Skip to main content
SpringerLink
Log in

Preliminary Results Suggest Tranexamic Acid is Safe and Effective in Arthroplasty Patients with Severe Comorbidities

  • Symposium: 2013 Knee Society Proceedings
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Tranexamic acid (TXA) reduces blood loss and transfusion after total joint arthroplasty (TJA) but concerns remain that patients with severe medical comorbidities might be at increased risk for thromboembolic complications.

Questions/purposes

Among patients undergoing primary TJA with severe systemic medical disease, (1) was TXA associated with increased symptomatic thromboembolic events; (2) was TXA associated with decreased blood transfusion rates; and (3) were there differences in symptomatic thromboembolism or transfusions in the subset of patients with a history of, or risk factors for; thromboembolic disease?

Methods

We performed a retrospective review of 1131 primary TJAs in 1002 patients with American Society of Anesthesiologists score III or IV. Of these, 402 had at least one of seven risk factors for thromboembolic events and were designated as high risk; 240 of those patients received TXA. Outcome measures included 30-day postoperative symptomatic thromboembolic events and postoperative transfusion.

Results

There were no differences in symptomatic thromboembolic events within 30 days of surgery between patients who received TXA and those who did not (2.5% versus 2.6%, p = 0.97). Fewer patients treated with TXA received transfusions (11% with versus 41% without; p < 0.0001). In high-risk patients, TXA was not associated with an increase in symptomatic thromboembolic events (6.7% with versus 4.3% without; p = 0.27) and was associated with a decrease in transfusion rates (17% with versus 48% without; p = 0.001).

Conclusions

Although TXA seemed safe and effective in this database review of patients with severe medical comorbidities, a larger prospective trial is warranted to confirm these results.

Level of Evidence

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

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Alvarez JC, Santiveri FX, Ramos I, Vela E, Puig L, Escolano F. Tranexamic acid reduces blood transfusion in total knee arthroplasty even when a blood conservation program is applied. Transfusion. 2008;48:519–525.

    Article  PubMed  Google Scholar 

  2. Benoni G, Fredin H, Knebel R, Nilsson P. Blood conservation with tranexamic acid in total hip arthroplasty: a randomized, double-blind study in 40 primary operations. Acta Orthop Scand. 2001;72:442–448.

    Article  CAS  PubMed  Google Scholar 

  3. Bierbaum B, Callaghan J, Galante J, Rubash H, Tooms R, Welch R. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am. 1999;81:2–10.

    CAS  PubMed  Google Scholar 

  4. 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.

    Article  CAS  PubMed  Google Scholar 

  5. Cid J, Lozano M. Tranexamic acid reduces allogeneic red cell transfusions in patients undergoing total knee arthroplasty: results of a meta-analysis of randomized controlled trials. Transfusion. 2005;45:1302–1307.

    Article  CAS  PubMed  Google Scholar 

  6. DailyMed [Internet]. Bethesda, MD, USA: National Library of Medicine; 2006 [updated February 26, 2013 Feb 26]. Current medication information: Cyklokapraon (tranexamic acid). Available at: http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=6e89a7d9-4da4-42aa-b7f8-c602c24eefe5. Accessed April 25, 2013.

  7. Dunn CJ, Goa KL. Tranexamic acid: a review of its use in surgery and other indications. Drugs. 1999;57:1005–1032.

    Article  CAS  PubMed  Google Scholar 

  8. Engel JM, Hohaus T, Ruwoldt R, Menges T, Jurgensen 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.

    Article  CAS  PubMed  Google Scholar 

  9. Eubanks JD. Antifibrinolytics in major orthopaedic surgery. J Am Acad Orthop Surg. 2010;18:132–138.

    PubMed  Google Scholar 

  10. Fergusson DA, Hebert PC, Mazer CD, Fremes S, MacAdams C, Murkin JM, Teoh K, Duke PC, Arellano R, Blajchman MA, Bussieres JS, Cote D, Karski J, Martineau R, Robblee JA, Rodger M, Wells G, Clinch J, Pretorius R. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med. 2008;358:2319–2331.

    Article  CAS  PubMed  Google Scholar 

  11. Gill JB, Rosenstein A. The use of antifibrinolytic agents in total hip arthroplasty: a meta-analysis. J Arthroplasty. 2006;21:869–873.

    Article  PubMed  Google Scholar 

  12. Gillette B, DeSimone L, Trousdale R, Pagnano M, Sierra R. Low risk of thromboembolic complications with tranexamic acid after primary total hip and knee arthroplasty. Clin Orthop Relat Res. 2013;471:150–154.

    Article  PubMed  Google Scholar 

  13. Henry DA, Carless PA, Moxey AJ, O’Connell D, Stokes BJ, Fergusson DA, Ker K. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2011;3:CD001886.

  14. Hiippala ST, Strid LJ, Wennerstrand MI, V Arvela JV, Niemala HM, Mantyla SK, Kuisma RP, Ylienen JE. Tranexamic acid radically decreases blood loss and transfusions associated with total knee arthroplasty. Anesth Analg. 1997;84:839–844.

    CAS  PubMed  Google Scholar 

  15. Ho KM, Ismail H. Use of intravenous tranexamic acid to reduce allogeneic blood transfusion in total hip and knee arthroplasty: a meta-analysis. Anaesth Intensive Care. 2003;31:529–537.

    CAS  PubMed  Google Scholar 

  16. Hutton B, Joseph L, Fergusson D, Mazer CD, Shapiro S, Tinmouth A. Risks of harms using antifibrinolytics in cardiac surgery: systematic review and network meta-analysis of randomised and observational studies. Br Med J. 2012; 345:e5798.

    Article  Google Scholar 

  17. Hynes M, Calder P, Scott G. The use of tranexamic acid to reduce blood loss during total knee arthroplasty. Knee. 2003;10:375–377.

    Article  CAS  PubMed  Google Scholar 

  18. Kagoma YK, Crowther MA, Douketis J, Bhandari M, Eikelboom J, Lim W. Use of antifibrinolytic therapy to reduce transfusion in patients undergoing orthopedic surgery: a systematic review of randomized trials. Thromb Res. 2009;123:687–696.

    Article  CAS  PubMed  Google Scholar 

  19. Lee GC, Hawes T, Cushner FD, Scott WN. Current trends in blood conservation in total knee arthroplasty. Clin Orthop Relat Res. 2005;440:170–174.

    Article  PubMed  Google Scholar 

  20. Lemay E, Guay J, Cote C, Roy A. Tranexamic acid reduces the need for allogenic red blood cell transfusions in patients undergoing total hip replacement. Can J Anaesth. 2004;51:31–37.

    Article  PubMed  Google Scholar 

  21. Murkin JM, Haig GM, Beer KJ, Cicutti N, McCutchen J, Comunale ME, Hall R, Ruzicka BB. Aprotinin decreases exposure to allogeneic blood during primary unilateral total hip replacement. J Bone Joint Surg Am. 2000;82:675–684.

    CAS  PubMed  Google Scholar 

  22. Sehat K, Evans R, Newman J. Hidden blood loss following hip and knee arthroplasty. J Bone Joint Surg Br. 2004;86:561–565.

    CAS  PubMed  Google Scholar 

  23. Shiga T, Wajima Z, Inoue T, Sakamoto A. Aprotinin in major orthopedic surgery: a systematic review of randomized controlled trials. Anesth Analg. 2005;101:1602–1607.

    Article  CAS  PubMed  Google Scholar 

  24. Slaughter TF, Greenberg CS. Antifibrinolytic drugs and perioperative hemostasis. Am J Hematol. 1997;56:32–36.

    Article  CAS  PubMed  Google Scholar 

  25. Veien M, Sorensen JV, Madsen F, Juelsgaard P. Tranexamic acid given intraoperatively reduces blood loss after total knee replacement: a randomized, controlled study. Acta Anaesthesiol Scand. 2002;46:1206–1211.

    Article  CAS  PubMed  Google Scholar 

  26. Yamasaki S, Masuhara K, Fuji T. Tranexamic acid reduces postoperative blood loss in cementless total hip arthroplasty. J Bone Joint Surg Am. 2005;87:766–770.

    Article  PubMed  Google Scholar 

  27. Yang Z, Chen W, Wu L. Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis. J Bone Joint Surg Am. 2012;94:1153–1159.

    PubMed  Google Scholar 

  28. Zohar E, Fredman B, Ellis MH, Ifrach N, Stern A, Jedeikin R. A comparative study of the postoperative allogeneic blood-sparing effects of tranexamic acid and of desmopressin after total knee replacement. Transfusion. 2001;41:1285–1289.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

We thank Robert T. Trousdale MD, for his assistance with this research and the following for their assistance in data analysis and verification: Christina Wood-Wentz MS, and Jordan Rosedahl BA, of the Division of Biomedical Statistics and Informatics as well as the staff of the Department of Transfusion Medicine.

Author information

Authors and Affiliations

  1. Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA

    Daniel R. Whiting MD, Blake P. Gillette MD, Christopher Duncan MD, Hugh Smith MD, PhD, Mark W. Pagnano MD & Rafael J. Sierra MD

Authors
  1. Daniel R. Whiting MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Blake P. Gillette MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christopher Duncan MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hugh Smith MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Mark W. Pagnano MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Rafael J. Sierra MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rafael J. Sierra MD.

Additional information

One of the authors (MWP) certifies that he has or may receive payments or benefits, in any one year, an amount in excess of USD 100,000 from DePuy (Warsaw, IN, USA), MAKO Surgical Corp (Ft Lauderdale, FL, USA), and Stryker Orthopaedics (Mahwah, NJ, USA). One or more of the authors (RJS) certifies that he has or may receive payments or benefits, in any one year, an amount in excess of USD 10,000 from Biomet Inc (Warsaw, IN, USA).

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

About this article

Cite this article

Whiting, D.R., Gillette, B.P., Duncan, C. et al. Preliminary Results Suggest Tranexamic Acid is Safe and Effective in Arthroplasty Patients with Severe Comorbidities. Clin Orthop Relat Res 472, 66–72 (2014). https://doi.org/10.1007/s11999-013-3134-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-013-3134-0

Keywords

Search

Navigation