A rationale for universal tranexamic acid in major joint arthroplasty: overall efficacy and impact of risk factors for transfusion

Abstract

BACKGROUND Tranexamic acid (TXA) therapy is effective in reducing postoperative red blood cell (RBC) transfusion in total joint arthroplasty (TJA), yet uncertainty persists regarding comparative efficacy and safety among specific patient subgroups. We assessed the impact of a universal TXA protocol on RBC transfusion, postoperative hemoglobin (Hb), and adverse outcomes to determine whether TXA is safe and effective in TJA, both overall and in clinically relevant subgroups. STUDY DESIGN AND METHODS A retrospective observational study was performed on patients undergoing TJA at our institution spanning 1 year before and after the implementation of a universal protocol to administer intravenous (IV) TXA. The primary outcome was percentage of patients transfused, and secondary outcomes were perioperative Hb and occurrence of adverse events (death, myocardial infarction, stroke, seizure, pulmonary embolism, deep vein thrombosis, and acute kidney injury ). Outcomes were compared in pre‐ and post‐protocol groups with χ2 analysis. Logistic regression compared risk of transfusion in pre‐ and post‐protocol subgroups of patients with differing risk for transfusion (anemia, body mass index [BMI], and sex). RESULTS No differences were found in baseline patient characteristics across pre‐ and post‐protocol groups (n = 1084 and 912, respectively). TXA use increased from 32.3% to 92.2% while transfusion rates decreased from 10.3% to 4.8% (p < 0.001). Postoperative Day 3 Hb increased from 95.8 to 101.4 g/L (p < 0.001). Logistic regression demonstrated reduced transfusion in post‐protocol subgroups regardless of sex, anemia, or BMI (p < 0.001). No increase in adverse events was observed (p = 0.8451). CONCLUSIONS Universal TXA was associated with a reduction of RBC transfusion, overall and in clinically relevant subgroups, strengthening the rationale for universal therapy.

ONTraC: A 20-Year History of a Successfully Coordinated Provincewide Patient Blood Management Program: Lessons Learned and Goals Achieved

“…Consistent with the report of Althoff et al, 10 the benefit of using multiple PBM measures in a patient is demonstrated in Figure 3. As reported previously, the use of TXA in patients undergoing cardiac, 11 orthopedic, [12][13][14] and gynecological surgeries 15,16 has been associated with positive outcomes, including a reduction in transfusions. In the ONTraC program, utilization of TXA increased from about 32% in 2011 to >90% in 2021 for orthopedic patients undergoing elective total joint arthroplasty.…”

Update on Applications and Limitations of Perioperative Tranexamic Acid

“…Elective, urgent, and emergent orthopedic surgery is associated with significant blood loss, and RBC transfusion, providing the rationale for broad utilization of PBM measures including perioperative TXA use. 13 The results of small randomized-controlled trials, as well as subsequent systematic reviews and meta-analyses, demonstrate that perioperative TXA is effective at reducing surgical blood loss and allogeneic transfusion in orthopedic surgery. [97][98][99][100] A recent retrospective analysis assessed prophylactic TXA use in noncardiac surgeries at high risk for blood transfusion in 14,300 patients between 2014 and 2016.…”

“…97,102 The use of TXA, as a component of PBM, has been strongly advocated for, and compliance with TXA administration has reached as high as 95% of elective patients in some centers. 13 TXA use for elective long bone procedures and repair of bone fractures has undergone several investigations. 99,103,104 Patients with acute fractures differ from elective patients in that they usually face urgent/emergent surgery and may have increased risks associated with thrombosis.…”

“…97,102 The use of TXA, as a component of PBM, has been strongly advocated for, and compliance with TXA administration has reached as high as 95% of elective patients in some centers. 13…”

Update on patient blood management 2019

“…In my hospital, we have implemented universal intravenous tranexamic acid administration in arthroplasty. This initiative led to a significant reduction in RBC transfusion rate and resulted in higher postoperative haemoglobin values [28].…”