A Study effectiveness of TXA in reducing peri operative blood loss in various orthopedic surgeries at tertiary health care centre

 

 

Abstract               Background: In modern day orthopedic surgeries, apart from the complications directly related to fractures and implants, a surgeon faces numerous perioperative complications. Aims and Objectives: Study effectiveness of TXA in reducing peri operative blood loss in various orthopedic surgeries at tertiary health care centre. Methodology: This was a cross-sectional study carried out in the patients undergoing the various orthopedic surgeries where more blood lost is anticipated during the one year period i.e. January 2019 to January 2020 by taking written and explained consent so during the one year period 60 patients were enrolled to study by all standard protocols . Out of them 30 included in Group A: Given tranexamic acid (TXA) intravenously and remaining 30 Group B : Given no any special drugs except routine management of patient. The statistical analysis was done by chi-square test and unpaired t-test SPSS 19- version software. Result: In Our study we have seen The average age in both the groups was comparable i.e. 45.73±4.28 and 46.19±3.27 (p>0.05,t=0.64,df=58) and the male to female composition was also comparable i.e. 2.33:1 and 2 :1 (X²=0.17,p>0.05,df=1). Pre-operative HB (mean ± SD)- 11.29± 1.87 and 11.92± 0.98 (p>0.05,t=0.98,df=58); Pre-operative HC (mean ± SD)- 34.92±4.12 and 35.78± 3.74 (p>0.05,t=0.34, df=58 ) was comparable but the Post-operative HB(mean ± SD) was 10.41± 1.76 and 9.42±2.87 (P<0.001,t=7.89, df=58); Post-operative HC (mean ± SD)- 33.57±4.98 and 33.72± 3.78 (P<0.001,t=8.92, df=58); Post operative blood lost in ml (mean ± SD)- 683± 31.21 and 769±20.78 (P<0.0001,t=10.34, df=58 ) was significantly differed in Group A as compared to Group B. Conclusion: It can be concluded form our study that the patients who was treated with TXA were significantly less blood lost peri-opretaively assessed by the various parameters like post operative HB , HC, blood lost hence it should be preferred to reduce blood lost whenever feasible.

Key words: Tranexamic acid (TXA), Blood lost, Hemostasis.

INTRODUCTION

In modern day orthopedic surgeries, apart from the complications directly related to fractures and implants, a surgeon faces numerous perioperative complications. These range from excessive intraoperative and postoperative blood loss, infection, poor wound healing, electrolyte imbalance to even acute renal shut down and shock. Surgeries in orthopedics being more invasive leads to more blood loss when compared to other surgical specialties¹ Various Orthopedic surgeries accounts for a significant proportion of all perioperative blood lost and requires packed red blood-cell transfusions². It is known that perioperative anemia and RBC transfusions are associated with increased healthcare resource utilization, hospital length of stay, delayed recovery and higher rates of postoperative morbidity and mortality^3,4. Various techniques have been introduced to reduce blood loss in the perioperative period and perioperative antifibrinolytic therapy is recommended as part of a comprehensive perioperative blood management strategy⁵. The use of antifibrinolytic agents is based on the fact that surgical trauma besides promoting clot formation by activating the intrinsic and extrinsic coagulation cascades also leads to a concomitant activation of plasminogen inducing a state of hyperfibrinolysis accelerating clot degeneration and increasing surgical site bleeding. Tranexamic acid (TXA) is a synthetic analogue of the amino acid lysine that reversibly occupies lysine-binding sites on plasminogen preventing its binding to the surface of fibrin and activation, resulting in inhibition of fibrinolysis⁶. Since the pioneering work of Hiippala and Benoni and colleagues^7,8 many prospective randomized studies and meta-analyses have confirmed the effectiveness of TXA to reduce perioperative blood loss and the need for allogenic and autologous blood transfusion in patients undergoing TKA ⁹.  So we studied the effectiveness of TXA in reducing peri operative blood loss in various orthopedic surgeries at tertiary health care centre.

 

METHODOLOGY

This was a cross-sectional study carried out in the patients undergoing the various orthopedic surgeries where more blood lost is anticipated during the one year period i.e. January 2019 to January 2020 by taking written and explained consent so during the one year period 60 patients were enrolled to study by all standard protocols . Out of them 30 included in Group A : Given tranexamic acid (TXA) intravenously and remaining 30 Group B : Given no any special drugs except routine management of patient. The patients randomly enrolled two above groups by computer generated random numbers . The investigations like –HB, Hematocrit were carried out pre-operatively and post operatively. The post operative blood lost was measured by dry and wet mop method and measurement of drain for 24 hours. The statistical analysis was done by chi-square test and unpaired t-test SPSS 19- version software.

DISCUSSION

Pharmacological agents can be used to achieve hemostasis during and after surgery by altering the delicate balance between blood clotting and fibrinolysis. During a surgical insult there is activation of the clotting mechanism. In order to check uncontrolled clot formation fibrinolytic mechanism also get activated simultaneously. Drugs used to reduce blood loss inhibit the fibrinolytic mechanism. Aprotinin, epsilon amino caproic acid and tranexamic acid are the three drugs in this group ¹. Tranexamic acid has the same mechanism of action as EACA, with comparable efficacy and safety at a lower cost. In high blood loss surgeries it is given intravenously at a dose of 10 mg per kg body weight, which can be repeated once or twice after 4 h. It is also available in oral formulation which can be used at a dose of 25 mg per kg body weight in prostatectomy, minor gynecological procedures, menorrhagia, epistaxis, haemophilia and hereditary angioneurotic edema. There are numerous studies with this drug that proved its efficacy.^11-13 Also a study conducted in our hospital showed this drug to be effective in reducing blood loss and transfusion in total knee replacement patients.¹⁴ In addition to the usual intravenous route this drug can be used topically as demonstrated by Wong et al. wherein 1.5 or 3 g of tranexamic acid in 100 ml of normal saline was applied to the joint surface for minutes at the end of surgery.¹⁵ In Our study we have seen The average age in both the groups was comparable i.e. 45.73±4.28 and 46.19±3.27 (p>0.05,t=0.64,df=58) and the male to female composition was also comparable i.e. 2.33:1 and 2 :1 (X²=0.17,p>0.05,df=1). Pre-operative HB (mean ± SD)- 11.29± 1.87 and 11.92± 0.98 (p>0.05,t=0.98,df=58); Pre-operative HC (mean ± SD)- 34.92±4.12 and 35.78± 3.74 (p>0.05,t=0.34, df=58 ) was comparable but the Post-operative HB(mean ± SD) was 10.41± 1.76 and 9.42±2.87 (P<0.001,t=7.89, df=58); Post-operative HC (mean ± SD)- 33.57±4.98 and 33.72± 3.78 (P<0.001,t=8.92, df=58); Post operative blood lost in ml (mean ± SD)- 683± 31.21 and 769±20.78 (P<0.0001,t=10.34, df=58 ) was significantly differed in Group A as compared to Group B. These findings are similar to Kuan-Ting Wu ¹⁶ et al. they found Administration of TXA is not only effective in reducing perioperative blood loss and length of hospital stay but also exerts an anti-inflammatory effect following CAS-TKA without causing major complications

 

CONCLUSION

It can be concluded form our study that the patients who was treated with TXA were significantly less blood lost peri-opretaively assessed by the various parameters like post operative HB , HC, blood lost hence it should be preferred to reduce blood lost whenever feasible.

 

REFERENCES

1. Balaji Sambandam, Sahil Batra, Rajat Gupta. Blood conservation strategies in orthopedic surgeries: A review. journal of clinical orthopaedics and trauma 4 (2013) 164 e170
2.  Kurtz S, Ong K, Lau E, et al.. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780-5.
3.  Ponnusamy KE, Kim TJ, Khanuja HS. Perioperative blood transfusions in orthopaedic surgery. J Bone Joint Surg Am 2014;96:1836-44.
4.  Wu WC, Smith TS, Henderson WG, et al.. Operative blood loss, blood transfusion, and 30-day mortality in older patients after major noncardiac surgery. Ann Surg 2010;252:11-7.
5.  Glance LG, Dick AW, Mukamel DB, et al.. Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 2011;114:283-92.
6. Practice guidelines for perioperative blood management: an updated report by the american society of anesthesiologists task force on perioperative blood management*. Anesthesiology 2015;122:241-75.
7. Mannucci PM. Hemostatic drugs. N Engl J Med 1998;339:245-53.
8. Hiippala S, Strid L, Wennerstrand M, et al.. Tranexamic acid (Cyklokapron) reduces perioperative blood loss associated with total knee arthroplasty. Br J Anaesth 1995;74:534-7.
9.  Benoni G, Carlsson A, Petersson C, et al.. Does tranexamic acid reduce blood loss in knee arthroplasty? Am J Knee Surg 1995;8:88-92.
10. Yang ZG, Chen WP, Wu LD. Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis. J Bone Joint Surg Am 2012;94:1153-9.
11.  Hippala S, Strid L, Wennerstrand M, et al.. Tranexamic acid (cyclokapron) reduces peri-operative blood loss associated with total knee arthroplasty. Br J Anesth. 1995;74:534e537.
12.  Benoni G, Fredin H. Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty: a prospective, randomised, double-blind study of 86 patients. J Bone Joint Surg Br. 1996;78-B:434e440.
13.  Jansen AJ, Andreica S, Claeys M, et al.. Use of tranexamic acid for an effective blood conservation strategy after total knee arthroplasty. Br J Anaesth. 1999;83:596e601.
14.  Gautam VK, Sambandam B, Singh S, Gupta P, Gupta R, Maini L. The role of tranexamic acid in reducing blood loss in total knee replacement. J Clin Orthop Trauma. 2013 Mar;4(1):36e39.
15.  Wong J, Abrishami A, Beheiry HE, et al.. Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. J Bone Joint Surg Am. 2010 Nov 03;92(15):2503-2513.
16. Kuan-Ting Wu , Ka-Kit Siu,Jih-Yang Ko et al.. Tranexamic Acid Reduces Total Blood Loss and Inflammatory Response in Computer-Assisted Navigation Total Knee Arthroplasty. BioMed Research International Volume 2019, Article ID 5207517, 7 pages https://doi.org/10.1155/2019/5207517

 

Policy for Articles with Open Access:
Authors who publish with MedPulse International Journal of Orthopedics, (Print ISSN: 2579-0889, Online) (ISSN: 2636-4638) agree to the following terms: Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
Authors are permitted and encouraged to post links to their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.