Dose optimisation of intravenous tranexamic acid for elective hip and knee arthroplasty

Abstract

ObjectivesWe have increased the dose of tranexamic acid (TXA) in our enhanced total joint recovery protocol at our institution from 15 mg/kg to 30 mg/kg (maximum 2.5 g) as a single, intravenous (IV) dose. We report the clinical effect of this dosage change.MethodsWe retrospectively compared two cohorts of consecutive patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery in our unit between 2008 and 2013. One group received IV TXA 15 mg/kg, maximum 1.2 g, and the other 30 mg/kg, maximum 2.5 g as a single pre-operative dose. The primary outcome for this study was the requirement for blood transfusion within 30 days of surgery. Secondary measures included length of hospital stay, critical care requirements, re-admission rate, medical complications and mortality rates.ResultsA total of 1914 THA and 2537 TKA procedures were evaluated. In THA, the higher dose of TXA was associated with a significant reduction in transfusion (p = 0.02, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.58 to 0.96) and rate of re-admission (p < 0.001, RR 0.50, 95% CI 0.35 to 0.71). There were reductions in the requirement for critical care (p = 0.06, RR 0.55, 95% CI 0.31 to 1.00), and in the length of stay from 4.7 to 4.3 days (p = 0.02). In TKA, transfusion requirements (p = 0.049, RR 0.64, 95% CI 0.41 to 0.99), re-admission rate (p = 0.001, RR 0.56, 95% CI 0.39 to 0.80) and critical care requirements (p < 0.003, RR 0.34, 95% CI 0.16 to 0.72) were reduced with the higher dose. Mean length of stay reduced from 4.6 days to 3.6 days (p < 0.01). There was no difference in the incidence of deep vein thrombosis, pulmonary embolism, gastrointestinal bleed, myocardial infarction, stroke or death in THA and TKA between cohorts.ConclusionWe suggest that a single pre-operative dose of TXA, 30 mg/kg, maximum 2.5g, results in a lower transfusion requirement compared with a lower dose in patients undergoing elective primary hip and knee arthroplasty. However, these findings should be interpreted in the context of the retrospective non-randomised study design.Cite this article: R. J. M. Morrison, B. Tsang, W. Fishley, I. Harper, J. C. Joseph, M. R. Reed. Dose optimisation of intravenous tranexamic acid for elective hip and knee arthroplasty: The effectiveness of a single pre-operative dose. Bone Joint Res 2017;6:499–505. DOI: 10.1302/2046-3758.68.BJR-2017-0005.R1.

Six-Dose Intravenous Tranexamic Acid Regimen Further Inhibits Postoperative Fibrinolysis and Reduces Hidden Blood Loss following Total Knee Arthroplasty

“…Sun et al 15 conducted a randomized, controlled trial and reported that a preoperative dose of TXA (15 mg/kg) was as effective as a dose of 10 mg/kg in TBL. In a retrospective study conducted by Morrison et al, 23 a total of 2,537 TKA procedures were included, the patients who received a preoperative dose of TXA (30 mg/kg) led to a significant reduction in transfusion requirement by one-third compared with the group who received the lower dose of 15 mg/kg. It seems a higher dose of TXA would be more effective; however, more prospective studies are in demand for exploring whether continuing to increase the preoperative dose of TXA could further reduce blood loss and transfusion requirement.…”

Effectiveness of pre-operative anaemia screening and increased Tranexamic acid dose on outcomes following unilateral primary, elective total hip or knee replacement: a statistical analysis plan for an interrupted time series and regression discontinuity study

“…Over time the orthopaedic department at Northumbria Healthcare NHS Foundation Trust (NHCT) has introduced a range of interventions aimed at improving post-operative outcomes for patients undergoing elective lower limb arthroplasty. These have been well documented in a series of pre-post cohort studies 13 , 15 , 16 . Details of the interventions and a timeline are given in Table 1 and Figure 1 .…”

“…This study is examining short-term outcomes, however, some delays to observed changes in outcomes are expected. The orthopaedic department has previously reported that a 6-month lag period was required to fully adopt the increased TXA dose policy 15 . This same lag will therefore be incorporated into the ITS analysis.…”

Comparison of Efficacy of Tranexamic Acid 10 Mg/Kg and 15 Mg/Kg in Reducing Bleeding and Transfusions in Total Knee Arthroplasty

“…Poeran et al [7] compared four study groups with none, ≤o g, 2 g, and ≥ g of tranexamic acid, and Castro-Menéndeza et al [32] conducted a study with empirical doses of tranexamic acid as high as 2 g and found that 2 g of tranexamic acid iv had the best effectiveness and safety profile. Morrison et al [33] compared 15 mg/kg versus 30 mg/kg intravenous tranexamic acid. While our study did not go higher than 15 mg/kg in terms of dosing, we have found comparable results with the same in terms of rates of transfusion and fall in hemoglobin.…”