Intraoperative Use Of Tranexamic Acid Research Articles

Quality Initiative Programs Can Decrease Total Joint Arthroplasty Transfusion Rates—A Multicenter Study Using the MARCQI Total Joint Registry Database

BackgroundThe Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) noted wide variability between member hospitals in blood transfusion rates after primary total hip and knee arthroplasty (THA and TKA). Blood transfusion has substantial risks and accepted recommendations exist to guide transfusion practices. MARCQI began an initiative to decrease unnecessary transfusions by identifying/reporting outliers, discussing conservative transfusion practices, and recommending transfusion guidelines. There was a later recommendation to consider intraoperative use of tranexamic acid. MethodsAll MARCQI-registered unilateral TKA and THA cases from the 28 member hospitals (pre-November 2013) were included. For 3 time periods (before November 13, 2013; November 13, 2013, to November 12, 2014; and after November 12, 2014), we calculated average risk and range of transfusion, transfusion with nadir hemoglobin >8 g/dL, mean length of stay, and 90-day risk of discharge to nursing home, readmission, deep infection, and emergency department visits. ResultsFor THA, risk and range of transfusion decreased over the 3 time periods: 12.6% (2.5%-36.2%), 7.6% (2.2%-23.8%), and 4.5% (0.7%-14.4%); for TKA, 6.3% (1.3%-15.6%), 3.1% (0%-12.5%), and 1.3% (0%-7.4%). Decreases were also noted for transfusion with a nadir hemoglobin >8 g/dL with a near elimination of “unnecessary” transfusions. There was no evidence of increase in length of stay, discharge to nursing home, readmission, deep infection, or emergency department visits. ConclusionA simple intervention can decrease unnecessary blood transfusions during and after elective primary unilateral THA or TKA. A collaborative registry can be used effectively to improve the quality of patient care and set a new benchmark for transfusion.

Intraoperative tranexamic acid use in major spine surgery in adults: a multicentre, randomized, placebo-controlled trial

BackgroundPerioperative tranexamic acid (TXA) use can reduce bleeding and transfusion requirements in several types of surgery, but level I evidence proving its effectiveness in major spine surgery is lacking. This study was designed to investigate the hypothesis that TXA reduces perioperative blood loss and transfusion requirements in patients undergoing major spine procedures. MethodsWe conducted a multicentre, prospective, randomized double-blind clinical trial, comparing TXA with placebo in posterior instrumented spine surgery. Efficacy was determined based on the total number of blood units transfused and the perioperative blood loss. Other variables such as the characteristics of surgery, length of hospital stay, and complications were also analysed. ResultsNinety-five patients undergoing posterior instrumented spine surgery (fusion of >3 segments) were enrolled and randomized: 44 received TXA (TXA group) and 51 received placebo (controls). The groups were comparable for duration of surgery, number of levels fused, and length of hospitalization. Transfusion was not required in 48% of subjects receiving TXA compared with 33% of controls (P = 0.05). Mean number of blood units transfused was 0.85 in the TXA group and 1.42 with placebo (P = 0.06). TXA resulted in a significant decrease in intraoperative bleeding (P = 0.01) and total bleeding (P = 0.01) relative to placebo. The incidence of adverse events was similar in the two groups. ConclusionsTXA did not significantly reduce transfusion requirements, but significantly reduced perioperative blood loss in adults undergoing major spinal surgery. Clinical trial registrationNCT01136590.

Effectiveness and Safety of Tranexamic Acid in Spinal Deformity Surgery.

ObjectiveSpinal deformity surgery has the potential risk of massive blood loss. To reduce surgical bleeding, the use of tranexamic acid (TXA) became popular in spinal surgery, recently. The purpose of this study was to determine the effectiveness of intra-operative TXA use to reduce surgical bleeding and transfusion requirements in spinal deformity surgery.MethodsA total of 132 consecutive patients undergoing multi-level posterior spinal segmental instrumented fusion (≥5 levels) were analyzed retrospectively. Primary outcome measures included intraoperative estimated blood loss (EBL), transfusion amount and rate of transfusion. Secondary outcome measures included postoperative transfusion amount, rate of transfusion, and complications associated with TXA or allogeneic blood transfusions.ResultsThe number of patients was 89 in TXA group and 43 in non-TXA group. There were no significant differences in demographic or surgical traits between the groups except hypertension. The EBL was significantly lower in TXA group than non-TXA group (841 vs. 1336 mL, p=0.002). TXA group also showed less intra-operative and postoperative transfusion requirements (544 vs. 812 mL, p=0.012; 193 vs. 359 mL, p=0.034). Based on multiple regression analysis, TXA use could reduce surgical bleeding by 371 mL (37 % of mean EBL). Complication rate was not different between the groups.ConclusionTXA use can effectively reduce the amount of intra-operative bleeding and transfusion requirements in spinal deformity surgery. Future randomized controlled study could confirm the routine use of TXA in major spinal surgery.

Transfusion requirements in burn patients undergoing primary wound excision: effect of tranexamic acid.

Early excision of burn wounds is the standard approach for burns, but it is usually associated with the need of allogeneic blood transfusion. Our aim was to determine if intravenous administration of tranexamic acid (TXA) was able to reduce packed red blood cell (pRBC) transfusion requirements in burn patients. We conducted a retrospective cohort study of 2 consecutive series of severely burned patients (≥20% total body surface are) admitted for primary burn surgery. We searched for differences in pRBC transfusion occurrence and requirements during surgery and up to 24 hours after surgery. A total of 107 patients were included in the study, and 48.6% (52 patients) received TXA during primary excision. The use of TXA exhibited an absolute risk reduction in the need for transfusion during surgery of 24.2% (95% CI: 7.1-41.4%). In total, patients receiving TXA required 1.6 units of pRBC in the perioperative period vs. 2.6 units in those not receiving TXA (P=0.017). The intraoperative use of TXA in burn patients undergoing primary burn excision reduced the incidence of allogeneic transfusion and the total number of pRBC transfused.

Efficacy and Safety of Intraoperative Tranexamic Acid Infusion for Reducing Blood Transfusion During Open Radical Cystectomy

To evaluate the safety and efficacy of intraoperative tranexamic acid (TA), an antifibrinolytic, in reducing perioperative blood transfusion (PBT) for patients undergoing open radical cystectomy (RC) for bladder cancer. We instituted a change in our institutional clinical practice starting in April 2013, whereby all patients undergoing open RC were administered intraoperative intravenous TA. Patients with a history of venous thromboembolism (VTE) or coronary stent insertion within the year prior to RC did not receive TA. Receipt of a PBT, defined as transfusion of red blood cells during RC or within the postoperative hospitalization, and VTE within 30 days of RC were recorded and compared with a matched cohort of patients treated with RC at our center prior to the initiation of TA utilization. A total of 103 patients received TA during open RC between April 2013 and July 2015. These patients were matched 1:2 to historic controls. We found that TA infusion was associated with a significantly decreased rate of PBT, as 32 of 103 (31.1%) patients treated with TA received a PBT, versus 115 of 200 (57.7%) matched controls (P < .0001). Importantly, TA did not significantly increase the rate of perioperative VTE, as 5 patients (4.9%) who received TA were diagnosed with a VTE within 30 days of RC, compared with 6 (3.0%) of the matched controls (P = .52). We noted that the use of intraoperative TA during open RC was associated with a significant reduction in PBT, and did not significantly increase perioperative VTE risk.

The value of tranexamic acid during fronto-orbital advancement in isolated metopic craniosynostosis

Craniofacial surgery in infants still harbors the risk of significant blood loss and the need for red blood cell (RBC) transfusion. Hence, the aim of the present study was to investigate the antifibrinolytic effect of tranexamic acid (TXA) on intraoperative blood loss and RBC transfusion rates during fronto-orbital advancement (FOA) in isolated metopic synostosis.A total of 33 children with metopic synostosis were operated on using standardized FOA, of which 16 patients (48.5%) were treated without intraoperative TXA (non-TXA group) and 17 patients (51.5%) received TXA intraoperatively (TXA group). To accurately evaluate the calculated blood loss (CBL) we analyzed the values for pre- and postoperative hematocrit and the volume of the RBC transfusion.The mean CBL and the mean weight-adjusted CBL was significantly lower for patients receiving TXA compared with the non-TXA group (158.8 ml vs. 198.5 ml, p = 0.0001; and 19.1 ml/kg vs. 22.3 ml/kg, p = 0.0293, respectively). In addition, the mean RBC transfusion and the mean weight-adjusted RBC transfusion was significantly lower for the TXA group (252.2 ml vs. 280.0 ml, p = 0.0001; and 27.9 ml/kg vs. 31.3 ml/kg, p = 0.0345, respectively). The mean duration of the surgical procedure did not differ statistically between the groups (132 min vs. 136 min, p = 0.4081), hence the lower CBL in the TXA-group was not related to a shorter cutting–suture time.As the use of intraoperative TXA minimizes blood transfusion volumes in children who undergo FOA, antifibrinolytics, such as TXA, should be considered for routine use in pediatric craniofacial surgery.

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Intraoperative use of tranexamic acid to reduce transfusion rate in patients undergoing radical retropubic prostatectomy: double blind, randomised, placebo controlled trial

Objectives To determine the efficacy of intraoperative treatment with low dose tranexamic acid in reducing the rate of perioperative transfusions in patients undergoing radical retropubic prostatectomy.Design Double blind, parallel group,...

Efficient strategy for controlling postoperative hemorrhage in total knee arthroplasty

PurposeThe objective of the present study was to compare the intraoperative use of tranexamic acid (TNA) plus intra-articular diluted-epinephrine (DEP) with preoperative autologous blood donations and transfusions in reducing an allogeneic blood transfusion (ABT) in primary unilateral total knee arthroplasty (TKA).MethodsPatients (n = 133) treated with unilateral primary TKA were divided into three groups retrospectively: patients administered autologous blood transfusions were assigned to group A (n = 51); patients administered preoperative injections of TNA and postoperative intra-articular injections of DEP were assigned to group B (n = 42); and patients treated with the drain-clamp method in addition to injections of TNA and DEP were assigned to group C (n = 40). The rate of avoidance of ABTs, postoperative blood loss, and complications (DVT/PE, skin problems) were examined.ResultsThe differences among the three groups were not significant in terms of the proportion of patients requiring no ABTs (94% in group A, 93% in group B and 95% in group C, n.s.). The total blood loss calculated was 1,140 ± 451 ml, 852 ± 343 ml, and 850 ± 296 ml, respectively (group B > A, group C > A, P = 0.0009). The significant complications were not observed in three groups.ConclusionThe results of the study showed that the TNA plus DEP combination exerted a comparable effect with preoperative autologous blood transfusion in avoiding ABTs in unilateral primary TKA. Considering several problems of preoperative autologous blood donation, the use of TNA plus DEP is recommended. In addition, it is highly possible that allogeneic blood transfusions can be avoided for patients with preoperative Hb values ≥10.5 using the method described in this study, and the need for preoperative autologous blood donations can be decreased.

Tranexamic Acid Reduces Allogenic Transfusion in Revision Hip Arthroplasty

Revision THA is associated with high blood loss and a high probability of blood transfusion in the perioperative period. In November 2003, government legislation established the Blood Utilization Program at our center to reduce the rate and risks associated with allogenic transfusion. The purposes of this study were to (1) determine whether the allogenic transfusion rate in patients undergoing revision THA decreased in those who were reviewed preoperatively by the Blood Utilization Program versus those who were not; (2) determine whether tranexamic acid reduced the rate of transfusion; and (3) identify potential perioperative clinical parameters that are associated with an increased risk of blood transfusion. We included all 159 patients who underwent revision THA from January 2006 to October 2008 having either a socket and/or femoral stem revision except those having only a liner exchange. One hundred and one patients attended the Blood Utilization Program preoperatively and 58 patients did not (ie, they required urgent/emergency surgery). The Blood Utilization Program referral made no difference in transfusion rate or transfusion amount; however, the transfusion rates and amount were decreased by 8% and one unit, respectively. In patients referred to the Blood Utilization Program, the intraoperative use of tranexamic acid (an antifibrinolytic) was associated with reduced transfusions, regardless of dosage; preoperative erythropoietin tended to reduce transfusions while preoperative oral iron supplements did not. To further increase the relevance of the blood utilization program, the guidelines for patients undergoing revision hip arthroplasty need to be redefined. Level III, therapeutic study. See the guidelines online for a complete description of level of evidence.

L’Anesthésie-réanimation dans le traitement des craniosténoses

Craniosysnostosis surgical corrections are routine procedures in the pediatric neurosurgical field. However, these procedures result in significant blood loss. Tranexamic acid (TXA) is an antifibrinolytic drug, which has demonstrated a significant reduction in perioperative blood loss in many pediatric surgical procedures such as cardiac surgery and scoliosis surgery. We conducted a systematic review to evaluate protocols of TXA use in pediatric craniosynostosis procedures and its effect on intraoperative blood loss and transfusions.A comprehensive literature review of the National Library of Medicine (PubMed) database was performed to identify relevant studies. We included any clinical study reporting on blood loss or blood transfusion for pediatric craniosynostosis surgery with intraoperative use of tranexamic acid, with the following limits: publication date from inception to May 2019; reports in English.Thirteen studies were eligible for our review. Of the 13 studies, 4 were prospective, randomised, double-blind controlled trials, 9 were retrospective studies, tailored as a “before–after” studies, comparing blood loss and transfusion without/with TXA. TXA significantly decreases the number and volume of packed red blood cell transfusions and the rate of transfusion in children undergoing craniosynostosis surgery. Significantly fewer fresh frozen plasma transfusions were required in the TXA groups in 2 randomised studies. Length of stay in hospital was significantly lower with the use of TXA in three studies. Advantages of TXA administration also include an excellent patient tolerance of side effects, ease of administration and low cost.TXA significantly reduces blood loss and the need for transfusions in children undergoing craniosynostosis surgery. TXA administration should be a routine part of strategy to reduce blood loss and limit transfusions in these procedures.