Preventing Surgical Site Hematoma Using Topical with or Without Intravenous Tranexamic Acid in Lumbosacral Surgery: A Quality Improvement Project

Abstract

Postoperative surgical site hematoma (SSH) following lumbosacral surgery carries significant morbidity and increased length of stay (LOS). Intravenous tranexamic acid (ivTXA) has been shown to reduce SSH rate. Topical TXA (tTXA) could benefit patients with contraindications to ivTXA. However, this has not been widely studied. We sought to demonstrate that a quality improvement (QI) protocol using tTXA with/without ivTXA in patients undergoing elective open and minimally invasive lumbosacral surgery could decrease the SSH rate and LOS with no increase in associated complications. A retrospective chart review for July 2018-June 2019 demonstrated our pre-implementation baseline SSH rate. We conducted interdisciplinary meetings to develop standardized institutional measures and perioperative tTXA administration protocol. The primary outcome was SSH necessitating evacuation. The secondary outcome was LOS and TXA-related complications. The post-implementation data were collected prospectively from July 2020-October 2020. Univariate analysis was used to compare pre-implementation and post-implementation cohorts. We considered a p-value <.05 significant. Comparing consecutive lumbosacral surgical patients in pre- (219 patients) and post-implementation (258 patients), the post-implementation group demonstrated a significantly reduced rate of SSH requiring evacuation (.38% vs. 3.3%, p<.001), significantly increased tTXA utilization (86.0% vs. 9.6%, p<.001), significantly lower incidence of SSH in tTXA patients (.45% vs.4.8%, p=.037), and significantly decreased LOS (3.4 ± 2.5 vs. 3.1 ± 2.7, p=.003). There were no complications attributable to TXA use. Our QI project successfully increased compliance with the use of tTXA. Post-implementation rate of SSH requiring evacuation and LOS was significantly lowered with no associated complications.