© 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)
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.
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.
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).
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).
The primary outcome was objective measures of perioperative blood loss and prevalence of blood transfusion among patients undergoing total joint arthroplasty. Accordingly, preoperative and nadir postoperative (usually postoperative day 1) hemoglobin and hematocrit levels were recorded and differences were determined. Blood product administrations were identified and recorded, including volumes or amounts and types of transfusion according to allogeneic or autologous blood. Secondary outcomes of interest included length of stay, relative health condition as described in the hospital discharge summary, and in-hospital occurrence rates for thrombotic, hemorrhagic, and other serious complications.
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.
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