Clinical Orthopaedics and Related Research®

, Volume 470, Issue 9, pp 2605–2612 | Cite as

Most Effective Regimen of Tranexamic Acid in Knee Arthroplasty: A Prospective Randomized Controlled Study in 240 Patients

  • Rajesh N. Maniar
  • Gaurav Kumar
  • Tushar Singhi
  • Ravi Mohan Nayak
  • Parul R. Maniar
Clinical Research

Abstract

Background

The antifibrinolytic tranexamic acid reduces surgical blood loss, but studies have not identified an optimal regimen.

Questions/purposes

We studied different dosages, timings, and modes of administration to identify the most effective regimen of tranexamic acid in achieving maximum reduction of blood loss in TKA.

Methods

We prospectively studied five regimens (four intravenous, one local; 40 patients each) with a control group (no tranexamic acid). The four intravenous (10-mg/kg dose) regimens included (1) intraoperative dose (IO) given before tourniquet deflation, (2) additional preoperative dose (POIO), (3) additional postoperative dose (IOPO), and (4) all three doses (POIOPO). The fifth regimen was a single local application (LA). Two independent parameters of drain loss and total blood loss, calculated by the hemoglobin balance method, were evaluated statistically.

Results

Both parameters were reduced in all five regimens as against the control. A significant reduction in drain loss was seen in the POIO, IOPO, and POIOPO groups whereas total blood loss was significantly reduced in the POIO, POIOPO, and LA groups. The POIOPO group had the least drain loss (303 mL) and least total blood loss (688 mL). The IO group had the greatest drain loss and the IOPO group the greatest total blood loss.

Conclusions

Single-dose tranexamic acid did not give effective results. The two-dose regimen of POIO was the least amount necessary for effective results. When compared against the control, this regimen produced reduction of drain loss and total blood loss, whereas the IOPO regimen did not. The three-dose regimen of POIOPO produced maximum effective reduction of drain loss and total blood loss.

Level of Evidence

Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

References

  1. 1.
    Benoni G, Carlsson A, Petersson C, Fredin H. Does tranexamic acid reduce blood loss in knee arthroplasty? Am J Knee Surg. 1995;8:88–92.PubMedGoogle Scholar
  2. 2.
    Benoni G, Fredin H. Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty: a prospective, randomized, double-blind study of 86 patients. J Bone Joint Surg Br. 1996;78:434–440.PubMedGoogle Scholar
  3. 3.
    Benoni G, Lethagen S, Fredin H. The effect of tranexamic acid on local and plasma fibrinolysis during total knee arthroplasty. Thromb Res. 1997;85:195–206.PubMedCrossRefGoogle Scholar
  4. 4.
    Boylan JF, Klinck JR, Sandler AN, Arellano R, Greig PD, Nierenberg H, Roger SL, Glynn MF. Tranexamic acid reduces blood loss, transfusion requirements, and coagulation factor use in primary orthotopic liver transplantation. Anesthesiology. 1996;85:1043–1048; discussion 30A–31A.PubMedCrossRefGoogle Scholar
  5. 5.
    Burkart BC, Bourne RB, Rorabeck CH, Kirk PG, Nott L. The efficacy of tourniquet release in blood conservation after total knee arthroplasty. Clin Orthop Relat Res. 1994;299:147–152.PubMedGoogle Scholar
  6. 6.
    Camarasa MA, Olle G, Serra-Prat M, Martin A, Sanchez M, Ricos P, Perez A, Opisso L. Efficacy of aminocaproic, tranexamic acids in the control of bleeding during total knee replacement: a randomized clinical trial. Br J Anaesth. 2006;96:576–582.PubMedCrossRefGoogle Scholar
  7. 7.
    Cushner FD, Friedman RJ. Blood loss in total knee arthroplasty. Clin Orthop Relat Res. 1991;269:98–101.PubMedGoogle Scholar
  8. 8.
    Dunn CJ, Goa KL. Tranexamic acid: a review of its use in surgery and other indications. Drugs. 1999;57:1005–1032.PubMedCrossRefGoogle Scholar
  9. 9.
    Engel JM, Hohaus T, Ruwoldt R, Menges T, Jürgensen I, Hempelmann G. Regional hemostatic status and blood requirements after total knee arthroplasty with and without tranexamic acid or aprotinin. Anesth Analg. 2001;92:775–780.PubMedCrossRefGoogle Scholar
  10. 10.
    Eubanks JD. Antifibrinolytics in major orthopaedic surgery. J Am Acad Orthop Surg. 2010;18:132–138.PubMedGoogle Scholar
  11. 11.
    Fahmy NR, Patel DG. Hemostatic changes and postoperative deep-vein thrombosis associated with use of a pneumatic tourniquet. J Bone Joint Surg Am. 1981;63:461–465.PubMedGoogle Scholar
  12. 12.
    Good L, Peterson E, Lisander B. Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement. Br J Anaesth. 2003:90:596–599.PubMedCrossRefGoogle Scholar
  13. 13.
    Hiippala S, Strid L, Wennerstrand M, Arvela V, Mäntylä S, Ylinen J, Niemelä H. Tranexamic acid (Cyklokapron) reduces perioperative blood loss associated with total knee arthroplasty. Br J Anaesth. 1995;74:534–537.PubMedCrossRefGoogle Scholar
  14. 14.
    Hiippala ST, Strid LJ, Wennerstrand MI, Arvela JV, Niemelä HM, Mäntylä SK, Kuisma RP, Ylinen JE. Tranexamic acid radically decreases blood loss and transfusions associated with total knee arthroplasty. Anesth Analg. 1997;84:839–844.PubMedGoogle Scholar
  15. 15.
    Jansen AJ, Andreica S, Claeys M, D”Haese J, Camu F, Jochmans K. Use of tranexamic acid for an effective blood conservation strategy after total knee arthroplasty. Br J Anaesth. 1999;83:596–601.PubMedCrossRefGoogle Scholar
  16. 16.
    Kambayashi J, Sakon M, Yokota M, Shiba E, Kawasaki T, Mori T. Activation of coagulation and fibrinolysis during surgery, analyzed by molecular markers. Thromb Res. 1990:60:157–167.PubMedCrossRefGoogle Scholar
  17. 17.
    Klenerman L, Chakrabarti R, Mackie I, Brozovic M, Stirling Y. Changes in haemostatic system after application of a tourniquet. Lancet. 1977;1:970–972.PubMedCrossRefGoogle Scholar
  18. 18.
    Langdown AJ, Field J, Grote J, Himayat H. Aprotinin (Trasylol) does not reduce bleeding in primary total hip arthroplasty. J Arthroplasty. 2000;15:1009–1012.PubMedCrossRefGoogle Scholar
  19. 19.
    Lisander B, Ivarsson I, Jacobsson SA. Intraoperative autotransfusion is associated with modest reduction of allogeneic transfusion in prosthetic hip surgery. Acta Anaesthesiol Scand. 1998;42:707–712.PubMedCrossRefGoogle Scholar
  20. 20.
    Lotke PA, Faralli VJ, Orenstein EM, Ecker ML. Blood loss after total knee replacement: effects of tourniquet release and continuous passive motion. J Bone Joint Surg Am. 1991;73:1037–1040.PubMedGoogle Scholar
  21. 21.
    Mangano DT, Tudor IC, Dietzel C; Multicenter Study of Perioperative Ischemia Research Group; Ischemia Research and Education Foundation. The risk associated with aprotinin in cardiac surgery. N Engl J Med. 2006;354:353–365.PubMedCrossRefGoogle Scholar
  22. 22.
    Mongan PD, Brown RS, Thwaites BK. Tranexamic acid and aprotinin reduce postoperative bleeding and transfusions during primary coronary revascularization. Anaesth Analg. 1998;87:258–265.Google Scholar
  23. 23.
    Nadler SB, Hidalgo JU, Bloch T. Prediction of blood volume in normal human adults. Surgery. 1962;51:224–232.PubMedGoogle Scholar
  24. 24.
    Nakahara M, Sakahashi H. Effect of application of a tourniquet on bleeding factors in dogs. J Bone Joint Surg Am. 1967;49:1345–1351.PubMedGoogle Scholar
  25. 25.
    Nilsson IM. Clinical pharmacology of aminocaproic and tranexamic acids. J Clin Pathol Suppl (R Coll Pathol). 1980;14:41–47.CrossRefGoogle Scholar
  26. 26.
    Petaja J, Myllynen P, Myllyla G, Vahtera E. Fibrinolysis after application of a pneumatic tourniquet. Acta Chir Scand. 1987;153:647–651.PubMedGoogle Scholar
  27. 27.
    Sehat KR, Evans R, Newman JH. How much blood is really lost in total knee arthroplasty? Correct blood loss management should take hidden loss into account. Knee. 2000;7:151–155.PubMedCrossRefGoogle Scholar
  28. 28.
    Slaughter TF, Greenberg CS. Antifibrinolytic drugs and perioperative hemostasis. Am J Hematol. 1997;56:32–36.PubMedCrossRefGoogle Scholar
  29. 29.
    Tanaka N, Sakahashi H, Sato E, Hirose K, Ishima T, Ishii S. Timing of the administration of tranexamic acid for maximum reduction in blood loss in arthroplasty of the knee. J Bone Joint Surg Br. 2001;83:702–705.PubMedCrossRefGoogle Scholar
  30. 30.
    Wellington K, Wagstaff AJ. Tranexamic acid: a review of its use in the management of menorrhagia. Drugs. 2003;63:1417–1433.PubMedCrossRefGoogle Scholar
  31. 31.
    Wong J, Abrishami A, El Beheiry H, Mahomed NN, Roderick Davey J, Gandhi R, Syed KA, Muhammad Ovais Hasan S, De Silva Y, Chung F. Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. J Bone Joint Surg Am. 2010;92:2503–2513.PubMedCrossRefGoogle Scholar
  32. 32.
    Zohar E, Fredman B, Ellis M, Luban I, Stern A, Jedeikin R. A comparative study of the postoperative allogeneic blood-sparing effect of tranexamic acid versus acute normovolemic hemodilution after total knee replacement. Anesth Analg. 1999;89:1382–1387.PubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • Rajesh N. Maniar
    • 1
  • Gaurav Kumar
    • 2
  • Tushar Singhi
    • 3
  • Ravi Mohan Nayak
    • 1
  • Parul R. Maniar
    • 4
  1. 1.Department of Orthopaedic SurgeryLilavati Hospital and Research CentreMumbaiIndia
  2. 2.Department of Orthopaedic SurgeryJhansi Orthopedic HospitalJhansiIndia
  3. 3.Department of Orthopaedic SurgeryBreach Candy HospitalMumbaiIndia
  4. 4.Department of OphthalmologyThe NookMumbaiIndia

Personalised recommendations