Universal tranexamic acid therapy to minimize transfusion for major joint arthroplasty: a retrospective analysis of protocol implementation

Baker, James E.; Pavenski, Katerina; Pirani, Razak A.; White, Alexander; Kataoka, Mark; Waddell, James P.; Ho, Alexander; Schemitsch, Emil H.; Lo, Nick; Bogoch, Earl R.; Pronovost, Antoine; Luke, Katherine; Howell, Alanna; Nassis, Anna; Tsui, Albert K.Y.; Tanzini, Rosa Maria; Pulendrarajah, Robisa; Mazer, C. David; Freedman, John; Hare, Gregory M. T.

doi:10.1007/s12630-015-0460-6

Cited by 9 publications

(10 citation statements)

References 35 publications

(42 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…The protocol for TXA administration was previously published in an article that reported on the outcomes from the initial 844 patients that are also included in the current analysis. Beginning October 21, 2013 , TXA was administered intraoperatively (20 mg/kg IV, to a maximum dose of 2 g) to all patients undergoing primary or revision THA or TKA.…”

Section: Methodsmentioning

confidence: 99%

“…Following initiation of the protocol, patient records were assessed following surgery to determine: 1) RBC transfusion events, 2) preoperative and postoperative (Day 1 and 3) Hb (as measured according to established clinical protocol), and 3) adverse events. The serious adverse events (SAEs) assessed were death, MI, stroke, seizure, PE, DVT, and acute kidney injury (as previously defined).…”

Section: Methodsmentioning

confidence: 99%

“…The decision for transfusion was made by the anesthesiologist and surgeon within the operating room and post‐anesthesia care unit and the surgical team on the ward. The transfusion threshold for patients on the ward was near 75 g/L between 2012 and 2014 …”

Section: Methodsmentioning

confidence: 99%

See 2 more Smart Citations

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

et al. 2018

Self Cite

View full text Add to dashboard Cite

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.

show abstract

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

See 1 more Smart Citation

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

et al. 2018

Self Cite

View full text Add to dashboard Cite

show abstract

“…A variety of approaches have been employed to reduce perioperative blood loss [52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67]. The development of protocols involves multidisciplinary collaboration between surgeons, anesthesiologists, hematologists, transfusion medicine and pharmacy.…”

Section: Reducing Perioperative Blood Lossmentioning

confidence: 99%

Transfusion Medicine: Time for a Change: Patient Blood Management and the Ontario ONTraC Program

Freedman¹

2016

J Perioper Crit Intensive Care Nurs

Self Cite

View full text Add to dashboard Cite

Despite increasing recognition of the potential adverse effects of blood transfusion there is evidence that the procedure is over-utilized and often inappropriately and unnecessarily administered. Patient Blood Management (PBM) is a recent world-wide initiative to optimize transfusion therapy by employing preoperative and perioperative maneuvers and alternatives to avoid unnecessary blood transfusion. These approaches are, however, not restricted to the surgical setting, but may be applied whenever transfusion is contemplated. A key component of PBM is the appropriate management of anemia, a prime determinant of transfusion. Another is tolerance of anemia through the use of restrictive transfusion thresholds for transfusion and of a single unit at a time policy. Among a number of options at surgery, antifibrinolytics have proven effective at reducing blood loss and transfusion. Burgeoning literature demonstrates that PBM (also known as Blood Conservation or as 'Bloodless Medicine/Surgery') is costeffective while improving patient outcomes and conserving the blood supply. Data from the ONTraC program in Ontario are described herein to illustrate the effectiveness of PBM approaches.

show abstract

“…In this issue of the Journal, Baker et al 5 present their data after implementing a universal protocol directing TXA administration in eligible patients undergoing arthroplasty surgery. They also assessed the impact of TXA administration on red blood cell (RBC) transfusion, postoperative hemoglobin, hospital length of stay, and adverse events.…”

mentioning

confidence: 99%

Tranexamic acid: When is enough (data) enough?

Ralley

2015

Can J Anesth/J Can Anesth

View full text Add to dashboard Cite

Tranexamic acid (TXA) is a synthetic analog of the amino acid lysine which exerts its effect by binding with the lysine-binding sites on the plasminogen molecule. It reversibly and competitively reduces the affinity of plasminogen binding with fibrin, decreases the activation of plasminogen to plasmin, and reduces the local degradation of fibrin by plasmin. Since its development in the early 1960s, TXA has been proven to be a remarkably effective drug in reducing perioperative blood loss and therefore the requirement for transfusion. 1,2 Nowhere has this been more apparent than in orthopedic surgery, especially in patients undergoing major joint replacement procedures. Until recently, concerns over TXA's theoretical potential to increase postoperative venous thrombotic events (VTE) have unfortunately delayed or even prevented its broader use among arthroplasty patients. Venous thrombotic events remain a concern in arthroplasty patients who are especially vulnerable to thrombotic complications postoperatively.Initial in vitro studies have shown that a concentration of 100 mgÁL -1 was required to produce a 98-100% reduction in fibrinolytic activity. 1 Subsequent clinical experience has shown that an 80% reduction in fibrinolytic activity was sufficient for clinical needs, and this was produced with a TXA concentration of 10 mgÁL -1 . 1 The optimal dose and route of administration to be used in arthroplasty patients remain unclear. In a recent meta-analysis, 46 randomized controlled trials involving 2,925 patients undergoing an orthopedic procedure were identified and included in the analysis. 3 In 21 studies, TXA was given in doses \ 15 mgÁkg -1 , and in 18 studies, TXA was given in doses [ 15 mgÁkg -1 . A single bolus given preoperatively was used in 20 studies, and repeated boluses were given in 26 studies. When all doses and schedules were pooled, TXA was associated with a mean reduction in total blood loss of -408 mL (95% confidence interval [CI], -506 to -311), leading to a halving of the likelihood of allogeneic blood transfusion (relative risk, 0.51; 95% CI, 0.46 to 0.56). Subgroup analysis showed that reductions in transfusion were similar in both single and multiple TXA dosing regimens. In addition, these authors did not observe any statistically significant increases in thromboembolic events. There were similar rates of deep venous thrombosis (DVT) in the TXA and control groups [30 of 1,376 (2.18%) patients and 26 of 1,313 (1.98%) patients, respectively; relative risk, 1.11; 95% confidence interval, 0.69 to 1.79].Despite the plethora of individual studies and meta-analyses, the routine use of TXA in this at-risk patient population has been limited by what some clinicians consider to be an insufficiency of data. This is mainly due to the small sample size of the majority of studies, thus requiring meta-analyses to characterize the safety and harm of therapy. A recent large retrospective cohort study drawn from administrative health data may have put some of these concerns to rest. 4 In this study of 872,4...

show abstract

Universal tranexamic acid therapy to minimize transfusion for major joint arthroplasty: a retrospective analysis of protocol implementation

Cited by 9 publications

References 35 publications

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

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

Transfusion Medicine: Time for a Change: Patient Blood Management and the Ontario ONTraC Program

Tranexamic acid: When is enough (data) enough?

Contact Info

Product

Resources

About