Background: Tranexamic acid (TXA) is an antifibrinolytic agent shown to reduce perioperative blood loss in patients undergoing total knee arthroplasty (TKA), but there are limited data regarding the efficacy of intravenous (IV) in comparison to oral (PO) TXA. Objective: The purpose of this research was to compare the effects of IV and PO TXA on perioperative hemoglobin (Hgb) levels in patients who have undergone TKA. Methods: In this single-center, retrospective chart review, patients at least 18 years of age who received IV or PO TXA following medical center protocol from 1 of 3 orthopedic surgeons were included. The primary outcome was the change in Hgb within 24 hours following TKA. Secondary outcomes included comparisons of postsurgical complications and hospital length of stay. Results: The IV TXA group contained 62 participants, and the PO TXA group contained 61 participants. Patients receiving PO therapy had a larger decrease in Hgb compared with the IV TXA group (−2.382 vs −1.908, P = 0.02), but there were no statistically significant differences in mean length of stay (3.13 vs 2.95, P = 0.27), venous thromboembolism (VTE) occurrence (0 vs 0, P = 1), or requirement for transfusions (6 vs 5, P = 0.76). Conclusions and Relevance: IV and PO TXA may not be equivalent in outcomes for patients undergoing TKA. This study found a statistically significant decrease in the mean change of Hgb in patients receiving PO TXA compared with IV TXA. However, the rate of transfusions, mean length of stay, and rate of VTE were similar between groups.

Background: Timely medication administration is integral to patient care, and operational delays can challenge timely administration. Within an inpatient pharmacy of an academic medical center, intravenous medications were historically compounded on a patient-specific basis. In 2020, the pharmacy began batching frequently-utilized medications. This analysis explored the impact of compounded sterile batching on pharmacy and nursing services. Methods: This pre- and post-interventional study compared data from February through March 2020 with a seasonally matched period from 2019. The primary endpoint was difference in time to administration of urgent (STAT) medications. Secondary endpoints included timeframes for a pharmacy technician to prepare, a pharmacist to check, and a nurse to administer the medications, as well as reprinted labels and estimated waste. Results: On average, it took one hour and 43 minutes to administer a STAT medication in 2019 and one hour and 57 minutes in 2020 ( p = 0.122). It took about four hours to administer routine medications in 2019 and 2020 ( p = 0.488). The number of labels reprinted decreased from 616 in 2019 to 549 in 2020 ( p = 0.195), relating to decreased missing doses. The mean time to check and send a medication decreased from 2019 to 2020 for STAT orders ( p < 0.001), and there was no difference in wasted medications looking at all orders in this time. Conclusion: Anticipatory batching decreased time to prepare, check, and send medications, though there was no effect on waste or on time to administration. Future studies can examine the correlation between pharmacy operations and medication administration.

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Apixaban has been associated with prolongation of the international normalized ratio (INR), but data surrounding the extent of elevation and its clinical significance are limited. Due to interaction between apixaban and the prothrombin assay, elevations in INR in patients receiving apixaban are common and not always grounds for concern. However, in high risk patients, elevations can represent a need for closer monitoring. This case summarizes an 82-year-old woman with a history of atrial fibrillation and left middle cerebral artery strokes with no residual deficits. She presented with right-sided hemiparesis and aphasia and underwent a mechanical thrombectomy with TICI 2b recanalization of a left M1 occlusion. Post-thrombectomy, she was found to have a left atrial thrombus and 10 days later was started on apixaban 5 mg twice daily. On the fourth day of apixaban therapy, she experienced an INR increase to 2.3, prompting initiation of a vitamin K challenge for nutritional deficiency. Despite initial improvement, her INR increased to 2.7 a week after apixaban was initiated, coinciding with a decline in mental status and an apixaban peak level of 435.6 ng/mL (reference range 91-321 ng/mL). A computed tomography (CT) scan of her head showed new intracranial hemorrhage in the area of her previous infarction, prompting apixaban reversal with andexanet alfa. Unfortunately, the patient expired. This case report highlights the importance and difficulty in performing therapeutic drug monitoring in patients receiving oral anti-factor Xa inhibitors, revealing a downside to administration of high-risk medications that do not have readily available monitoring.