic acid in THA has only recently been characterized in a small number of studies. QUESTIONS/PURPOSES The purpose of this study was to compare (1) the greatest hemoglobin decrease after surgery; (2) transfusion rates; and (3) symptomatic thromboembolic events among patients undergoing THA who did and did not receive topical tranexamic acid. METHODS We retrospectively compared 135 patients (154 THAs) who received 10 mL 5% tranexamic acid added in a topical cocktail solution during surgery between January 2009 and July 2011 with 211 patients (234 THAs) who received only the topical cocktail solution (analgesic and antibiotic agent) between January 2005 and December 2008. Contraindications for the use of tranexamic acid included a documented history of a venous thromboembolic event, an allergy to tranexamic acid, thrombophilia, or a high risk of venous thromboembolism based on the guidelines of the American Academy of Orthopaedic Surgeons; the 135 patients who received it during that period represented 99.4% of the patients undergoing THA during that time. We compared changes in Hb, transfusion rates, estimated blood loss, surgical results, and complications between the groups. The transfusion threshold was the same, when the Hb values were < 10 g/dL. Patients were screened for thromboembolic disease if symptoms or signs appeared. RESULTS Hb decreased less in the tranexamic acid group (1.87 ± 1.10 g/dL) than in the control group (2.2 ± 1.36 g/dL; p = 0.01) on the first postoperative day. The frequency of transfusion was lower in patients receiving tranexamic acid (17% as compared with 35% in the control group; p < 0.001). There was only one nonfatal pulmonary embolism in the control group during the study period. CONCLUSIONS Use of topical tranexamic acid in patients undergoing THA reduces postoperative bleeding and decreases blood transfusion rates. No increase in major complications was identified in patients managed with topical tranexamic acid. This retrospective study confirms the results of a smaller randomized trial on the same topic by another group. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Chih-Hsiang Chang
- />Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin Street, Kweishan, Taoyuan, Taiwan , />College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yuhan Chang
- />Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin Street, Kweishan, Taoyuan, Taiwan , />College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Dave W. Chen
- />Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin Street, Kweishan, Taoyuan, Taiwan , />College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Steve W. N. Ueng
- />Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin Street, Kweishan, Taoyuan, Taiwan , />College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Mel S. Lee
- />Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin Street, Kweishan, Taoyuan, Taiwan , />College of Medicine, Chang Gung University, Taoyuan, Taiwan , />Department of Orthopaedic Surgery, Chia-Yi Chang Gung Memorial Hospital, 6, W. Sec., Jiapu Road, Puzi, Chiayi, Taiwan
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Young B, Moondi P. A questionnaire-based survey investigating the current use of tranexamic acid in traumatic haemorrhage and elective hip and knee arthroplasty. JRSM Open 2014; 5:2042533313516949. [PMID: 25057371 PMCID: PMC4012650 DOI: 10.1177/2042533313516949] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To record the current use of tranexamic acid during traumatic haemorrhage and elective arthroplasty of the hip and knee. DESIGN A questionnaire-based postal survey. SETTING The questionnaire was sent to the 'anaesthetic lead' at all acute trusts in England, excluding centres for children, women's health, cancer and cardiac care. PARTICIPANTS Ninety-nine (66%) centres replied to the questionnaire. MAIN OUTCOME MEASURES Is tranexamic acid used as part of routine standardized treatment for traumatic haemorrhage and for elective hip and knee arthroplasty, and if so what dosage regime was administered? RESULTS Few trusts (31%) use tranexamic acid during traumatic haemorrhage, with various dosages used. Its use in hip and knee arthroplasty was also low (38%) with a diverse range of doses prescribed. CONCLUSIONS Despite many trials showing its efficacy and low risk of side effect, it is clear that its use is not part of standard practice in most centres. Further studies could clarify these concerns and provide a definitive dosing schedule improving patient care and saving lives.
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Affiliation(s)
- Ben Young
- Queen Elizabeth Hospital, Gayton Road, King's Lynn, Norfolk PE30 4ET, UK
| | - Parvez Moondi
- Queen Elizabeth Hospital, Gayton Road, King's Lynn, Norfolk PE30 4ET, UK
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Saleh A, Hebeish M, Farias-Kovac M, Klika AK, Patel P, Suarez J, Barsoum WK. Use of Hemostatic Agents in Hip and Knee Arthroplasty: A Critical Analysis Review. JBJS Rev 2014; 2:01874474-201401000-00001. [PMID: 27490809 DOI: 10.2106/jbjs.rvw.m.00061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anas Saleh
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, A41, Cleveland, OH 44195
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Rasouli MR, Gomes LSM, Parsley B, Barsoum W, Bezwada H, Cashman J, Garcia J, Hamilton W, Hume E, Malhotra R, Memtsoudis S, Ong A, Orozco F, Padgett D, Reina R, Teloken M, Thienpont E, Waters JH. Blood conservation. J Orthop Res 2014; 32 Suppl 1:S81-9. [PMID: 24464900 DOI: 10.1002/jor.22551] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Aguilera X, Martinez-Zapata MJ, Bosch A, Urrútia G, González JC, Jordan M, Gich I, Maymó RM, Martínez N, Monllau JC, Celaya F, Fernández JA. Efficacy and safety of fibrin glue and tranexamic acid to prevent postoperative blood loss in total knee arthroplasty: a randomized controlled clinical trial. J Bone Joint Surg Am 2013; 95:2001-7. [PMID: 24257657 DOI: 10.2106/jbjs.l.01182] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Postoperative blood loss in patients after total knee arthroplasty may cause local and systemic complications and influence clinical outcome. The aim of this study was to assess whether fibrin glue or tranexamic acid reduced blood loss compared with routine hemostasis in patients undergoing total knee arthroplasty. METHODS A randomized, single-center, parallel, open clinical trial was performed in adult patients undergoing primary total knee arthroplasty. Patients were divided into four groups. Group 1 received fibrin glue manufactured by the Blood and Tissue Bank of Catalonia, Group 2 received Tissucol (fibrinogen and thrombin), Group 3 received intravenous tranexamic acid, and Group 4 (control) had no treatment other than routine hemostasis. The primary outcome was total blood loss collected in drains after surgery. Secondary outcomes were the calculated hidden blood loss, transfusion rate, preoperative and postoperative hemoglobin, number of blood units transfused, adverse events, and mortality. RESULTS One hundred and seventy-two patients were included. The mean total blood loss (and standard deviation) collected in drains was 553.9 ± 321.5 mL for Group 1, 567.8 ± 299.3 mL for Group 2, 244.1 ± 223.4 mL for Group 3, and 563.5 ± 269.7 mL for Group 4. In comparison with the control group, Group 3 had significantly lower total blood loss (p < 0.001), but it was not significantly lower in Groups 1 and 2. The overall rate of patients who had a blood transfusion was 21.1% (thirty-five of 166 patients analyzed per protocol). Two patients required transfusion in Group 3 compared with twelve patients in Group 4 (p = 0.015). No significant difference was observed between the two fibrin glue groups and the control group with regard to the need for transfusion. There was no difference between groups with regard to the percentage of adverse events. CONCLUSIONS Neither type of fibrin glue was more effective than routine hemostasis in reducing postoperative bleeding and transfusion requirements, and we no longer use them. However, this trial supports findings from previous studies showing that intravenous tranexamic acid can decrease postoperative blood loss.
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Affiliation(s)
- X Aguilera
- Orthopedic Surgery and Traumatology Department (X.A., J.C.G., M.J., J.C.M., and F.C.) and Anesthesiology Department (J.A.F.), Hospital de la Santa Creu i Sant Pau, Sant Antoni Mª Claret 167, 08025 Barcelona, Spain
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Konig G, Hamlin BR, Waters JH. Topical tranexamic acid reduces blood loss and transfusion rates in total hip and total knee arthroplasty. J Arthroplasty 2013; 28:1473-6. [PMID: 23886406 PMCID: PMC3807723 DOI: 10.1016/j.arth.2013.06.011] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 05/02/2013] [Accepted: 06/09/2013] [Indexed: 02/01/2023] Open
Abstract
The objective of this study was to determine if tranexamic acid (TXA) applied topically reduced postoperative bleeding and transfusion rates after primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA). Two hundred and ninety consecutive patients from a single surgeon were enrolled. In TKA, TXA solution was injected into the knee after closure of the arthrotomy. In THA, the joint was bathed in TXA solution at three points during the procedure. In both THA and TKA the TXA solution was at a concentration of 3 g TXA per 100 mL saline. The mean blood loss was significantly higher in the non-TXA patients in both TKA and THA groups. Postoperative transfusions decreased dramatically with TXA, dropping from 10% to 0%, and from 15% to 1%, in the TKA and THA groups, respectively. Topical application of TXA significantly reduces postoperative blood loss and transfusion risk in TKA and THA.
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Affiliation(s)
- Gerhardt Konig
- Department of Anesthesiology, University of Pittsburgh School of Medicine
| | - Brian R. Hamlin
- The Bone and Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center
| | - Jonathan H. Waters
- Department of Anesthesiology, Magee-Womens Hospital of the University of Pittsburgh Medical Center # The McGowan Institute For Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pa
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