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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 24-27

Tranexamic acid reduces blood loss and need of blood transfusion in hemiarthroplasty: An observational study


1 Department of Orthopedics, SUT Academy of Medical Science (SUTAMS), Trivandrum, Kerala, India
2 Department of Pharmacology, SUT Academy of Medical Science (SUTAMS), Trivandrum, Kerala, India
3 Department of Community Medicine, SUT Academy of Medical Science (SUTAMS), Trivandrum, Kerala, India

Date of Submission25-Feb-2020
Date of Decision11-Mar-2020
Date of Acceptance05-May-2020
Date of Web Publication23-Oct-2020

Correspondence Address:
Dr. Sangeetha Gopinath
Department of Pharmacology, SUT Academy of Medical Science (SUTAMS), Vencode P.O. Vattappara, Trivandrum, Kerala.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhrr.JHRR_10_20

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  Abstract 

Aim: The aim of this study was to evaluate the effects of tranexamic acid on postoperative bleeding and transfusion requirement. Materials and Methods: A total of 70 patients who underwent hemiarthroplasty between January 2015 and December 2016 were retrospectively analyzed using patient case files, discharge database, and blood bank database. The blood transfusion requirement, preoperative and postoperative hemoglobin levels, and drain volume were noted. Pearson chi-square test and independent t test were applied to analyze the data. Results: The blood transfusion requirements were significantly lower in those who received tranexamic acid (17.5% vs. 66.67%; P < 0.001). Patients who had received tranexamic acid had significantly less drop in postoperative hemoglobin (0.99 ± 0.32 vs. 2.46 ± 0.52; P < 0.001) and drain volume (102.50 ± 29.62 vs. 274.67 ± 70.01; P < 0.001). Conclusion: In patients who underwent hemiarthroplasty, tranexamic acid reduced the blood loss and the transfusion requirement.

Keywords: Hemiarthroplasty, tranexamic acid, transfusion requirements


How to cite this article:
Pillai AS, Gopinath S, Pallipurathu Raghunath S. Tranexamic acid reduces blood loss and need of blood transfusion in hemiarthroplasty: An observational study. J Health Res Rev 2020;7:24-7

How to cite this URL:
Pillai AS, Gopinath S, Pallipurathu Raghunath S. Tranexamic acid reduces blood loss and need of blood transfusion in hemiarthroplasty: An observational study. J Health Res Rev [serial online] 2020 [cited 2020 Nov 30];7:24-7. Available from: https://www.jhrr.org/text.asp?2020/7/1/24/298873




  Introduction Top


Hemiarthroplasty is associated with a considerable amount of blood loss; reportedly 1500mL of blood is lost during the surgery.[1] This necessitates blood transfusion, which, though lifesaving, is not risk free. Transfusions are associated with increased risk of immune reactions, disease transmission, and postoperative infection in addition to increasing the costs.[2],[3],[4],[5] There are various methods for effective patient blood management, which include preoperative anemia assessment, appropriate surgical positioning, prevention of hypothermia, controlled hypotension technique, and administration of antifibrinolytics and topical hemostasis agents.[6]

Tranexamic acid (TXA) is one of the most widely used antifibrinolytic agents. This drug blocks plasmin-induced degradation of the fibrin clot. It competitively and reversibly binds to the lysine-binding sites of plasminogen and inhibits binding of fibrin to plasminogen.[7]

Several studies have shown the efficacy of TXA in reducing total (both intraoperative and postoperative) blood loss, hemoglobin drop, transfusion requirements, and average hospital stay.[8],[9],[10],[11],[12],[13],[14] Other studies have pointed out that TXA reduces early postoperative blood loss but not transfusion requirements.[15],[16]

Reduction of the postoperative blood loss and the need for blood transfusions are said to improve the clinical outcome after hip arthroplasty.[6] Therefore, effective blood management has a significant impact on the economic burden, patient recovery, and safety. Effective blood management is the need of the hour. Our aim was to study whether the use of TXA during hemiarthroplasty would result in significant reduction of blood loss and the need for blood transfusion.


  Materials and Methods Top


Study design

The study was a retrospective observational study. The study protocol was approved by the institutional ethics committee of SUT Academy of Medical Sciences (IEC 02/6/2018 SUTAMS). All patients who underwent hemiarthroplasty between January 2015 and December 2016 by the same surgeon in our hospital were retrospectively analyzed using patient charts, hospital admission, discharge database, and blood bank database. Since January 2016, TXA (Cyclokapron, Pfizer, Mumbai, India) has been routinely administered to all patients undergoing hemiarthroplasty. The duration of the study was 2 years.

Patients

Patients who underwent hemiarthroplasty between January 2015 and December 2016 were recruited into this study. The required details were collected from hospital records during the period of the study. The inclusion criteria of the study were patients who were above 60 years old who underwent elective hemiarthroplasty.

The exclusion criteria of the study were patients who had a history of congenital or acquired bleeding disorder, previous history of thromboembolic disease, renal failure, hepatic failure, significant comorbidities, severe ischemic heart disease, or previous myocardial infarction.

Thirty patients who underwent hemiarthroplasty prior to routine use of TXA could be compared with the 40 patients who underwent it, with its use.

TXA was administered as a 1 g intravenous (IV) infusion 30–60 min before surgery and 500 mg administered as an IV infusion 4–5 h after surgery.

Patient details including age and sex were documented. To address the bias of age, we have performed stratified analysis.

Outcome measures

The efficacy outcome was assessed by comparing the postoperative hemoglobin drop, drain volume, and transfusion requirements.

All patients whose hemoglobin dropped <9.5 g/dL were administered blood transfusion. The numbers of transfused whole blood units, plasma expanders, or packed red blood cells were documented.

Hemoglobin levels were measured before surgery and 24 h postoperatively. The drain output from the suction drain on removal at 48 h was also noted. All the patients would have received deep vein thrombosis (DVT) prophylaxis.

Documented complications such as occurrence of DVT were also noted.

Statistical Analysis

The two treatment groups were investigated for differences in baseline variables. Independent t test and chi-square test were used to compare the data. All statistical analyses were carried out using the Statistical Package for the Social Sciences (SPSS) software program, version 16.0 (IBM, India).


  Results Top


Between January 2015 and December 2016, 70 patients underwent hemiarthroplasty. There were 30 patients (43%) who underwent hemiarthroplasty before December 2015. Our hospital started to introduce routine TXA injections from January 2016. Therefore, the 40 patients (57%) who underwent hemiarthroplasty after January 2016 received TXA.

The baseline characteristics did not differ significantly between the two groups. The overall mean age of the patients who underwent hemiarthroplasty was 71.9. The mean age of those who received TXA (72.12 ± 6.89) was comparable to those who did not receive it (71.53 ± 7.0) [Table 1].
Table 1: Patient characteristics

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The majority of the patients were females 65.7% (46/70). This was also reflected in both the groups (20/30:66.67%) in those who did not receive TXA; (26/40:65%) in those who did.

Transfusion requirements

A total of 27 patients (38.6%) received blood transfusion of at least 1 unit of Packed red blood cells (PRBC) postoperatively. The percentage of patients who received transfusions was significantly lower in those who received TXA. Only 7 of 40 patients (17.5%) in the TXA group received blood transfusion as compared to 20 of 30 patients in the other group (66.67%; P < 0.001) [Table 2].
Table 2: Efficacy outcomes

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Postoperative hemoglobin drop

The mean preoperative and postoperative hemoglobin levels were 12.26 ± 1.28 and 10.67 ± 1.63, respectively. The mean hemoglobin drop was 1.62 ± 0.84. The occurrence of postoperative hemoglobin drop was low and differed significantly between the groups. The mean hemoglobin drop was 2.46 ± 0.52 in those who did not receive TXA as compared to 0.99 ± 0.32 in those who did (P < 0.001).

Drain volume

Similarly, the drain volume differed significantly between the groups. The mean drain volume was 176.29 ± 99.17. The mean drain volume was 102.50 ± 29.62 in those who received TXA and 274.67 ± 70.01 in those who did not (P < 0.001).


  Discussion Top


Our study shows that the rates of transfusion were significantly lower in those who received TXA. This reduction is highly beneficial to the patient both economically and safety wise. Reduction in blood transfusion rates was shown in the retrospective cohort study conducted by Xie et al.[17] in hip fracture patients. The study conducted by Kwak et al.[18] has even shown that topical TXA in patients who underwent hemiarthroplasty reduced the transfusion requirements.

The studies by Lack et al.[19] and Orpen et al.[15] is in variance with the above studies. According to their study, there was no difference in transfusion rate between those who were administered TXA acid and those who were not.

The postoperative hemoglobin drop tended to be significantly lower for those who received TXA than those who did not. The finding is in concurrence with the studies by Hynes et al.,[10] Peck et al.,[11] and Vijay et al.[14] who all showed that the mean hemoglobin decrease was significantly lower in the patients receiving TXA. The study by Kwak et al.[18] though came to the conclusion that hemoglobin values were comparable and did not differ significantly between the two groups. This might be due to the fact that they had used topical TXA.

In our study, the drain volume was also significantly lower in those who received TXA acid. Consistent with our findings, Vijay et al.[14] and Kwak et al.[18] showed a significant reduction in drain volume with the use of TXA.

The meta-analysis by Zhang et al.[20] too pointed out that the groups that received TXA had less total blood loss, postoperative hemoglobin decline, and lower transfusion rates compared to the control group. Our study was a record-based observational study. The sample size was small. Our study points out that TXA significantly reduces blood loss and transfusion requirements. A randomized clinical trial with a larger population of study subjects can more effectively show this.

Financial support and sponsorship

Nil

Conflict of interest

There are no conflicts of interest.



 
  References Top

1.
Park JH, Kim HS, Yoo JH, Kim JH, Sung KH, Kim JY, et al. Perioperative blood loss in bipolar hemiarthroplasty for femoral neck fracture: Analysis of risk factors. Hip Pelvis 2013;25:110-4.  Back to cited text no. 1
    
2.
Goel R, Tobian AAR, Shaz BH Noninfectious transfusion-associated adverse events and their mitigation strategies. Blood 2019;133:1831-9.  Back to cited text no. 2
    
3.
Tormey CA, Hendrickson JE Transfusion-related red blood cell alloantibodies: Induction and consequences. Blood 2019;133:1821-30.  Back to cited text no. 3
    
4.
Busch MP, Bloch EM, Kleinman S Prevention of transfusion-transmitted infections. Blood 2019;133:1854-64.  Back to cited text no. 4
    
5.
Dean CL, Wade J, Roback JD Transfusion-transmitted infections: An update on product screening, diagnostic techniques, and the path ahead. J Clin Microbiol 2018;56:e00352-18.  Back to cited text no. 5
    
6.
Song JH, Park JW, Lee YK, Kim IS, Nho JH, Lee KJ, et al. Management of blood loss in hip arthroplasty: Korean hip society current consensus. Hip Pelvis 2017;29:81-90.  Back to cited text no. 6
    
7.
Cai J, Ribkoff J, Olson S, Raghunathan V, Al-Samkari H, DeLoughery TG, et al. The many roles of tranexamic acid: An overview of the clinical indications for TXA in medical and surgical patients. Eur J Haematol 2020;104: 79-87.  Back to cited text no. 7
    
8.
Gausden EB, Garner MR, Warner SJ, Levack A, Nellestein AM, Tedore T, et al. Tranexamic acid in hip fracture patients: A protocol for a randomised, placebo controlled trial on the efficacy of tranexamic acid in reducing blood loss in hip fracture patients. BMJ Open 2016;6:e010676.  Back to cited text no. 8
    
9.
Kashyap S, Mahajan S, Lal M Effects of topical tranexamic acid during open reduction and internal fixation of acetabular fractures: A retrospective study. Acta Orthop Traumatol Turc 2019;53:175-9.  Back to cited text no. 9
    
10.
Hynes M, Calder P, Scott G The use of tranexamic acid to reduce blood loss during total knee arthroplasty. Knee 2003;10:375-7.  Back to cited text no. 10
    
11.
Peck J, Kepecs DM, Mei B, Safir OA, Backstein D, Gross AE, et al. The effect of preoperative administration of intravenous tranexamic acid during revision hip arthroplasty: A retrospective study. J Bone Joint Surg Am 2018;100: 1509-16.  Back to cited text no. 11
    
12.
Hines JT, Hernandez NM, Amundson AW, Pagnano MW, Sierra RJ, Abdel MP Intravenous tranexamic acid safely and effectively reduces transfusion rates in revision total hip arthroplasty. Bone Joint J 2019;101-B:104-9.  Back to cited text no. 12
    
13.
Liu W, Hui H, Zhang Y, Lin W, Fan Y Intra-articular tranexamic acid injection during the hip hemi-arthroplasty in elderly patients: A retrospective study. Geriatr Orthop Surg Rehabil 2018;9:2151459318803851.  Back to cited text no. 13
    
14.
Vijay BS, Bedi V, Mitra S, Das B Role of tranexamic acid in reducing postoperative blood loss and transfusion requirement in patients undergoing hip and femoral surgeries. Saudi J Anaesth 2013;7:29-32.  Back to cited text no. 14
    
15.
Orpen NM, Little C, Walker G, Crawfurd EJ Tranexamic acid reduces early post-operative blood loss after total knee arthroplasty: A prospective randomised controlled trial of 29 patients. Knee 2006;13:106-10.  Back to cited text no. 15
    
16.
Hu M, Liu ZB, Bi G Efficacy and safety of tranexamic acid in orthopaedic trauma surgery: A meta-analysis. Eur Rev Med Pharmacol Sci 2019;23:11025-31.  Back to cited text no. 16
    
17.
Xie J, Hu Q, Huang Q, Chen G, Zhou Z, Pei F Efficacy and safety of tranexamic acid in geriatric hip fracture with hemiarthroplasty: A retrospective cohort study. BMC Musculoskelet Disord 2019;20:304.  Back to cited text no. 17
    
18.
Kwak DK, Jang CY, Kim DH, Rhyu SH, Hwang JH, Yoo JH Topical tranexamic acid in elderly patients with femoral neck fractures treated with hemiarthroplasty: Efficacy and safety? A case-control study. BMC Musculoskelet Disord 2019;20:228.  Back to cited text no. 18
    
19.
Lack WD, Crist BD, Seymour RB, Harvin W, Karunakar MA; TXA Study Group II. Effect of tranexamic acid on transfusion: A randomized clinical trial in acetabular fracture surgery. J Orthop Trauma 2017;31:526-30.  Back to cited text no. 19
    
20.
Zhang H, Chen J, Chen F, Que W The effect of tranexamic acid on blood loss and use of blood products in total knee arthroplasty: A meta-analysis. Knee Surg Sports Traumatol Arthrosc 2012;20:1742-52.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2]



 

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