Tranexamic acid during TJA associated with fewer blood transfusions, minimal complications
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According to published results, tranexamic acid use in high-risk patients during total hip and total knee arthroplasties was associated with decreased odds of blood transfusion with no increased risk for complications.
Jashvant Poeran, MD, PhD, and colleagues at the Icahn School of Medicine at Mount Sinai analyzed three groups of patients who underwent either THA or TKA between 2013 and 2016 and were deemed high-risk for complications.
Group 1 consisted of 27,890 patients with a history of venous thromboembolism, myocardial infarction, seizures or ischemic attack. Of this group, 46.6% received tranexamic acid during surgery. Group 2 consisted of 44,608 patients with renal disease, of which 50.3% received tranexamic acid. Group 3 consisted of 45,952 patients with atrial fibrillation, of which 48.7% received tranexamic acid.
According to the study, outcome measures included blood transfusion; new-onset venous thromboembolism, myocardial infarction, seizures or ischemic attack; renal failure and resource utilization. The most common dose of tranexamic acid was 2,000 mg administered intravenously.
Poeran and colleagues found all three high-risk tranexamic acid groups had decreased odds of blood transfusion compared with high-risk patients who did not receive tranexamic acid. Researchers observed no increased risk of measured complications in the three high-risk tranexamic acid groups. They also noted a shorter length of stay and lower cost of hospitalization with tranexamic acid use among the high-risk groups.
“These results target a clinical challenge and prominent evidence gap on tranexamic acid use in high-risk patients,” the researchers wrote in the study. “Adding to this challenge is the fact that tranexamic acid is still considered ‘off label’ for use in total hip and knee arthroplasty surgery, and safety concerns remain, despite the availability of high-quality evidence supporting the use of tranexamic acid in this surgical cohort in terms of its beneficial impact on blood loss and transfusion risk,” they added.
Perspective
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As an orthopedic surgeon, the most exciting thing about this study is that it is from the anesthesia literature. In most surgical settings, it is the anesthesiologist who administers tranexamic acid. When assessing the benefit-to-risk ratio of tranexamic acid, the surgeon is better positioned to appreciate the reduction in blood loss and the associated improved outcomes, while the anesthesiologist may give more weight to the thromboembolic risks.
This study, from a large health care database, showed that tranexamic acid use was associated with decreased risk of blood transfusion in high-risk groups with no increased risk of composite complications in these high-risk groups: 1.) patients with a history of venous thromboembolism, myocardial infarction, seizures or ischemic stroke/transient ischemia, 2.) patients with renal disease or 3.) patients with atrial fibrillation. An additional benefit: shorter OR times (by eliminating this debate between the surgeon and the anesthesiologist).
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