© Borgis - Postępy Nauk Medycznych 6/2017, s. 321-325
Magdalena Kwiatkowska1, 2, Muhammad Alam Hashmi2, Luoise Grimes2, Anant Mahapatra2, Jarosław Czubak1
Tranexamic acid combined with iron pathway may significantly decrease the postoperative rate of transfusion after elective total hip and knee replacement
Kwas tranexamowy połączony z przedoperacyjną suplementacją preparatami żelaza zmniejsza liczbę pooperacyjnych transfuzji u pacjentów po endoprotezoplastyce biodra i kolana
1Department of Orthopaedics, Pediatric Orthopaedics and Traumatology, Centre of Postgraduate Medical Education, Gruca Teaching Hospital, Otwock
Head of Department: Associate Professor Jarosław Czubak, MD, PhD
2Department of Orthopaedic Surgery, Our Ladys Hospital, Navan, Ireland
Head of Department: Alan Walsh MBBS, MSc. (Orth), FRCSI, FRCS (Ed)
Streszczenie
Wstęp. Zastosowanie transfuzji po endoprotezoplastykach stawów kolanowych i biodrowych wciąż pozostaje istotnym elementem opieki pooperacyjnej.
Cel pracy. Celem badania było porównanie utraty krwi, wartości Hgb oraz konieczności przeprowadzenia transfuzji po planowanych endoprotezoplastykach stawów biodrowych i kolanowych po rutynowym zastosowaniu okołooperacyjnej suplementacji preparatami żelaza oraz kwasu tranexamowego.
Materiał i metody. Badanie przeprowadzono w sposób retrospektywny. Analizie poddano historie chorób 2416 pacjentów hospitalizowanych w Klinice Ortopedii Our Ladys’ Hospital, Navan w Irlandii przyjętych w celu wykonania planowych zabiegów endoprotezoplastyki stawów biodrowych (n = 1509) oraz kolanowych (n = 907) w okresie 2010-2015.
Pacjentów podzielono na 2 grupy:
A. Pacjenci operowani w okresie od stycznia 2010 do grudnia 2012 roku – przed wprowadzeniem rutynowej suplementacji preparatami żelaza oraz kwasem tranexamowym.
B. Pacjenci operowani w okresie od stycznia 2013 do grudnia 2015 roku – po wprowadzeniu rutynowej suplementacji preparatami żelaza oraz kwasem tranexamowym.
Wyniki. Podczas okresu obserwacji 1246 pacjentów otrzymało kwas tranexamowy okołooperacyjnie, a 74 zostało zakwalifikowanych do suplementacji preparatami żelaza. Średni wzrost poziomu Hgb wynosił 0.8 g/dl.
W grupie A (okres 2010-2012 – przed wprowadzeniem rutynowej profilaktyki) 1154 pacjentów, u których przeprowadzono operacje endoprotezoplastyki, 648 (56.1%) poddano transfuzji z powodu wskazań klinicznych i labolatoryjnych.
W grupie B (okres 2013-2015 – po wprowadzeniu rutynowej profilaktyki) 1262 pacjentów, u których przeprowadzono operacje endoprotezoplastyki, 240 (19.01%) poddano transfuzji z powodu wskazań klinicznych i labolatoryjnych.
Wnioski. Zastosowanie rutynowej okołooperacyjnej profilaktyki z użyciem kwasu tranexamowego oraz suplementacji preparatami żelaza zmniejszyło liczbę koniecznych transfuzji krwi po planowych operacjach endoprotezoplastyki biodra i kolana.
Pooperacyjny poziom Hgb był wyższy u pacjentów z grupy B.
Pacjenci, u których poziom Hgb nie uległ poprawie po zastoowaniu suplementacji żelazem, powinni być poddani badaniom diagnostycznym w celu określenia przyczyny niedokrwistości.
Summary
Introduction. Transfusion associated with joint replacement surgery has long been recognized as a substantive issue.
Aim. In the present study, we compared blood loss, Hb levels, and transfusion requirements after elective primary total hip and knee arthroplasty when tranexamic acid (TXA) and iron pathway when indicated were used as a routine prophylaxis.
Material and methods. A total of 2416 consecutive patients, with the diagnosis osteoarthritis undergoing unilateral primary hip (n = 1509) or knee (n = 907) arthroplasty at Our Ladys’ Hospital, Navan, Ireland were included in the study between January 2010 and December 2015.
The patients were divided into two groups:
A. Patients operated on between January 2010 and December 2012 before the introduction of tranxemic acid and iron pathway.
B. Patients operated on between January 2013 and December 2015 when tranxemic acid was used routinely as prophylaxis and iron pathway when needed.
Results. During the period of observation, 2416 patients underwent total joint arthroplasty performed by participating surgeons. Among these, 1262 patients received perioperative TXA (treatment group) and 74 entered the iron pathway. The average increase in Hb level was 0.8 g/dl.
Group A patients (patients treated before TXA and iron pathway introduction 2010-2012): Among 1154 patients undergoing joint replacement 648 (56.1%) were transfused with RBC units.
Group B patients (patients treated after TXA and iron pathway introduction 2013-2015): Among 1262 patients undergoing joint replacement 240 (19.01%) were transfused with RBC units.
Conclusions. The introduction of tranxemic acid and iron pathway has reduced transfusion rates with improved outcomes and cost reduction
The level of post operative Hb level was higher after the introduction of tranxemic acid.
Patients who fail to respond to iron treatment should be followed up to ensure no serious pathology.
Introduction
Transfusion associated with joint replacement surgery has long been recognized as a substantive issue. Investigations performed in the 1980s revealed that intraoperative blood losses in total knee arthroplasty (TKA) averaged more than 1000 mL per procedure (1). More recent studies have shown that non-visible blood loss such as bleeding into tissues and hemolysis with reinfusion typically accounts for volume losses equivalent to an additional 500 mL (2-11).
Aim
In the present study, we compared blood loss, Hb levels, and transfusion requirements after elective primary total hip and knee arthroplasty when tranexamic acid (TXA) and iron pathway when indicated were used as a routine prophylaxis.
Material and methods
A total of 2416 consecutive patients, with the diagnosis osteoarthritis undergoing unilateral primary hip (n = 1509) or knee (n = 907) arthroplasty at Our Ladys’ Hospital, Navan, Ireland were included in the study between January 2010 and December 2015. Exclusion criteria were known liver disease or coagulation disorder.
Patients greater than 18 years of age who underwent joint reconstruction at Our Lady of Lourdes Hospital, Navan, Ireland between January 2010 and December 2015 were identified by review of computerized inpatient and their medical records were retrospectively examined. Patients were included if they received primary, revision, or bilateral TKA or THA performed by either of six participating orthopedic surgeons. The patients were divided into two groups:
A – patients operated on between January 2010 and December 2012 before the introduction of tranexamic acid and iron pathway,
B – patients operated on between January 2013 and December 2015 when tranexamic acid was used routinely as prophylaxis and iron pathway when needed.
The following baseline variables were recorded in group A and B: age; gender; BMI; medication prior to surgery, including the use of acetylsalicylic acid (ASA), nonsteroidal anti-inflammatory drugs (NSAIDs), or selective serotonin receptor inhibitors (SSRIs); type of surgery; and thrombosis prophylaxis. Patients on ASA or NSAIDs were urged to discontinue these medications 3 days before surgery. Medication with potent platelet inhibitors, such as clopidogrel, were stopped at least 1 week before surgery. Blood samples from a peripheral vein for hemoglobin (Hb), platelet count, activated partial thromboplastin time (aPTT), and prothrombin time (PT) analyses were obtained < 24 h before surgery. Hemoglobin level was also measured 24-48 h postoperatively in order to calculate blood loss.
The following perioperative variables were recorded in group A and B: duration of operation, bleeding during surgery (intraoperatively), transfusion requirements intraoperatively, and postoperatively until discharge or until reoperation and autologous transfusion of wound blood after cell saver processing. Intraoperative bleeding was calculated from blood retrieved from wound suction plus the estimated amount of blood in the swabs.
Additionally to the above mentioned measures the group B patients were pre-assessed at least 28 days before the date of the surgery. The FBC was obtained and anemic patients were identified. The anemia was diagnosed according to WHO as Hb level < 12 g/dl in adult females and Hb < 13 g/dl in adult males. The results were forwarded to the GPs with guidance for treatment. The patients were commonly prescribed with Ferrous Sulphate 200 mg TDS or Ferrous Fumarate 325 mg BD-TDS.
The average increase in Hb level was 0.8 g/dl. Patients with no increase in hemoglobin were interviewed and asked about compliance with oral iron; follow up was arranged as appropriate.
A standardized prescribing regimen was established in which patients received TXA 1gram as a direct intravenous (IV) injection immediately prior to skin incision and once again immediately after the surgery was complete.
With the exception of insertion of drains in TKAs, all participating reconstructive orthopedic surgeons used identical operative techniques for joint reconstruction. All surgeons used similar postoperative pain management techniques, antithrombotic therapy (subcutaneous enoxaparin 40 mg daily beginning on postoperative day 1), and rehabilitation strategies and both employed a standardized protocol for daily laboratory monitoring. All surgeons routinely followed identical criteria for decisions regarding blood transfusion (hemoglobin < 8.0 g/dL, unless anemic symptoms are present).
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Piśmiennictwo
1. Berman AT, Geissele AE, Basacco SJ: Blood loss with total knee arthroplasty. Clin Orthop Relat Res 1988; 234: 137-138.
2. Sehat KR, Evans R, Newman JH: How much blood is really lost in total knee arthroplasty? Correct blood loss management should take hidden loss into account. Knee 2000; 7: 151-155.
3. Spahn DR: Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Anesthesiology 2010; 113: 182-195.
4. Shander A, Hofmann A, Gombotz H et al.: Estimating the cost of blood: past, present, and future directions. Best Pract Res Clin Anaesthesiol 2007; 21: 271-289.
5. Banerjee S, Issa K, Pivec R et al.: Intraoperative pharmacotherapeutic blood management strategies in total knee arthroplasty. J Knee Surg 2013; 34: 566-585.
6. Mak JCS, Fransen M, Jennings M et al.: Evidence-based review for patients undergoing elective hip and knee replacement. ANZ J Surg 2014; 84: 17-24.
7. Memtsoudis SG, Hargett M, Russell LA et al.: Consensus statement from the consensus conference on bilateral total knee arthroplasty group. Clin Orthop Relat Res 2013; 471: 2649-2657.
8. Shander A, Hofmann A, Ozawa S et al.: Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion 2010; 50: 753-765.
9. Hiippala S, Strid L, Wennerstrand M et al.: Tranexamic acid (Cyklokapron) reduces perioperative blood loss associated with total knee arthroplasty. Br J Anaesth 1995; 74: 535-537.
10. Benon G, Fredin H: Fibrinolytic induction with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty: a prospective, randomized, double-blind study of 86 patients. J Bone Joint Surg Br1996; 78: 434-440.
11. Hiippala ST, Strid LJ, Wennerstrand MI et al.: Tranexamic acid radically decreases blood loss and transfusions associated with total knee arthroplasty. Anesth Analg 1997; 84: 839-844.
12. Poeran J, Rasul R, Suźuki S et al.: Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety. BMJ 2014; 349: g4829.
13. Kagoma YK, Crowther MA, Douketis J et al.: Use of antifibrinolytic therapy to reduce transfusion in patients undergoing orthopedic surgery: a systematic review of randomized trials. Thromb Res 2009; 123: 687-696.
14. Yang Z-G, Chen W-P, Wu L-D: 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.
15. Gandhi R, Evans HMK, Mahomed SR et al.: Tranexamic acid and the reduction of blood loss in total knee and hip arthroplasty: a meta-analysis. BMC Res Notes 2013; 6: 184.
16. Zhou X-D, Tao L-J, Wu L-D: Do we really need tranexamic acid in total hip arthroplasty? A meta-analysis of nineteen randomized controlled trials. Arch Orthop Trauma Surg 2013; 133: 1017-1027.
17. Huang F, Wu D, Ma G et al.: The use of tranexamic acid to reduce blood loss and transfusion in major orthopedic surgery: a meta-analysis. J Surg Res 2014; 186: 318-327.
18. Wu Q, Zhang H-A, Liu S-L et al.: Is tranexamic acid clinically effective and safe to prevent blood loss in total knee arthroplasty? A meta-analysis of 34 randomized controlled trials. Eur J Orthop Surg Traumatol 2015; 25: 525-541.
19. Moskal JT, Harris RN, Capps SG: Transfusion cost savings with tranexamic acid in primary total knee arthroplasty from 2009 to 2012. J Arthroplasty 2015; 30: 365-368.
20. Harris RN, Moskal JT, Capps SG: Does tranexamic acid reduce blood transfusion cost for primary total hip arthroplasty? A case-control study. J Arthroplasty 2015; 30: 192-195.
21. McGillivray RG, Tarabichi SB, Hawari MF et al.: Tranexamic acid to reduce blood loss after bilateral total knee arthroplasty: a prospective, randomized double blind study. J Arthroplasty 2011; 26: 24-28.
22. Kelly TC, Tucker KK, Adams MJ et al.: Use of tranexamic acid results in decreased blood loss and decreased transfusions in patients undergoing staged bilateral total knee arthroplasty. Transfusion 2014; 54: 26-30.
23. Smit KM, Naudie DDR, Ralley FE et al.: One dose of tranexamic acid is safe and effective in revision knee arthroplasty. J Arthroplasty 2013; 28 (suppl. 1): 112-115.
24. Maniar RN, Kumar G, Singhi T et al.: Most effective regimen of tranexamic acid in knee arthroplasty: a prospective randomized controlled study in 240 patients. Clin Orthop Relat Res 2012; 470: 2605-2612.
25. Zohar E, Ellis M, Ifrach N et al.: The postoperative blood-sparing efficacy of oral versus intravenous tranexamic acid after total knee replacement. Anesth Analg 2004; 99: 1679-1683.
26. Lin S-Y, Chen C-H, Fu Y-C et al.: The efficacy of combined use of intraarticular and intravenous tranexamic acid on reducing blood loss and transfusion rate in total knee arthroplasty. J Arthroplasty 2015; 30: 776-780.
27. Apfelbaum JL, Nuttall GA, Connis RT et al.: Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology 2015; 122: 241-275.
28. Gillette BP, DeSimone LJ, Trousdale RT et al.: Low risk of thromboembolic complications with tranexamic acid after primary total hip and knee arthroplasty. Clin Orthop Relat Res 2013; 471: 150-154.
29. Duncan CM, Gillette BP, Jacob AK et al.: Venous thromboembolism and mortality associated with tranexamic acid use during total hip and knee arthroplasty. J Arthroplasty 2015; 30: 272-276.
30. Bruce-Brand R, Dragomir R, Baker J et al.: Cerebrovascular infarction following bilateral total knee arthroplasty and tranexamic acid administration. Acta Orthop Belg 2013; 79: 351-354.
